An Integrative Literature Review of Resilience in Adult Children of Alcoholics: Focusing on Operational Definitions and Moderators

Hee Kyung Kim; Yoonwoo Ko

doi:10.12934/jkpmhn.2019.28.1.50

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Kim and Ko: An Integrative Literature Review of Resilience in Adult Children of Alcoholics: Focusing on Operational Definitions and Moderators

Original Article

J Korean Acad Psychiatr Ment Health Nurs 2019;28(1):50-63.

Published online: 17 March 2019

DOI: https://doi.org/10.12934/jkpmhn.2019.28.1.50

An Integrative Literature Review of Resilience in Adult Children of Alcoholics: Focusing on Operational Definitions and Moderators

Hee Kyung Kim¹, Yoonwoo Ko²

¹Assistant Professor, Department of Nursing, Sangji University, Wonju, Korea

²Doctoral Student, Department of Nursing, Inha University, Incheon, Korea

Corresponding author: Kim, Hee Kyung https://orcid.org/0000-0002-3591-2507 Department of Nursing, Sangji University, 83 Sangjidae-gil, Wonju 26339, Korea. Tel: +82-33-738-7626, Fax: +82-33-738-7620, E-mail: kheekyung@sangji.ac.kr

Received 20 January 201920 February 2019 Accepted 12 March 2019

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

The objective of this study was to explore operational definitions and moderators of the resilience of adult children of alcoholics (ACOA) and its associated variables.

Methods

This integrative review was conducted based on a literature review method suggested by Whittemore and Knafl. Databases including PubMed, CINAHL, PsycINFO, and RISS were searched using the combinations of search terms such as; ‘adult children of alcoholics,’ ‘parental alcoholism,’ ‘resilience,’ and ‘children of alcoholics.’

Results

Seventeen studies were selected for this review. Findings of integrative reviews reported operational definitions for the resilience of ACOA and moderators. The operational definition of ACOA's resilience is: (1) having no behavioral and emotional problem, (2) meeting social and developmental expectancies, (3) having the ability to cope with adversity, (4) having high self-concept, and (5) having a meaningful relationship. In addition, the varying environmental moderators include family communication, qualities of caring environment, parental communication, parentification, and social support. Several moderators were identified as positive effect, self-esteem, alcohol-specific coping style, locus of control, spirituality, the image of God, and dyadic cohesion in marital communication.

Conclusion

Our study findings emphasize comprehensive understanding of diverse definition of resilience and moderators in developing nursing interventions to promote resilience in ACOA.

Keywords: Resilience, Psychological, Adult children, Alcoholism, Review

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Figure 1.

Flow diagram of study selection.

Figure 2.

Operational definition of adult children of alcoholics (ACOA)' resilience.

Table 1.

