Frequency of Psychiatric Disorders in Children of Opioid or Methamphetamine-Dependent Patients.

BACKGROUND: Addiction is one of the main problems of human societies, which is more common in developing countries. In addition, it causes to personal and social problems and family problem. The aim of this study was to examine the prevalence of psychiatric disorders in children 5-15 years old of opioid or methamphetamine dependence patients.
METHODS: For this study, three groups including: (1) children of parents addicted to opium, (2) children of parents addicted to methamphetamine, and (3) control group were examined. Child symptom inventory-4 (CSI-4) questionnaires completed by non-hospitalized guardian and control group; then make interviews with the children by the Kiddie-schedule for affective disorders and schizophrenia (K-SADS). Data were analyzed by chi-square test and ANOVA.
FINDINGS: Survey showed that the frequency of attention deficit hyperactivity disorder (ADHD), major depressive disorder (MDD), generalized anxiety disorder, obsessive-compulsive disorder, specific phobia (SP), and separation anxiety disorder in children of addicted parents were more than a non-addicted parent. However, there was no significant difference between the two groups in the frequency of conduct disorder, social phobia, and oppositional defiant disorders (ODDs).
CONCLUSION: Parental addiction can lead to an increase in some psychiatric disorders in the children. Therefore follow-up, early diagnosis, treatment, and prevention of these disorders in children of the drug-dependent parent are necessary to reduce health costs and improve the health system.

Introduction

Addiction has a long history in Iran and is one of the social problems, which causes psychological and social conflicts for addicts and their families.1 Children of addicted parents show affective, cognitive, as well as social experiences and behavioral problems. Clinical experiences of children indicate that most of their behavioral problems and affective disorders are closely associated with the family in which they live. This problem is related to the family structure and system on the one hand and to a specific understanding of each child from his or her family on the other hand.2 In one study, the prevalence of drug use disorders by parents was 9 and 8% for children of less than 5 years old and between 5 and 18 years old, respectively. Furthermore, this study demonstrated that drug use disorder is the most common psychiatric disorder among the parents of less than 12-year-old children.3

Opiates and stimulants are the two groups of illegal materials which are different from each other in terms of chemical structure, physical and psychological effects, and potential risk for drug abusers.4 The family and physical environments which are provided by the parents consuming methamphetamine are mostly turbulent, neglecting, and misconducting. Moreover, they face children with delinquent behaviors and dangerous substances.5 According to the survey of Haight et al.6 the children of methamphetamine using parents suffer from more affective problems, post-traumatic stress disorder (PTSD) symptoms, and behavioral problems. In the study of Clark et al.7 children of drug-dependent parents showed increased risk of psychopathologies such as conduct disorder, attention deficit hyperactivity disorder (ADHD), depression, and anxiety disorders.

Since children’s psychiatric disorders usually remain up to their adulthood,8,9 it is essential to identify these children and take preventive measures to reduce health costs and promote the health system.10 To prevent the development of substance use disorders and other psychopathologies in children, it is important to eliminate the causative forces from the environment and strengthen coping skills in children. Therefore, the first step in the development of better intervention and prevention strategies is to know the important factors associated with poor psychosocial compliance in the children of parents with substance abuse.11

Since few studies have been done on the prevalence of psychiatric disorders among the children of drug-dependent patients in Iran and these works have examined a number of psychiatric disorders using questionnaires,12-15 this study is aimed to investigate a wider range of psychiatric disorders in children and diagnose based on structured clinical interview in three groups of drug-dependent parents, methamphetamine-using parents, and control. The results of this study and identification of the problems of these children and adolescents can be the beginning for future works in terms of prevention and therapeutic interventions for parents and children.

