Experiences of drug dependent fathers in relation with their children: a qualitative study.

BACKGROUND: The effects of substance abusing on children of all ages has been considered. The major problem of these children is the inability of their parents to implement their parental tasks and duties. In Iran, addressing the issue of substance abuse has a history of several decades. Identifying the experiences of these individuals about relating to their children is important in effective therapeutic planning to help drug dependent people continue their treatment.
METHODS: This qualitative study was conducted using phenomenological approach. Subjects were selected from among the referrals to the substance abuse treatment centers in Kerman. This study lasted for 11 months from October 2008 to August 2009 and tried to use purposive sampling to select the subjects with as much diversity as possible from the drug-dependent males who had at least one child. All those who had history of addiction less than two years were excluded. Thematic analysis was used to analyze the findings.
FINDINGS: Participants were 35 opiate-dependent males. The mean age of subjects was 43.18 ± 8.25. Five themes were extracted from analyzing the interviews including emotional relations, economical problems, experiences of communicating with children, the effects of substance abuse on children, and the role of children on the quitting process.
CONCLUSION: To promote the quality of services offered to drug-dependents who have decided to quit, family therapy and psychotherapy are recommended to help addicted individuals reduce the problems they have with their children.

Introduction

The impact of parents’ substance abuse can be seen on development and growth of children in all ages.1-3 The effects of parents’ substance abuse can begin even before child’s birth and a high percent of children, who have been under the influence of drugs during their mother’s pregnancy, would face many serious medical problems.4 In addition to medical problems, the mental, emotional and psychological problems of children of drug-dependent individuals have always been considered. The emotional problems children with addicted parents experience depend upon familial environment. One of the main issues of familial environment is the inability of parents to implement their parental tasks and duties.5 Mothers, who are physically or mentally drug-dependent, represent more deficiency in parental skills during all the stages of their child's growth.6 These mothers have problems in understanding their children's basic needs, and they would show conflicting feelings about child care and low capacity in responding toward children’s cognitive and emotional needs.7,8

However, many experts believe that parental problems of addicted individuals are resulted from not only substance abuse but also a wide range of issues like environmental stress, low mental health, low socioeconomic and marital status.9,10 Although many studies evaluated the role of drug-dependent mothers, a few studies about the fathers are available.11-13

Stanger et al. showed that although there was a strong correlation between having a drug-dependent mother and family problems, such a relation was not observed between drug-dependency in fathers and familial problems.14 That is why the effect of drug use is not identified in paternal role and further studies are required; it is obvious that studies should be done according to the importance of paternal role in different cultures. Close physical relation of the father with his child, occupational status, men and fathers’ social role, and the presence of other male relatives can affect the involvement rate of fathers in the process of communication with children.15-17 In addition, due to changes in the definition of fathers’ responsibilities and the growing emphasis on fathers' involvement in their children’s upbringing, an increasing need is felt in men to solve their stress and problems that disable them in playing paternal role.18 For a long time, supporting the children and families who are faced with substance abuse have been considered. However, those who work in addiction-related fields have problems meeting relatively complicated needs of parents and children in such families. In most cases, when the problems influence the children, they emphasize on parents more.19 It seems that interventions in parents and family status are more effective than behavioral interventions of children. Parental education has been reported to be helpful in reducing the negative effects of parents' substance abuse on children20 and is suggested as a part of a comprehensive therapeutic program for addicted women. Tracy and Martin showed that children, particularly aging 6-11 years, can be an incentive for parents to withdraw. This effect has been more in women due to “a good mother” role which is expected from them.21 In Eastern culture, family is the most important and sometimes is the only source of individual support especially for children. Therefore, even when the parents are drug-dependent, children would still live with their parents. Studies have shown that addicted parents usually need family support or social support services.22 Most of the time, grandparents help addicted parents to raise the children and this can largely keep children away from injuries of such parents.

