Preventing the Intergenerational Transmission of Substance Use Disorder: Lessons Learned From Developmental Science on Parenting and Adolescence

Abstract

In 2019, approximately 21 million children in the United States lived with a parent who misused substances, and over 2 million lived with a parent with a substance use disorder (SUD). While parents with SUD are often invested in preventing intergenerational transmission of substance use, there has been little research devoted to addressing this challenge particularly among parents of adolescents. In this narrative review of existing literature, we take a bioecological perspective that includes individual, interpersonal, and societal factors that offer opportunities for intervention. Specifically, we suggest that there is a need to consider key developmental tasks of adolescence—establishing a sense of autonomy, developing personal identity, and cultivating meaning and purpose—in tandem with effective parenting practices and societal considerations to prevent the intergenerational transmission of substance misuse and use disorders among adolescents when a parent has SUD. We offer specific research recommendations and strategies for leveraging impactful preventative interventions.

Keywords

adolescence parenting substance use disorder intergenerational transmission intervention policy education

Introduction

In 2023, 19 million children lived with at least 1 parent with SUD as defined by Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition; DSM-5).¹ Research and interventions for supporting parents with SUD is mostly focused on parents of infants and young children.^2-4 However, intervening to support parents with SUD when their child is an adolescent—when initiation of substance use may begin and psychopathology may emerge—is important for preventing intergenerational transmission.⁵ The purpose of this article is to emphasize opportunities to prevent intergenerational transmission of SUD and substance misuse broadly among adolescent children of parents with SUD. We organize our review using a bioecological model that includes individual, interpersonal, and societal factors that offer opportunities for intervention.

Bioecological Perspective

We consider a bioecological model focused on the adolescent and features of the parent-adolescent dyad.⁶ In Bronfenbrenner’s Ecological Model,⁷ a child’s development is shaped by the interplay of societal, interpersonal, and individual factors. Societal factors include culture, socio-political environment, and socioeconomic context. Interpersonal factors include the interactions between adolescent and parent. While peer and other relationships are important, this review focuses on the parent-adolescent relationship. At the center of the bioecological model is the individual.⁷ Key developmental tasks among adolescents include establishing a sense of autonomy, developing personal identity, building peer and intimate relationships, and cultivating meaning and purpose.

Individual Considerations

Beginning with puberty and ending with the achievement of independence, the time scale of adolescence is dependent on biological events (eg, puberty, brain development, etc.) and social context.⁸ What remains constant are the key tasks that underpin this developmental chapter: establishing a sense of autonomy and cultivating meaning and purpose. Adolescents also seek to understand and construct a sense of self,⁹ including a clear concept of their family context and history. These developmental processes are central motivators that underlie behavior among adolescents.^10-12

Autonomy can be broadly understood as achieving a sense of psychological freedom and authenticity or choice in decision making.^13,14 While autonomy has been linked to positive psychosocial outcomes for adolescents, those who have a parent with SUD may actually benefit from limits on autonomous decision making if they have previously had fewer boundaries.¹⁵ Thus, it is important to consider context when evaluating the generalizability of developmental tasks.

Adolescence is a time of heightened risk-taking in which substance use and other health-risking behaviors can be normative.¹⁶ Risk-taking is an expression of autonomy and independence and is not inherently a threat to well-being. Rather, providing opportunities for youth to engage in positive risk-taking has the potential to feed this developmental need.¹⁷ The Lifespan Wisdom Model posits that youth take risks and engage in sensation-seeking behavior to gain experiences and explore their environments.¹⁸ Increasing opportunities for adolescents to experience a sense of reward from healthy risk-taking or prosocial actions may positively alter behavioral trajectories and prevent or reduce substance use, while simultaneously promoting adolescent growth and well-being.^6,19,20

Emotion regulation is a facet of autonomy as an exertion of decision-making control. Strategies such as active coping, which is defined by orienting toward the stressor rather than avoiding the problem, become more readily accessible to adolescents as they mature.²¹ These strategies buffer against the development of avoidant, impulsive, and negative risk-taking behaviors, which are associated with substance use and thus may disrupt patterns of intergenerational transmission.²²