Methods

This study was a cross-sectional analysis. Due to time limitations of the study within 14 months, the case group consisted of 80 children of drug-dependent and 40 children of methamphetamine using parents admitted to a psychiatric hospital who were selected using convenience sampling method. The demographic characteristics form was completed for all the patients addicted to drugs or methamphetamine at the time of admission, and then the study’s goal was briefly explained to the family of the married patients who had at least one child between 5 and 15 years old over the phone. After obtaining the consent of the non-hospitalized guardian, the meeting sessions were arranged to complete child symptom inventory (CSI)16 by them and make interviews with the children (in the case the criteria for each disorder exceeded the cut-off point), a psychiatric interview was conducted with the child based on kiddie-schedule for affective disorders and schizophrenia (K-SADS).17 The control group consisted of 80 children of the married staff of university hospitals who had at least one child between 5 and 15 years old. CSI screening form was completed by the parents, and the meeting sessions were arranged to make interviews with the children after explaining the study’s method and objectives and ensuring lack of addiction according to parents’ statements.

The exclusion criteria included diagnosis of mental retardation, primary psychotic disorder, primary bipolar disorder without substance dependence, and diagnosis of serious neurological diseases (including epilepsy) in all three groups of parents (control, opium, and methamphetamine) and the diagnosis of mental retardation and serious neurologic disease among their children.

Screening based on CSI questionnaire

The retest reliability coefficients or test-retest for 11 disorders; from the minimum (0.29) for social phobia disorder to the maximum (0.76) for estimated conduct disorder, all of which are significant at 0.05 and 0.01, except social phobia disorder. Although some CSI disorders, such as hyperactivity disorder (HD), major depressive disorder (MDD), and specific phobia (SP), have lower correlation coefficients than other disorders, in general, these results confirm the validity and reliability of CSI-4. The results of investigating the opinions and judgments of 9 psychiatrists confirm the consistency and appropriateness of CSI-4 content with the field it is measuring and approve that this questionnaire has enough validity. In ADHD, the cut-off point 9 with the sensitivity of 0.91 and specificity of 0.97 is considered the best score to separate the children.16

K-SADS based interview

A semi-structured clinical interview to assess psychiatric disorders with the inter-rater reliability for oppositional defiant disorder (ODD) and ADHD as 0.69 and test-retest reliability of 0.8, 0.67, and 0.56 for ADHD, ODD, and tic disorders, respectively. Its Persian edition is the validity and reliability interview tool for assessing and diagnosing psychiatric disorders in children and adolescents.17

After describing the background variables in the three groups, SPSS software (version 17, SPSS Inc., Chicago, IL, USA) was used to analyze quantitative data by ANOVA statistical test. Furthermore, qualitative data analysis was done using Fisher’s exact test and Pearson chi-square statistical test in the cases where the sample size of each group was less than and more than five subjects, respectively. Finally, the necessary results were obtained for the research hypotheses.

Results

In this study, 200 children were entered into the study after investigating 817 drug-and methamphetamine-dependent persons, excluding single and divorced persons, and considering other exclusion criteria for children and parents. The case group consisted of 80 and 40 children of drug-and methamphetamine-dependent parents, respectively, and the control group consisted of 80 children of non-addicted parents. The demographic and descriptive characteristics of these three groups are presented in table 1.

Table 1

Demographic characteristics

Demographic	Groups			P
	Opium	Methamphetamine	Control
Mean age of addicted parents (year)	40.09	40.40	-	0.30
Boys [n (%)]	42 (52.5)	21 (25.5)	33 (41.3)	< 0.01
Mean age of children (year)	10.44	10.63	9.13	0.20

Based on CSI-4 questionnaire, the frequency of psychiatric disorders (ADHD, conduct disorder, autism, depression, MDD, ODD, generalized anxiety disorder, social phobia, obsessive-compulsive disorder, SP, and separation anxiety disorder) showed no significant difference between the three groups of control and children with parents addicted to opium and stimulants.