In traditional culture of Iran, father is known as responsible for family and providing their needs. The children are expected to keep a mostly formal and respectful behavior toward their father throughout their lives. The children are identified by father’s name and they keep the name of the family. In contrast, the relationship of children is more intimate with their mothers. Upbringing and caring for children, as well as a strong emotional relationship is mothers’ duty. In most Iranian families, the mother acts an interface between the children and the father and she should transfer the needs of the sides to each other. Despite lifestyle changes in Iran that caused more intimate relationships between fathers and children, many families still keep the traditional and conventional relationships.

In Iran, addressing the issue of substance abuse has been a history of several decades and the number of drug-dependent individuals in is reported to be 2-4 million in the country. However, determining the peripheral issues of addicts such as family status and their children is a relatively new issue. Almost 90 percent of Iranian addicts live with their parents and 50 percent of them are married.20 In the past ten years, substance abuse treatment centers and clinics have been dramatically extended in Iran. These clinics use standard and scientific methods like methadone therapy or camping programs and detoxification to treat addicts. One of the most important concerns these centers should take into account is the status of family and children of the individuals with drug dependency. Although Iranian governmental and non-governmental organizations are protectors of young children, most children kept in these centers have addicted parents. Since no study was conducted about specific problems in the families of addicts considering Iranian culture, the present study was performed to identify experiences of drug-dependent fathers in association with their children. The results can perhaps point out the risk factors of family problems in drug-dependent individuals to reduce the risks of drug use for families, especially children and youths.

Methods

This was a qualitative study conducted using phenomenological approach. The reasons of using this approach were: 1) possibility of a shared experience from different points of view; 2) interpretation of perceptions and experiences of different people; and 3) using the experiences of the researcher.23 In this study, thematic analysis was used because it has been widely employed as a method for identification, analysis and reporting themes of data. In Streubert model, which has the highest efficiency in this regard and was used in the present study, interviews are first written down and read repeatedly. Then the interview is summarized by the team members to achieve the general meaning and find the main essence. Thereafter, the summaries would be given to the interviewees to maximize the common content understanding. In this model, main stages of analyzing the interviews include open encoding, pivotal encoding, and selective encoding. In open or free encoding, thoughts, ideas and comments which were of high importance are identified and encoded. In pivotal encoding, main classification of data is done and in addition to integration of conceptually similar codes, the related categories are placed in a common pivot. In this stage, main themes of study are extracted.24

Furthermore, each data was compared to all the data using continuous comparative analysis process. Encoded data and overlapped themes were compared to each other and primary data were encoded. Then, the second interview was encoded according to the original model.

Moreover, annotation was used to help analyzing the qualitative data. Thus, from the beginning of the study, the ideas and relations that came to the researcher’s mind through collecting and analyzing the data, were immediately noted.25

This study was done on drug-dependent males who were withdrawing using methadone therapy in an outpatient addiction treatment clinic in Kerman. It lasted for 11 months from October 2008 to August 2009 and tried to select the greatest possible diversity of referrals using purposive sampling among the drug-dependent males who had at least one child based on the research objectives and additional usefulness of the subject.25 Since the history of drug-dependency was of importance, individuals with a history of addiction less than two years were excluded.

Besides, according to the study objectives, the individuals who were selected had to be willing to participate in the study and cooperate with researcher. They also had to be able to describe and express their perceptions clearly as a result of the history of referring to centers and cooperation with experienced medical staff. Semi-structured in-depth interview plus open-ended questions were used for data collection in this part of the study. Interviews continued until data saturation stage. The entire interviews were recorded and written down word by word to be used in analysis. In order to prepare the interviews for qualitative encoding and classifying, the text of each interview was studied several times and broken into themes.

Finally, with respect to all the conditions, 35 interviews were performed according to particular conditions of each participant and the time he had appointed. Each interview lasted about 20-80 minutes. In three cases, interviews were done in two time parts. The interviews were performed in a quiet place as much as possible. SPSS 16 software was used to analyze underlying characteristics of the participants.