Characteristics of Selected Studies

Authors (year)/Country	Parental alcoholism assesses	Design	TP/mean age/sample size	Independent variables	Dependent variables
Haverfield et al. (2017) [23] /USA	Alcohol use disorder	Longitudinal & quantitative	COA/14.80/30 Parents/46.62/30	Parental communication of responsiveness; control	Adolescent emotion regulation; adolescent impulsivity
Haverfield et al. (2016) [27] /USA	3-items of self-reporting questions	Cross-sectional & quantitative	ACOA/47.96 /622	Topic avoidance about alcoholism; 3 types stigma	Resilience; depression; self-esteem
Haverfield et al. (2016) [27] /USA				covariates
Drapkin et al. (2015) [7] /USA	SMST	Cross-sectional &	ACOA/19.20	Alcohol-specific coping styles	Psychosocial functioning:
Drapkin et al. (2015) [7] /USA		quantitative	/465		depression, life events, alcohol problem, and parental contact
Lee et al. (2013) [6] /South Korea	CAST-K	Cross-sectional & quantitative	ACOA/no report/415	Parent and peer attachment; god image	Resilience
Kim et al. (2011) [5] /South Korea	CAST-K	Cross-sectional & quantitative	ACOA/21.20 /459	Social support; self-esteem; family adaptability and	Resilience
Kim et al. (2011) [5] /South Korea				cohesion
Heitzeg et al. (2008) [18] /USA	Questions extracted from	Cross-sectional &	COA/17.80/28	AUD risk; externalizing	Brain response (neural
	an ongoing longitudinal study of families with	l quantitative		behavior	activation)
	parental alcoholism
Kim (2008) [26] /South Korea	CAST-K	Cross-sectional &	ACOA/18~27	Locus of control; spirituality;	Student adaptation to college
Kim (2008) [26] /South Korea		quantitative	(range)/820	parental attachment; social support
Lee et al. (2008) [4] /USA	CAST-K	Cross-sectional & quantitative	COA/14.40/482	Parental problem drinking; internalizing behaviors;	Adolescent's resilience
Lee et al. (2008) [4] /USA				eternalizing behaviors
Hall (2007) [24] /USA	CAST-6	Cross-sectional and	ACOA/20~44	Parental alcohol problem;	Coping responses; self-esteem
		multi-method (qualitative &	(median age) /128	kinship social support
		quantitative)
Hall et al. (2007) [21] /USA	CAST	Cross-sectional &	ACOA/20 (median	Multiple stressor; traumatic	Subsequent adjustment;
Hall et al. (2007) [21] /USA		quantitative	age) /354	symptom	resiliency
Barrera et al. (2004) [22] /USA	SMST	Cross-sectional & quantitative	COA/12.94/234	Ethnicity; gender	Parents' problem drinking; conduct problems; depression;
Barrera et al. (2004) [22] /USA					anxiety; psychological distress composite
Carle et al. (2004) [25] /USA	Computerized version of the DIS (based on	Longitudinal & quantitative	COA/14.20/417	Internalizing symptom; positive affect	Competence (social, conduct/ rule abiding, and academic)
Carle et al. (2004) [25] /USA	DSM-III)
Godsall et al. (2004) [20] /USA	CAST	Cross-sectional &	COA/14.10/377	Parental alcohol misuse;	Self-concept
Godsall et al. (2004) [20] /USA		quantitative		parentification
Werner et al. (2004) [19] /USA	) Longitudinal study	Longitudinal &	ACOA/30~32	Locus of control; emotionality,	Coping problem; the divorced,
	follow up questions	quantitative	(range of median age)	activity, and sociability; temperament; relationship;	criminal record; mental and chronic health problems;
			/65	happy or satisfied with life	dying in young adulthood
Jennison et al. (1997) [8] /USA	Questions on familial	Longitudinal &	ACOA/27~35	Dyadic cohesion in marital	High risk drinking
Jennison et al. (1997) [8] /USA	alcoholism	quantitative	(range)/4,235	communication; family history of parental alcoholism
Hinz (1990) [9] /USA	Single question asking whether a parent had or	r Cross-sectional & quantitative	ACOA/23.90 /419	Parental alcohol problem; gender; age	Interpersonal anxiety; depression/dysphoria;
Hinz (1990) [9] /USA	currently have a problem with alcohol use				academic skills; family problems
Werner (1986) [11] /USA	Interview with primary caretaker	Longitudinal & quantitative	COA/2~18 (range)/49	Pre-perinatal stress; quality of the caregiving environment;	Physical, cognitive, and social development
				socioeconomic status; educational stimulation;
				emotional support

ACOA=adult children of alcoholics; AUD=alcohol use disorder; CAST=Children of Alcoholics Screening Test; CAST-K=The Korean version of the Children of Alcoholics Screening Test; COA=children of alcoholics; DIS=Diagnostic Interview Schedule; DSM-III=Diagnostic and Statistical Manual of Mental Disorders III; SMST=Short Michigan Alcoholism Screening Test.

Table 2.