After conducting interviews with the children, the frequency of none of the assessed disorders was significant in the comparative study of three groups of children with parents addicted to opium and methamphetamine, as well as the control. Although the frequency of generalized anxiety disorder, social phobia, obsessive-compulsive disorder, SP, and separation anxiety disorder was higher in the children of opium-dependent parents, this difference was not significant. The frequency of ODD was higher in the children of opium-dependent than methamphetamine dependence group and similar to the control group. The frequency of ADHD was higher in the children of methamphetamine-dependent than opium-dependent parents, as well as the control group. The frequency of conduct disorder was equal in the three groups.

In investigating the frequency of disorders in each group, ADHD had the highest frequency (12.5%) among the children of methamphetamine-dependent parents. Among the children of opium-dependent parents, maximum frequency was related to SP (10.0%) followed by ADHD (5.0%). In the control group, maximum frequency was related to SP (8.8%), ADHD (3.8%), and ODDs (3.8%), respectively.

Considering the low sample size of methamphetamine group (due to time limitation), comparing the frequency of disorders in the two groups of children with opium-and methamphetamine dependent parents were not sufficient for the analysis; therefore, these two groups were merged. After investigating two groups of children with drug-dependent parents and the control, the frequency of disorders was not significantly different between the two groups based on the questionnaire.

Based on the interviews with the children of drug-dependent parents and the control, 42 (35.0%) and 17 (21.2%) of parents had at least one psychiatric disorder, respectively, and the comparison of the two groups of children with drug-dependent parents and the control showed that the frequency of ADHD, generalized anxiety disorder, major depression, obsessive-compulsive disorder, SP, and separation anxiety disorder was statistically significant between the two groups (P < 0.05). The frequency of the conduct, oppositional defiant, and social anxiety disorders was a higher in the children of drug-dependent parents, but this difference was not statistically significant (Table 2).

Table 2

Comparing frequency of disorders in drug-dependent and control groups based on interviews

Interview-based disorder	Drug-dependent group [n (%)]	Control group [n (%)]	P	OD
ADHD	9 (7.5)	3 (3.8)	0.03	2
Conduct disorder	2 (1.7)	1 (1.3)	0.68	1.3
MDD	4 (3.3)	1 (1.3)	0.05	2.7
ODD	4 (3.3)	3 (3.8)	0.26	0.8
Generalized anxiety disorder	11 (2.5)	0 (0.0)	0.02	1.6
SP	11 (9.2)	7 (8.8)	0.04	1
Disorder social phobia	1 (0.8)	0 (0.0)	0.48	1.6
Obsessive compulsive disorder	3 (2.5)	0 (0.0)	0.02	1.684
Separation anxiety disorder	5 (4.2)	2 (2.5)	0.04	1.696

ADHD: Attention deficit hyperactivity disorder; MDD: Major depressive disorder; ODD: Oppositional defiant disorder; SP: Specific phobia; OD: Odds ratio

In addition, in the survey conducted based on the gender of children, the two groups of drug-dependent parents and control had no significant difference. In the group of children with addicted parents, ADHD was higher among boys, which was statistically significant (P = 0.01), while there was no significant difference between the two genders in the control group. MD disorder was higher among the girls in the groups of children with addicted parents, and this difference was significant (P = 0.05), while in the control group, there was no significant difference between the two genders. SP disorder was higher in both groups among the girls, and the difference was significant (P = 0.02). Other disorders investigated between two genders showed no significant difference, but in the drug-dependent group, the frequency of conduct and separation anxiety disorders was higher among the boys and, in the control group, oppositional defiant and separation anxiety disorders were higher among the girls (Table 3).