To evaluate the credibility of participants’ views, the texts of the interviews were randomly given to a large number of subjects to determine whether the interpretation of results was similar to their views. In order to resolve the ambiguity issues in cases where no similarities were found, the individuals were interviewed again and all the stages of processing and encoding were repeated. Moreover, long-term involvement of the researcher with details of interviews was one of the other cases. For confirmability, inconsistent and contradictory cases were investigated to find the main cause of the contradiction. Dependability method was also used during which interviews’ texts and their summaries were shown to the coordinate researcher and an expert in qualitative researches and they also did some encodings based on their own perceptions. Thereafter, communicational meetings were held to make the codes of the researcher and the experts closer in cases which had no consistency.

This study was approved and accepted by Ethics Committee of Kerman University of Medical Sciences. Oral and written informed consents were obtained from the participants after they were explained about the study objectives, advantages of participating in the study, data collection, recording and keeping method. The researchers emphasized on the voluntary nature of participation and withdrawal from the study at any stage. The subjects were also ensured about the confidentiality of the information and that the voice recorder would be turned off at any point the subject asks to. It was clearly explained that whether they participated in the study or not would by no means interfere their treatment process. In addition, they were told that they could access the study results at the end. Finally, the researchers provided their telephone number and address for follow-up.

Results

The study population consisted of 35 opiate-dependent men referred to addiction withdrawal centers. Mean age of the participants was 43.18 ± 8.25 years. The mean (SD) number of children was 2 (1.08). Fourteen were self-employed, 4 unemployed and 17 were employees.

Five themes were extracted from analyzing the interviews including: emotional relations, economical problems, communicational experiences with children, the effects of substance abuse on children and the role of children in withdrawal process.

One of the most important themes the majority of participants mentioned was the effect of drug consumption on emotional relationships with other family members particularly children. In their opinion, drug use and its related issues, such as depression which exists in most drug addicts, cause difficulty in establishing close relationships with children. According to their opinion, what ruins a relationship between a father and his children is problems resulted from addiction and its consequences. A 47-year-old participant (employee) said: “I love my children but they want me to talk to them; if I am stoned or trance, I would only like to be by myself and if I’m languid, I feel I can’t do anything. They have to know I love them but I can’t show them”. One of the other participants (a 35-year-old employee) said: “I was always afraid to have a child because a child needs a lot of time and due to the depression I have, I can’t afford such a time”. The third participant (a 28-year-old driver) said: “Lassitude and depression caused me to be addicted. Now, drugs and depression together make me unable to show my interest toward my kid”.

A self-employed 24-year-old participant stated: “I have a little kid but I’m always afraid I can’t have a good relationship with her because even right now I can’t stand her. I can’t tolerate to see her and even once I beat her so bad and then I felt so regretful”.

From participants’ speech, we can conclude that all of them like their children but addiction makes them unable to express their feelings.

This theme consisted of two main classes; A) Denial of the effects of drug use on the family's economic status, B) Feeling sadness, tribulation and guilty due to the effects of drugs on family’s costs and attempting to compensate it. A group of participants, although denied the effects of substance abuse on their children’s economic status, tried to justify the effects. A participant (a 37-year-old employee) announced: “My addiction has never had any effects on supplying my children’s needs but do they have to want me or my money? If I can’t buy whatever they want, is that because the cost of my drugs is so extravagant?”

One of the other respondents (50-year-old; self-employed) said: “Is it only them that need things? So, how about me? I also want to spend some money for myself. Besides, when I consume drugs, it makes me feel better and I can work more and provide more money for them”. A participant (39-year-old; self-employed) said: “I try to prepare whatever my children want so that others don’t say you can’t supply your children because you’re addicted. I can’t stand it”. However, some of the participants viewed the effects of drug use on the family's economic status and satisfying their children’s needs from another perspective. A 42-year-old participant (employee) said: “Obviously if I didn’t use drugs, I could provide a financially better life for my children.” or the other (35-year-old; self-employed) said: “Substance use makes me unable to provide for my children’s costs. Therefore, I have to work more which in turn keeps me more away from them”.

This theme consisted of three conceptual categories including the quality of family members’ relations with each other and with the drug-dependent father, the quality of interactions between the father and the children, and supervising educational status of children.

A 40-year-old participant (employee) said: “Due to addiction, I’m not patient and tolerant enough. Children would tell their mom about their needs and if necessary, she would tell me”.

