The results corroborate previous research suggesting that COAs are not a homogeneous group. Rather, in both studies we found five distinct personality patterns in adolescent and adult COAs, four of which showed strong similarities across the two age-groups. The subtypes identified were similar to, but non-overlapping with, personality subtypes previously identified in prior work with the SWAP (Westen, Dutra, & Shedler, 2005
; Westen & Shedler, 2007
). The emergence of non-overlapping subtypes with significantly different external correlates than a comparison group supports the implication that these personality subtypes are unique to adolescent and adult children of alcoholics.
Among adolescents, the first subtype is Angry/Externalizing
. These adolescents show psychopathic features such as taking advantage of others, expressing little empathy, and appearing impervious to consequences. These characteristics have been associated with conduct problems at a younger age of onset (Wooten, Frick, Shelton, & Silverthorn, 1997
). Patients who matched this profile also tended to be deceitful, manipulative, angry, impulsive, and critical. As expected, these adolescents showed significantly higher rates of substance abuse disorder and antisocial personality disorder. In addition, adolescents who matched this prototype showed poor global adaptive functioning, poor school functioning, and an adverse childhood environment, childhood attachment disruption, physical abuse, childhood psychopathy, and a family history of criminality. The antisocial and delinquent nature of adolescents in this subtype is quite similar to those described in Wegscheider’s (1981)
clinical descriptions of ‘The Scapegoat’.
Adolescents in the Awkward/Inhibited
subtype showed social deficits and internalizing problems. These adolescents have a tendency to be passive, avoidant, depressed, and may fear rejection or abandonment. Our hypothesis was supported in that they also showed the highest rates of avoidant personality disorder and poor school functioning. Adolescents in this subtype resemble Wegscheider’s (1981)
The third adolescent personality subtype was Hyperconscientious/High-functioning. This subtype includes a range of healthy attributes such as a tendency to be conscientious, responsible, articulate, empathic, and able to respond to humor; however, this group also includes variables associated with negative affectivity, such as a tendency to feel guilty, to be self-critical, and to expect themselves to be perfect. As expected, the Hyperconscientious/High-functioning adolescents were associated with high global adaptive functioning, school functioning, and a negative association with most developmental and familial risk factors.
The fourth subgroup, Emotionally Dysregulated
, is strongly reminiscent of BPD, and has been identified in other studies of adults and adolescents using the SWAP (Westen et al., 2003
). Patients who match this prototype are characterized by intense emotional experiences and relational instability. As expected, these adolescents had high rates of BPD. High loadings on this factor were also associated with poor global adaptive functioning, suicide attempts and hospitalizations, an adverse childhood environment, and physical and sexual abuse.
The last adolescent subtype was Sexualized/Self-defeating. This subtype tends to abuse alcohol, act promiscuously and sexually seductive while becoming quickly attached in abusive relationships, act impulsive and engage in thrill-seeking behaviors, and engage in self-mutilating behavior. As expected, these adolescents showed high rates of substance abuse disorder and BPD, and were more likely to have been sexually abused.
Study 2 examined personality subtypes in a separate adult sample. Four of the five subtypes seem to be adult analogues of the adolescent subtypes. The first subtype, Inhibited, is similar to the Awkward/Inhibited adolescents, characterized by passive and constricted behaviors with feelings of guilt, depression, and anxiety. As expected, these adults had the highest rates of generalized anxiety disorder.
The High-functioning adults were similar to the Hyperconscientious/High-functioning adolescents, showing healthy attributes such as a tendency to be conscientious, responsible, and empathic. The pathological features of guilt and perfectionism found in the adolescent subtype appear less frequently in the adult subtype. A possible hypothesis for this change might be that adults were able to work out some of their conflicts from adolescents by no longer living with the alcoholic parent. As expected, high loadings on the High-functioning Q-factor was associated with high global adaptive functioning and employment, and negatively associated with most developmental and familial risk factors.
The Externalizing adult subtype is very similar to the adolescent Angry/Externalizing subtype, with psychopathic features and a tendency to abuse alcohol. These adults fit the model of children of alcoholics who themselves become alcoholics. As expected, the extent to which patients matched this dimension predicted poor adaptive functioning, poor childhood attachment, childhood psychopathy, and a family history of criminality.
The Emotionally Dysregulated
subgroup is almost identical to the adolescent Emotionally Dysregulated subtype. Emotionally Dysregulated adults had the highest rates of major depression and BPD. High loadings on this Q-factor were associated with poor adaptive functioning, a poor childhood environment, sexual and physical abuse, and suicide, all of which have been found to be associated with BPD (Zanarini, 1997
Finally, the Reactive/Somatizing subtype tended to be sensitive and reactive to interpersonal conflicts, develop somatic symptoms in response to stress, ruminate on problems, hold grudges, and be critical, controlling, anxious, and angry. These adults also showed a significantly high rate of major depression. These adults diverged from the adolescent Sexualized/Self-defeating subtype. One hypothesis would be that some of the histrionic aspects of the adolescent subtype were expressed in adults through somatic symptoms. However, this hypothesis is speculative and deserves further research.
The study has several limitations. First, patients were included as part of a study of adolescent and adult personality pathology, and those with an alcoholic parent were identified by clinician report. A more accurate method to identify COAs would involve administering an assessment measure to the parent (i.e., SCID-II) to determine clinical levels of alcohol use. However, clinicians knew their patients on average 20 weeks, those who worked with adolescents are likely to have known the parents, and clinicians followed a highly conservative decision rule in answering developmental history questions, namely to check “absent” unless they were “certain.” Thus, our control groups were more likely to contain false negatives than our COA groups were to include false positives. Further, most prior research has been based on self-reports of parental alcohol use, which are unlikely to be more reliable. With respect to the representativeness of the sample, the identification of a high-functioning subgroup in both populations suggests that clinicians did indeed follow our directions to select patients with any degree of personality pathology, from relatively mild to relatively severe, although the percent of high-functioning patients in non-patients samples would likely be higher. Future research should attempt to replicate these findings using broader samples and better validated measures of parental substance use and abuse.
Second, we relied on a single informant (the treating clinician), which could potentially have led to biases in patient descriptions, although the fact that we found subtypes unknown to clinician-informants and that they predicted external criterion variables in predictable ways mitigates the extent to which such biases could have influenced the results. Nevertheless, future research should rely on data from multiple informants.
Third, relying on clinician report prohibited the collection of other important types of data, including laboratory measures of impulsivity or effortful control, neuroimaging data, or molecular genetic variables that might distinguish the groups (e.g., DAT1, SERT, MAOA). Thus, using a direct interview method in future research would allow for easier access to external correlates beyond those studied here.
Children of alcoholics are a heterogeneous, not homogeneous, group. While we cannot assume that parental alcoholism causes the identified subtypes, we can assume that research investigating COAs as a homogeneous group is inappropriate given that the heterogeneity is not random. It seems advisable to include personality subtyping in all research on children of alcoholics, given the clear heterogeneity within and across disorders that can be accounted for by them. A sample that mixes emotionally dysregulated, psychopathic, inhibited, and high-functioning adolescents and adults is likely to yield findings that are difficult to generalize and may offset each other to show null findings (e.g., inhibited and psychopathic). The data presented here also have clinical implications, in pointing clinicians to different personality patterns they are likely to encounter in working with adolescent and adult COAs.