Throughout adolescence, youth question who they are and who they want to become, thereby developing a consistent and coherent sense of identity, meaning, and purpose.²³ Those who have a less stable sense of identity are at greater risk of engaging in substance use.²⁴ In contrast, a sense of purpose can protect against substance use among adolescents.^25,26 Parenting that affirms and accepts adolescent identity is associated with lower levels of substance use in emerging adulthood.²⁷

In addition to developmental tasks, adolescent cognition and genetic predisposition play a role in intergenerational transmission. Sociodemographic variables are the most predictive of substance use initiation even when compared to hormone levels, neurocognitive assessment, and structural neuroimaging.²⁸ However, while considering social interventions, it remains important to understand neurodevelopmental processes like cognitive control to intervene simultaneously on contextual and proximal factors.²⁹ Due in part to differential rates of cognitive maturation, the ability to prioritize long-term goals over short-term pleasure is often overpowered by the pursuit of emotionally charged rewards like social connection, which substance use may facilitate.^10-12,30 While adolescents’ developing brains are especially vulnerable to the effects of drug use and the possibility of addiction,³¹ they are also poised to benefit from positive changes in their relational environments.

Adolescents experience a confluence of biological and behavioral changes.³² Such developmental changes are, in part, driven by genetic factors passed on from parents.³³ Specifically, genetic effects account for about half of the variance in the prediction of SUD.^34,35 Parenting interventions that promote supportive and involved parenting can buffer genetic risk for substance use problems and disrupt intergenerational transmission.^36,37 Thus, while individual factors such as heritability are important to consider, social processes are unignorable in addressing intergenerational transmission.³⁸ Given the importance of the adolescent-parent relationship and the malleability of parenting practices, there is an opportunity to implement interventions that address parenting features predicting risk and nurture those that offset risk.

Interpersonal Considerations for Parent-Child Relationships

Vulnerability to early onset adolescent substance use emerges in part from processes within the family system.^39-41 Adolescents are particularly sensitive to social norms and witnessing parental substance use might normalize and provide a model for adolescents to use substances themselves.^4,39,42,43 Parenting behavior is a changeable mechanism of intergenerational transmission.^44-46 Parents can offer a consistent and nurturing parent-child relationship through parenting practices that include effective relationship building, clear expectations, and discipline. Parents can also model and scaffold emotion regulation skills.⁴⁷ Among adolescents whose parents have a history of cannabis use, engaging in active coping strategies, such as seeking information and working toward solutions, disrupt the intergenerational transmission of cannabis use.⁴⁸ These effective parenting practices provide an important foundation for adolescents to build healthy relationships and make safer, values-aligned decisions.^49-51

Many individuals in treatment are motivated to grow in their roles as parents. When interviewed, women who were in remission for stimulant use disorder expressed motivation to maintain structure, increase parenting knowledge, and disrupt cross-generational family dysfunction.⁵² Established protective factors, such as parental monitoring, parent-child relationship quality, parental support, and parental involvement can be promoted among parents in treatment and recovery.⁵³

A systematic review of adolescents’ experiences living with parents with high levels of substance use revealed key overarching themes for youth: (1) unpredictability and insecure relationships with parents, (2) the difficult social and emotional impact of having a parent with SUD, (3) a pervasive need to try to “control the situation,” (4) searching for ways to cope, and (5) seeking formal and informal support.⁵⁴ Children of parents with SUD may also avoid or be unable to seek help from people outside of their family unit because of shame, isolation, or fear that they may become separated from their family.⁵⁵ This may lead to a decreased likelihood that youth will seek support if they experience psychological distress or challenges managing substance use in the future.⁵⁶ These themes point to difficult but modifiable parent-child dynamics and social systems.

When a parent struggles with SUD, youth may experience “parentification,” which occurs when youth take on adult roles too early, effectively parenting their own parent.^57,58 Adolescents may learn to assume practical responsibilities (eg, complete housework, take care of siblings) and/or take on emotional labor within the family (eg, acting as parent’s protector against domestic violence or danger, taking responsibility for parent’s well-being and emotions). A possible result of this dynamic is that adolescents are delayed in developing emotion regulation skills and establishing a differentiated sense of self. This developmental trajectory can lead to difficulties within future romantic and caregiving relationships.⁵⁹