Another participant (a 43-year-old employee) said: “Once I told my children to watch a movie together and after that I gave a few comments about it. The kids were very surprised; they couldn’t believe it at all”. Similarly, another participant (50-years old; employed) said: “Once I asked my girl about her school stuff and she then told her mom that I was weird and asked her strange questions”.

Another participant (41-years-old; self-employed) said: “I’m never in the mood. My wife does all the stuff related to kids. When there is a mom, there’s no need for a father’s presence. They are also comfortable”.

Participants presented different opinions in this theme. Generally, there were four conceptual classes in this part including imitating addicted father; decreased social relationships due to the father’s addiction; arguments between the children and the father due to his addiction; and feeling embarrassed and ashamed.

One of the participants (28-years-old; self-employed) stated: “My father wasn’t an addict but I am. You shouldn’t care about those who say addiction causes children to incline to addiction. If I educate my child properly, my addiction would have no effects on her”. Another participant (35-years-old; self-employed) announced: “Children are able to recognize and as they can learn my good things, they know that they shouldn’t do my wrong acts. Even if addiction has effects on children, at least I know they wouldn’t repeat the things I do”.

The other participant (48-years-old; employee) said: “My addiction wouldn’t cause my children to be addicted. Although it would cause them feel depressed and ashamed and their spirit would be ruined, if their mother raises them appropriately, they wouldn’t be addicted”.

The fourth participant (42-years-old; driver) said: “All of my kids are embarrassed and don’t like to go out with me. I realize that every time they somehow escape from me”. A 38-year-old participant (employee) said: “My addiction has caused me not to visit my relatives very much. Therefore, my children are not well-socialized and they don’t know the relatives. They would be deprived from family support”. Another participant (30-years-old; employee) said: “Many times I argue with my children due to my addiction. Thus they won't talk to me even when I’m OK. That makes me so sad”.

A participant (33-years-old; self-employed) announced: “Once, my son failed in some of his lessons, I objected to him. He said that if I was a good father, I wouldn’t have let him be like this and then punish him”.

Another participant (53-years-old; self-employed) said: “Although I try to be serious, I can’t object to them most of the time because the media taught them addicted parents don’t have perseverance and you shouldn’t listen to them”.

The other said: “I won’t let my kids know that I use drugs because I feel ashamed. Even when the TV shows these people, I blame them”.

In this part, the participants talked about the effects of children on their decision to start or continue withdrawal. There were two conceptual categories here including decision to withdraw for children’s future; and stop withdrawing to provide for children.

A participant (32-year-old; self-employed) said: “I decided to withdraw for my children’s sake. I don’t like my children to tell me not to go to their school because I stink”. Another participant (48-year-old; self-employed) stated: “In the future, I don’t like my son-in-law to use opium. I know that if my daughter objects, he would say that her father uses it as well. I have to make my children proud”. The other one (38-year-old; employee) said: “I’ve already withdrawn many times for the sake of my children. If they did not exist, I would have never gone for withdrawal”.

Another participant (38-year-old; self-employed) said: “Sometimes I’m afraid if I quit, I wouldn't be able to supply for my children as much as I do now due to tiredness and depression”.

Table 1 summarizes the main themes and classes.

Table 1

Extracted themes and classes from interviews with drug-dependent fathers about the effects of drugs on their children

	Theme	Conceptual category
1	Emotional relation
2	Economic problems	A. Denying the effect of drug abuse on family's economic status.
		B. Feeling sad, hurt and guilty due to the effects of drugs on family costs and try to make up for it.
3	General relationship in the family (upbringing, monitoring)	The quality of family members’ relations with each other and with their drug-dependent father.
	.	The quality of interactions between the father and the children
	.	Handling and supervising children’s lives and academic status
4	The effects of drugs on children	Modeling their addicted father.
		Decreasing social relationships due to father’s addiction.
		Confronting their father due to his addiction.
		Feeling embarrassed and ashamed.
5	The effects of children on quitting	Deciding to quit for children’s future.
		Abandon quitting to provide for children.