The Quality Appraisal of the Selected Studies

Authors (year)	Summary of the study findings	Measurements	Analysis	CI	Quality appraisal
Haverfield et al. (2017) [23]	Parental responsiveness may be more important for promoting adolescents' emotion regulation than it is for tempering their behavioral impulsivity.	Responsiveness and control (parent); Emotion regulation; Impulsive behavior	Pearson correlation; hierarchical linear regression	N	4
Haverfield et al. (2016) [27]	Positive aspect stigma as a unique form of stigma that reflects the ways in which individuals are strengthened from having suffered hardship.	Topic avoidance about alcohol(4 questions); stigma scale/CES-D(depression scale); self-esteem/resilience scale	Pearson correlation; regression	N	4
Drapkin et al. (2015) [7]	ACOA are not necessarily adversely affected by having a parent with an AUD and the potential of alcohol-specific coping strategies to predict psychosocial outcomes in college non-ACOA.	AUDIT; BDI-II; LES; CQ	Factor analysis; MANOVA; t-test; chi-squared statistics; Pearson correlation	N	4
Lee et al. (2013) [6]	ACOA group showed lower significance for attachment to parents, 'acceptance' (sub-variables of God's image) than non-ACOA group.	IPPA; Resilience scale; GIA	Pearson correlation; t-test; regression	N	3
Kim et al. (2011) [5]	The results of the study show that self-esteem and social support are important determinants of resilience in ACOA.	MSPSS (social support); self-esteem; FACES	T-test/chi-squared statistics; pearson correlation; ANOVA/regression	N	3.5
Heitzeg et al. (2008) [18]	The pattern observed in the resilient COA represents an active emotional monitoring function, which may be a protective factor in this group.	YSR; fMRI task; MRI–Brain blood oxygen level dependent	MANOVA; ANCOVA; Pearson correlation	N	3
Kim (2008) [26]	Parent's alcoholism carries negative effects on four dimensions of college adjustment and the moderators buffering between parent's alcoholism and college adjustment are spirituality, attachment.	Rotter's locus of control; INSPIRIT; IPPA; MSPSS (social support)	T-test/VIF; Pearson correlation; Hierarchical multiple regression	N	4
Lee et al. (2008) [4]	Resilience was negatively associated with externalizing and internalizing behaviors.	Hong's problem behavior profiles; adolescent resilience scale	Pearson correlation; hierarchical regression	N	4
Hall (2007) [24]	Coping styles appear to be a significant factor in determining the effects of ACOA's self-esteem and the kin network is protective factor.	Self-esteem; CRI; kinship social support scale	T-test; Pearson correlation; regression	N	4
Hall et al. (2007) [21]	ACOA who experienced further traumatic events had more difficulty demonstrating and taking the initiative in coping with life stressors.	TSI; HRS	MANOVA; ANOVA	N	4
Barrera et al. (2004) [22]	This study adds to the evidence that adolescent girls show greater vulnerability to life stress than boys.	MESA; CBCL; CDI; RCMAS; YSR	T-test/Chi-squared statistics; Pearson correlation; regression	N	4
Carle et al. (2004) [25]	Efforts to encourage competent performance in ACOA should be associated with decreased internalizing symptom and increased positive affect.	CBCL; positive and negative affect schedule competence scale & range achievement test	Pearson correlation; regression	N	4
Godsall et al. (2004) [20]	Parentification plays either a mediating or primary role in children's self-concept.	Piers-Harris Self-concept scale for children; PQ-Y	Correlation; hierarchical regression	N	3
Werner et al. (2004) [19]	Our research shows that protection factors affect the process of life for children growing up under vulnerable conditions. And except for the most persistent disadvantages, all propose a perception of the tendency to move children toward normal adult development.	Caregivers' perceptions of the children's temperamental characteristics; California psychological inventory; Nowicki Locus of control scale; EAS; temperament survey for adults	Frequencies and percentages	N	3.5
Jennison et al. (1997) [8]	Positive interpersonal communication patterns effectively moderated the direct relationship that existed between parental alcoholism and subsequent risk behavior for women ACOA.	Self-reported frequency and quantity estimates; DAS; MCS	Regression	N	3
Hinz (1990) [9]	College student ACOA may be functioning well academically they represent a population at risk for developing other psychological problems.	Eight hundred need assessment (19 personal problem areas)	Chi-squared statistics; factor analysis; MANOVA	N	4
Werner (1986) [11]	Children of alcoholics who developed no serious coping problems by age 18 differed from those who did in characteristics of temperament, communication skills, self-concept and locus of control.	Assessment of the home environment; Cattell infant intelligence test; PMA; CPI; SCAT	Discriminant analysis	N	3

ACOA=adult children of alcoholics; AUD=alcohol use disorder; AUDIT=Alcohol Use Disorder Identification Test; BDI-II=Beck Depression Inventory-2; CBCL=Child Behavior Checklist; CDI=Children's Depression Inventory; CES-D=Center for Epidemiologic Studies Depression Scale; CI=confidence interval; COA=children of alcoholics; CPI=California Psychological Inventory; CQ=Coping Questionnaire; CRI=Coping Responses Inventory; DAS=Dyadic Adjustment Scale; EAS=Emotionality Activity and Sociability; FACES=Family Adaptability and Cohesion Evaluation Scale; fMRI=Functional Magnetic Resonance Imaging; GIA=God Image Assessment; HRS=Hall Resiliency Scale; INSPIRIT=Index of Core Spiritual Experiences; IPPA=Inventory of Parent and Peer Attachment; LES=Life Experience Survey; MCS=Marital Communication Scale; MESA=Multicultural Events Schedule for Adolescents; MSPSS=Multidimensional Scale of Perceived Social Support; N=no report; PMA=Primary Mental Abilities Test; PQ-Y=Parentification Questionnaire-Youth; RCMAS=Revised Children's Manifest Anxiety Scale; SCAT=School and College Ability Test; TSI=Trauma Symptom Inventory; YSR=youth self-report.

Table 3.

Environmental and Personal Moderators Targeted for Intervention

Items	Modifiable factors	Non-modifiable factors
Environmental moderators	Family communication: topic avoidance, stigma; qualities of caring environment; parental communication: responsiveness and control; parentification; social support	Multiple stressors during childhood; traumatic experience; family adaptability and cohesion; kinship support: non-alcoholics; parents, sibling, grandparents, and cousin; mother's alcoholism
Personal moderators	Positive affect: interest, strong, enthusiastic, inspired, and active; self-esteem; alcohol specific coping style; locus of control; spirituality; the image of god; dyadic cohesion in marital communication	Attachment; ethnicity; gender; age

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