Parents reuniting with their families after a period of separation due to SUD treatment, incarceration, or child welfare involvement face additional challenges. Depending on custody history, separation can impede the opportunity for youth to develop a secure attachment early in life.⁵⁹ Separation may also cause a sense of confusion and ambiguity.^60,61 Adolescents may experience boundary ambiguity, or the experience of not knowing who is responsible for which tasks within a family system. The process of repair can confer added stress on the parent-adolescent dyad.⁶¹ While reinstating norms, parents may feel unsure of how to build a relationship with their adolescent, have a more active role in their child’s life, be a positive and affirming parent, and enforce guidelines and boundaries to keep their adolescent safe. They also must contend with their adolescent’s growing desire for autonomy alongside the increased risk that more independence might lead to substance use behaviors.⁶²

In the early stages of remission from SUD, parents experience complex competing demands which can include initiating medication. Starting medication entails multiple, frequent provider appointments and may coincide with withdrawal, identifying new ways to regulate emotional arousal, and building new daily routines. Parents in early remission may also struggle with concurrent mental health issues, depend on other substances, have limited parenting support from partners, or experience community disenfranchisement.^2,3,63 Taken together, early recovery from substances is a major transition period and providing parenting support at this time could be especially useful.

For parents in remission, there may be an additional need to first focus on trust. For example, if parents provided substances to their child, placed their child in dangerous situations, or caused other harms, repair may require reducing or eliminating substance use and identifying ways to communicate safety in the relationship.⁶⁴ This could include protecting adolescents from unsafe adults and promoting autonomy by respecting their interpersonal boundaries.⁶⁵ Parents with SUD may struggle with affect regulation, which may drive an increase in internalizing (depression or anxiety) or externalizing (oppositional behavior) symptoms among adolescents.⁵⁸ Supporting parental affect regulation could reduce the risk of adolescent mental health problems and substance use.

Parents can focus on nurturing healthy relationships by expressing affection, providing emotional support, and openly talking about feelings within healthy parent-adolescent boundaries.⁶⁴ Some studies have found differences between the parenting practices that are most impactful for disrupting intergenerational transmission via maternal versus paternal pathways. Specifically, closeness between mothers and youth partially accounted for the association between maternal substance misuse and adolescent alcohol use. In contrast, fathers’ parental monitoring seems to partially account for the connection between paternal substance use and adolescent alcohol, cigarette, marijuana, prescription, and inhalant use. These effects remained significant across adolescent gender identity and whether they lived with 1 or both parents.⁶⁶ In addition, a supportive and transparent relationship with a parent significantly increases youths’ ability to develop a sense of self-concept.⁵¹ Allowing the adolescent to understand the parent’s trajectory of substance use may reinforce self-concept clarity and promote resilience and other positive psychosocial outcomes.^61,67,68 However, these conversations must avoid stories that inadvertently make substance use sound more appealing.^69-71 Building a parent-adolescent relationship that promotes open communication confers lasting positive effects.^72,73

Societal Considerations

Substance use, parenting and intergenerational dynamics are all shaped by societal and cultural factors. A family’s cultural orientation can be protective against substance use even when a parent is seeking treatment for SUD. Expectations and norms around an adolescent’s role in their family vary considerably across cultures and geographic regions.^74,75 Parents of Black youth are more likely to make explicit rules about substance use when compared to parents of White youth, in part explained by substantiated fear of disproportionate punishment for substance use among Black families in the United States.^42,76,77 Stronger affiliation with Hispanic identity is associated with lower risk of substance use.⁷⁸ Further, holding the values of simpatía (interpersonal relationship harmony) and familism (family connectedness) are associated with lower substance use among Hispanic adolescents.⁷⁴ A family’s religious affiliation and community involvement can be associated with lower rates of adolescent substance use as well. Youth who identify as members of the Church of Latter-day Saints are significantly less likely to engage in substance use than those who do not.²⁸ Black youth living in rural areas use substances less often compared to Black youth living in urban regions, which researchers attribute to the protective effects of religious affiliation.^79,80