Discussion

Family is the smallest but the most important social institution where the basic characteristics of a person are formed. Like any other social institution, family has a structure with different components and mutual interactions between the members. Paternal-filial relationship is among the most important mutual relationships. One of the major roles of fathers in Iranian families is to establish rules and regulations as well as to protect the rules that regulate interrelations. As children are expected to respect their parents in expressing verbal-behavioral and emotional domains, men are expected to have more control and avoid expressing their emotions or hugging their children particularly in their teens. Like in many other cultures, in Iranian culture, due to reasons such as attitude, stereotype, and cultural issues, fathers try not to show their attention toward the family status.26 It is true that there is no information about how addicted fathers behave with their children emotionally. However, the participants in this study were not satisfied with their relationship with their children and they believed the cause was drug consumption and/or its consequences.

The reason many addicted fathers are not able to have a friendly and good relationship with their children is their inability to communicate. Addiction causes individuals to lose various individual skills such as parental-filial communication. Mostly, drug-dependent parents are known as more cold tempered, more phlegmatic, more rejecting and more permissive than other parents. The issues addicted parents are faced with are feeling ashamed and guilty toward the roles the society expects from them.17,27 The economic role of a father in Iranian family is an important and prominent role. Fathers are always considered as the manifestation of activity and moneymaking. On the other hand, fathers also have some expectations from family members. They monitor house affairs and behaviors of children. However, in families with an addicted father, moneymaking problems, as well as disturbed mutual expectations, rights and duties are seen. Therefore, the father's authority, dignity and power are affected.

Secrecy and anxiety usually are the dominant behaviors of addicted fathers. They have a kind of excitement, concern and justification in their speech. In these types of families, mutual respect and kindness would be eliminated inside the family system and incompatibility rate among family members would increase. These behaviors would gradually damage the familial relationships and social interactions so that the mother and the children feel unsecure and uncomfortable in conversations with the father present. Therefore, in social relations of families with addicted fathers, kindness and love would be replaced by violence. Members of such families have very little familiarity with their relatives and acquaintances and in they feel embarrassed and ashamed rather than comfort and pride when the father is present as social occasions.

Many parents who use substances are informed about the negative effects of drugs on their children and somehow need support and help; some however, deny the facts.28 Denial is the most common pattern of these families. Severity of aggression, abuse, emotional explosion, home escaping, late and delayed returning home and abnormal sexual activities of children and adolescents are denied by addicted parents. Children would learn to deny their parents’ addiction and parents also ignore behavioral and emotional problems of children which are the reflection of their own addiction.

Kroll et al. revealed that the major problems of these children who are raised with these parents will remain hidden.1 Children, much earlier than parents imagine, would know about their parents’ addiction; its concept may not be clear though. However, parents rarely clarify this issue to their children.2,29,30

Many parents are concerned about damaging their reputation among their children, their probable angriness, and their urge to withdraw drugs. In contrast, many parents do not know how to talk about it with their children. However, they would not talk even when they have the chance. Hogan showed that many parents believe secrecy about the addiction issue is a way to immunize and protect their children from bigger complications of drug use.30

Conclusion

The family and familial relations of the addicts can be effective in encouraging them to continue their treatment. Neglecting parental duties is one of the issues that can ruin the quantity and quality of relations inside the family. Family members should learn to have more positive interactions with each other, support each other more and consider the neglected cases. However, justification and education alone would not lead to achievement of these objectives. Psychotherapy methods should also be used. Therefore, in treatment programs of addicts, considering family therapy is of high importance. Although studies have shown that short-term interventions of parents can improve developmental status of children,31 in many addicted parents, children have a motivational and incentive role for withdrawal of parents.21,32 According to the family function in Iran, children and family communications are expected to affect the decision for withdrawal and its continuation. Therefore, emphasis on the role of family interactions, quality of relationships with family especially with children, the quality of conflicting emotions, as well as the drug-dependent's parental feelings such as shame, embarrassment and inability is recommended in treatment programs for drug addicts. Obviously, this requires a substantial and long-term planning in addition to conventional therapies for substance abuse treatment.