Table 3

Gender separation of each disorder in the children of drug-dependent parents and control group

Interview-based disorder	Drug-dependent group (%)		P	Control group (%)		P
	Boy	Girl		Boy	Girl
ADHD	8 (88.9)	1 (11.1)	0.01	0 (0)	3 (100)	0.19
Conduct disorder	2 (100)	0 (0)	0.25	1 (100)	0 (0)	0.41
MDD	0 (0)	4 (100)	0.05	1 (100)	0 (0)	0.41
ODD	2 (50)	2 (50)	0.67	0 (0)	3 (100)	0.19
Generalized anxiety disorder	1 (33.3)	2 (66.7)	0.48	0 (0)	0	-
SP	2 (18.2)	9 (81.8)	0.02	0 (0)	7 (100)	0.02
Disorder social phobia	0 (0)	1 (100)	0.49	0 (0)	0 (0)	-
Obsessive compulsive disorder	1 (33.3)	2 (66.7)	0.48	0 (0)	0 (0)	-
Separation anxiety disorder	4 (80)	1 (20)	0.19	0 (0)	2 (100)	0.34

ADHD: Attention deficit hyperactivity disorder; MDD: Major depressive disorder; ODD: Oppositional defiant disorder; SP: Specific phobia

Discussion

For this study, 40.0% of the children investigated in the methamphetamine group had at least one case of psychiatric disorder. In this group, frequencies of ADHD and depression disorders were 12.5 and 5.0%, respectively, which was consistent with Messina’s findings on the use of methamphetamine by parents and the consequences faced by American children and families, in which 44.0% of the children referring for of mental health evaluation had at least one psychiatric disorder; these disorders included 20.0% adjustment disorder, 9.0% PTSD, 5.0% ODD, 5.0% ADHD, 5.0% developmental disability, and 2.0% depression.18 ADHD is one of the most common disorders in children and adolescents,19 which is associated with physical, psychological, and economic problems in adulthood.20

In investigating disorders among the group of children with opium-dependent parents, maximum frequency was related to SP (10.0%) and then ADHD (5.0%). Studies have shown that children of parents with substance dependency have behavioral characteristics and temperamental style, which makes them prone to incompatibility in the future.21 Life events have often a causative role in the onset of phobia. In general terms, life experiences that seriously threaten health and safety are the factors that trigger or aggravate anxiety disorders.22

Moreover, the results showed that ADHD was higher in the group of children with methamphetamine-dependent parents than other two groups; however, there was no statistically significant difference. In the study of LaGasse et al.23 that was performed to assess children born to methamphetamine using mothers and the control group, children were assessed at the ages of 3 and 5 years old. Confrontation with methamphetamine was related to increased affective reactions, anxiety and depression problems at both ages, and ADHD and externalizing disorders at the age of 5. Although the ages studied in this study were different from the present work, they were consistent considering higher frequency of ADHD.

After the interview, in the comparative study of the two groups of children with drug-dependent parents and the control group, significant difference was observed in the former group in terms of the frequency of the following disorders: ADHD (7.5 vs. 3.8%), major depression (3.3 vs. 1.3%), generalized anxiety disorder (2.5 vs. 0%), obsessive-compulsive disorder (2.5 vs. 0%), specific phobia (9.2 vs. 8.8%), and separation anxiety disorder (4.2 vs. 2.5%). In addition, although no significant difference was observed in the frequency of the conduct, social anxiety, and ODDs between the two groups, the frequency of these disorders was higher in the children of drug-dependent parents than the healthy parents.

In the study by Eslami et al. that was conducted in Kerman, Iran, to compare disruptive behavior disorders among 8-14 years old children of opium and heroin-dependent parents with the control group using child behavior checklist questionnaire, there was no significant difference between the two groups in terms of scales of coping behaviors and conduct problems.12 This issue was consistent with the results of the present work. In the study by Parvaresh et al.13 which was conducted in Kerman using Rutter behavioral questionnaire, frequency of ADHD was higher in the group of children from the parents with bipolar disorder and drug-dependent parents than the children of healthy parents, which demonstrated a significant difference. Although the frequency of conduct disorder was higher than the children of healthy parents, it was not significant.