Experiences of discrimination also have meaningful effects on SUD among adolescents.^81,82 While Black youth show lower rates of substance use than White youth during adolescence, rates of use climb throughout adulthood, indicating a unique trajectory of use.⁸³ Substance use might be associated with racism in part as a coping strategy.⁸⁴ Rates of substance use are substantively higher among American Indian/Alaska Native youth when compared to White youth, and this pattern continues into adulthood.⁸⁵ Native Hawaiian and Pacific Islander youth report greater rates of use than Asian American adolescents, though rates are often aggregated between these 2 populations.⁸⁶ In contrast, among American Indian and Alaska Native emerging adults, mindfulness, connection to nature, and a deep historical and cosmological perspective offer “binding pathways” for positive behavioral health.⁸⁷ Community connection is also associated with lower cannabis use among American Indian youth.⁸⁸ Supporting cultural affiliation may offer strength and resilience to protect against parent and adolescent substance use.⁸⁰

SUD also operates within the context of societal inequities. Parents with SUD who live with their children are more likely to be women, live in rural settings, and have limited access to facilities offering medication-assisted treatment.⁸⁹ Other intersecting experiences include houselessness, financial insecurity, and legal system navigation. Parents in remission may also have limited employment history or possess criminal records that make employment access more challenging.⁹⁰ As such, parents may be forced to accept lower paying jobs, jobs with inflexible hours, or jobs that do not provide paid leave. This may lead to parent-adolescent relationship stress as parents experience stress from multiple competing demands. Full-time employment and a living wage improve parenting involvement,⁹¹ indicating a need to investigate how programs that support parent employment can have downstream positive effects on youth. Socioeconomic strain increases substance use in part when adolescents have fewer opportunities to engage with pleasurable substance-free activities and more opportunities to participate in activities that include substance use.⁹²

Fear of discrimination following the disclosure of substance use is a central reason why many parents do not receive care and why adolescents do not disclose to others that their parent(s) struggle with SUD.^54,93 Parents with SUD experience a greater sense of stigma than non-parents. A recent study documented that this effect is perhaps greatest for parents who feel like they have “the most to lose” in terms of social status.⁹⁴ Parents also often fear disclosing their substance use in primary care settings for fear of a punitive response.²⁰ This underscores the need to destigmatize the pursuit of treatment for the benefits of both parents and adolescents.

Changes at the policy level have shifted the availability of and beliefs around different substances. For example, the legalization of cannabis for both medical and recreational use has shifted the cultural zeitgeist toward a more favorable view of marijuana.⁹⁵ Meanwhile, geopolitical forces have influenced the influx and availability of fentanyl in the United States as crackdowns on pharmaceutical companies have made it more difficult to receive opioid-based medications like Oxycontin and Percocet.⁹⁶ Simultaneously, state-level legislation that decriminalizes personal possession of small quantitates of illegal drugs has increased funding for harm reduction initiatives.⁹⁷ While discussion of how these policy changes have affected the intergenerational transmission of substance use is outside the scope of this paper, we acknowledge the cascading impacts on adolescents and parents alike.

Implications for Practice

While many existing treatment programs for substance use involve parents of young children, few interventions for parental substance use focus specifically on parents of adolescents. Given that substance use occurs within complex familial dynamics,³ it is necessary to guide the development of interventions for parents with SUD tailored to the needs of both parents and their adolescents.

Related to prevention and intervention to support adolescents of parents with SUD, prior research indicates the effectiveness of programs that are grounded in supporting positive parenting practices and family relationships.^98,99 Programs like Parent Management Training,¹⁰⁰ Strong African American Families,¹⁰¹ Familias Unidas,¹⁰² and Family Check-Up¹⁰³ are proven to be effective across multiple contexts and offer opportunities to be adapted for parents with SUD.^104-106 Examples of effective programs for parents of young children like Parents Under Pressure or The Family Check-Up Online adaptation,^63,107 can provide a roadmap for how to simultaneously treat parents’ SUD and support parent-child relationships. Key considerations for parents of adolescents include teaching and discussing ways to scaffold the achievement of developmental milestones like healthy risk-taking, identity exploration, social connection, and independence-seeking. Creating opportunities to intentionally repair the parent-child relationship could be especially impactful for adolescents. Specifically, SUD programs could help parents facilitate conversations about establishing appropriate boundaries between parent and child responsibilities, building trust, addressing past harms, and increasing opportunities for adolescents to voice their own emotions and needs. Existing studies also suggest that adolescents benefit most when they feel a sense of agency and right to be involved in decisions regarding their own services and treatments.¹⁰⁸ The same is likely true when it comes to their involvement in parents’ SUD treatment.