In the study by Taiebi-Masule,14 the mean of behavioral disorders of the children with addicted parents was higher than the normal children using Rutter’s child behavior disorders (teacher’s evaluation form). Furthermore, these children had more suffering from anxiety-depression, aggression-hyperactivity, social conflict, anti-social behavior, and attention deficit. Since the frequency of anxiety, depression and hyperactivity was higher, this study was consistent with the findings of the present work. Chassin et al.24 suggested that children of drug-dependent parents live in the environment with permanent stress, have lower self-confidence, and suffer more from depression than children with independent parents, which was in line with the results of this study.

Moreover in the study by Raiisi et al.,15 adolescents of addicted fathers had more behavioral-affective disorders than those with non-addicted fathers, and there was significant difference in the interpersonal disorder and depression in adolescents15,25,26 with addicted parents, which was consistent with the current study’s results in terms of depression. Data analyses showed that, in the group of drug-dependent parents, there was significant difference between the ratio of boys to girls suffering from ADHD and its prevalence was higher among boys. However, no significant difference was found between the genders in the control group, which was consistent with the results by Clark et al.7 showing that the frequency of ADHD was higher in boys than girls. In general, the rate of ADHD in school-aged children was reported as 7-8%. ADHD was 2 to 9 times more prevalent among boys than girls and in children than adolescents.27

Further in the group of children with addicted parents, MDD was higher in the girls with significant difference, while there was no significant difference between the genders in the control group. Moreover, in the study by Gross and McCaul, the frequency of depression was higher among the girls with addicted parents than the boys, which was consistent with the result of the present study.28 The prevalence of major depression was 2-3 times higher in female than male adolescents. Family factors, such as parental addiction, marital problems, parent-child problems, and reduced family cohesion, increased the likelihood of depression and affected its recurrence.29

In this study, SP disorder was higher among girls than boys in the children with drug-dependent parents and the control group and both groups showed significance difference in terms of gender. In the study by Drucker et al.30 in which 5-13 years old children of addicted parents were assessed in terms of depression and anxiety, the overall scores of anxiety and depression were the same for boys and girls. The findings of the current study were consistent with those of this study in terms of more frequency of depression in girls with drug addicted parents. But, in the present study, the frequency of depression was higher among girls with drug-dependent parents, which could be caused by cultural differences in Iran compared with this study. On the other hand, in study of Drucker et al.30, diagnosis was solely based on a questionnaire and clinical interview was not conducted with children.

Since we did not find any interview-based comparative study between two groups of children with parents addicted to drugs and the control group in our search among the previous studies and it is the first study in this regard, it was impossible to compare the frequency of children with psychiatric disorders between two groups with other studies. Another limitation of this study was lack of trust in expressing the type of substance used by people or responding to the questions in the questionnaire, which was due to the fear of disclosure. This issue was more evident in the control group; so, attempts were made to provide the assurance in this respect by explaining the study’s goals and importance of the issue to the participants.

In spite of high hospital admission of stimulant-dependent patients, low number of married persons and parents with children in this age group compared with those addicted to drugs was unpredictable. This matter was revealed during the research and, within the 14 months research period, the sample size of the methamphetamine group was small due to time constraints.

Since the mean age of parents addicted to drugs and stimulants was similar, it can be inferred that stimulants are more likely to affect family stability, performance and, consequently, number of children than opioids. Larger sample size in future studies would help understand the possible difference of this issue as well as frequency and types of disorders in the children of two groups of drug and methamphetamine-dependent parents. Considering the point that the mental health of children with addicted people can indicate harm reduction in therapeutic interventions, conservative treatment, and rehabilitation of addicted people; it is necessary to do further research with larger sample size and longer duration.

Conclusion

According to the results of this research and higher frequency of some psychiatric disorders in the children of drug-dependent patients; it is necessary to pay particular attention to these families in terms of child protection, early diagnosis of psychiatric disorders, early intervention, and treatment.