Some adolescents of parents with SUD may already have a use disorder. Adolescent-focused SUD treatment programs that include parents significantly outperform those that do not.^108,109 One example is Parent SMART, a technology-assisted intervention for parents whose adolescents were recently discharged from residential substance use treatment programs.¹¹⁰ It focuses on the key elements of the adolescent-parent relationship: parental monitoring via adolescent disclosure, supervision, and communication.¹¹¹ Intervention participants showed significant improvements in parental monitoring and parent-adolescent communication compared to those who received treatment as usual. Multidimensional Family Therapy is another potential intervention that may be adapted for parents with SUD. Although currently focused on family therapy to support an adolescent struggling with substance use and externalizing behaviors, the core domains of the intervention include tools for youth, education for the parent, effective practices for the whole family, and specific skills around how to effectively engage with community resources.¹¹²

Adolescent SUD treatment programs that integrate the whole family offer a model for interventions for parents with SUD.¹¹³ The Five Step Method¹¹⁴ and the Community Reinforcement and Family Training (CRAFT)¹¹⁵ interventions focus on reducing stress-related symptoms, bolstering coping skills, and improving well-being for all family members. Incorporating youth-focused elements that encourage positive family relationships and an optimistic view of the future can prevent the development of a SUD in another family member while offering traditional parenting support and supporting recovery.⁹⁹

While the focus of this paper remains on disrupting the path from parental SUD to adolescent substance use, Problem-Behavior Theory acknowledges the likelihood of the co-occurrence of a range of behavioral and emotional challenges.¹¹⁶ All of the parenting skills and developmentally appropriate considerations discussed throughout have the potential to positively impact psychosocial and behavioral outcomes for youth in addition to preventing and confronting substance use. For example, the development of emotion regulation skills for both adolescents and their parents seeking treatment confers personal and relational benefits beyond the context of substance use.⁴⁷ In this sense, the recommendations communicated in this paper are intended not only to address the intergenerational transmission of SUD and substance misuse, but may also work to address emotional and behavioral challenges during adolescence.

Limitations

This narrative review has limitations. First, there is heterogeneity in substance use in terms of substance type and severity that may influence intergenerational transmission of SUD and substance misuse. There is also variation in family structure, identity, and culture that can inform the nature of intergenerational dynamics and transmission of SUD. While we sought to discuss some of these considerations, future reviews may also consider gender identity, sexuality, other facets of identity, peer affiliation, and family networks that were beyond the scope of the paper. Finally, narrative reviews are inherently born from the authors’ selection and exclusion of relevant studies. The manuscript’s synthesis of the literature and practical recommendations reflect the authors’ professional judgment rather than what a systematic or scoping review might have yielded.

Conclusion

Disrupting the intergenerational transmission of SUD and substance misuse requires creating empathic systems that facilitate involved, supportive, and communicative parent-adolescent relationships. Concurrent with SUD treatment, parents should be offered tools to promote effective parenting skills and mutually rewarding relationships. Systems of care and future research must respond to the unique opportunity to provide supports to parents with SUD who are parenting adolescents, to prevent adolescent use, substance misuse and the intergenerational transmission of SUD.

Footnotes

Acknowledgements

The preparation of this manuscript was supported by the National Institute on Drug Abuse of the National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. We also wish to acknowledge and thank all of the adolescents, caregivers, and families who have participated in the studies cited throughout this article.

ORCID iDs

Estelle L. Berger

Ann-Marie Y. Barrett

Simone Mendes

Leslie D. Leve

Jennifer H. Pfeifer

Camille C. Cioffi

Ethical Considerations

No ethics approval was required for this article.

Author Contributions

Estelle L. Berger—Conceptualization; Writing—Original Draft Preparation. Ann-Marie Y. Barrett—Conceptualization; Writing—Original Draft Preparation. Simone Mendes—Conceptualization; Writing—Original Draft Preparation. Veronica Oro—Conceptualization; Writing—Original Draft Preparation. Leslie D. Leve—Conceptualization; Writing—Review & Editing; Funding acquisition. Jennifer H. Pfeifer—Conceptualization; Writing—Review & Editing. Camille C. Cioffi—Conceptualization; Writing—Review & Editing.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This publication was supported by the National Institute on Drug Abuse of the National Institutes of Health under Award Numbers P50DA048756 and R24 DA061209. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

No original data were used in this article.

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