At the end of the three rounds of selection, 13 studies were selected for meta-analysis. Table 1 summarizes their characteristics.
The articles selected only for the narrative review have been summarized in Table 2.
The risk of bias estimates of the selected articles for the meta-analyses have been mentioned in Table 3. To impart an impartial judgment, for all studies the “failure of confounding control” was mentioned as “unclear risk”. As all the studies used validated instruments, for “flawed measurements” the bias was estimated to be of “low risk”.
The Summary of Finding tables for the numerical outcomes as well as for the categorical outcomes are shown respectively in Tables 4 and 5. As shown in Table 4, for the numerical outcomes of depression, anxiety, internalizing behavior and externalizing behaviors, significant mean differences were noted. The measurements had been higher for the exposed (i.e. father alcoholic) group.
A significantly higher relative effect (OR=2.18, 95% CI= 2.03-2.33) was noted for the exposed group (i.e. with paternal alcoholism) for the occurrence of childhood anxiety among children when analyzed as a categorical outcome.
The sensitivity analysis was done by re-doing the meta-analysis using SMD and with the random model assumptions. The observed effect measures remained statistically significant demonstrating the robustness of the findings (Table 6).
Even though meta-analysis of three studies(32,33,37) (Singh-2017, Jacob-1999 and Jacob-2000) yielded a pooled Odds Ratio of 1.68 (95 CI=1.28 to 2.20) for depression as a categorical outcome, statistical heterogeneity was noted (I2= 74%). Hence those findings were described in the narrative review section below.
The Figures 3A to 7A shows the Forrest plots for the mentioned meta-analyses. Immediately below , Figures 3B to 7B demonstrate the Funnel plots drawn for selected studies.
The narrative review based on the articles or outcomes of articles which were not included in the meta-analyses is described below
Depression and mood disorders
When fathers are active-problem drinkers, children were found to have 1.56 times greater likelihood of having depressive symptoms (95% CI= 1.24-1.96). Even when stratified for gender, significantly higher likelihoods were observed for males (OR=1.75, 95% CI=1.14-2.68) and females (OR=1.49, 95% CI= 1.13-1.96)(47). In the study by Jacob & Windle (2000), the RDC-depression percentages were 35.9% and 33.3% respectively for the exposed and control groups(33). Following structural equation modeling, done with data collected among undergraduate students, it was revealed that paternal alcoholism had a “total effect on depressive symptoms” (beta coefficient=0.118, 95% CI= 0.006 to 0.230, p=0.039)(54). In a study done in California, a slight increase of depression was noted in the group with paternal alcoholism amidst gender differences(32). A North Indian study revealed a significant association between the alcohol use of the father and depression in the school children(37). A non-significant independent association with “drinking father” and depression was found by Kelley et al (2010)(46).
Similarly, mood disorders were higher among the exposed group (18.6% to 7.0%).(48) The problem drinking of the father was associated with an increased life time risk of mood disorders among children(48). Malone, Lacona & McGue (2002) showed that paternal alcoholism is associated with depression among 17 year old offspring but not at 14 years(41).
Self-perceived mental health problems and personality
In a longitudinal study done in United States, the SF-12 mental health index values were found to be worse for the children of alcoholic fathers even at age 40, compared to those of non-alcoholic fathers (39). In the study by Jacob and Windle (2000), for the five domains (i.e. extraversion, neuroticism, agreeableness, conscientiousness and openness to experience) assessed by NEO-Personality Inventory, the children of alcoholic fathers reported less favorable outcomes compared to children with non-alcoholic fathers(33).
Edwards et al (2006b) conducted a study to explore aggressive behavior of children who experienced paternal alcoholism. It was found that, by 48 months, 22% of children were in the clinical range for aggression in the father-alcoholic group compared to 5.4% in the non-alcohol group(49).
As concluded by Grekin and others (2005), paternal alcoholism is a predictor of both violent and non-violent delinquency at age 15(52). The study by Finan et al (2015) showed that paternal alcoholism was a direct predictor for aggressive behavior for boys. For both girls and boys indirect associations of paternal alcoholism and aggressive behavior of children were demonstrated(51). Malone, Lacono & Mcgue (2002), showed the positive association of paternal alcoholism with disruptive behaviors(41). In a study done in Croatia, it was revealed that the auto-aggressiveness of school students was associated with paternal alcoholism in the univariate analysis but not in the multivariate analysis(44).
Attention Deficit Hyperactive Disorder (ADHD)
In a twin study done by Knopik et al (2005), paternal alcohol dependence was significantly associated with ADHD (OR= 2.11, 95% CI= 1.39-3.22)(40). With further studies, this association was suspected to be influenced by indirect pathways(45). The association between paternal alcoholism and ADHD at 17 years was shown in a study done in Minnesota, United States(41). In another study, the standardized incidence ratio of ADHD among children who experienced paternal alcoholism was 2.15 (95% CI= 2.11 and 2.20)(43).
Having a father with problem-drinking has been found to a significant predictor for getting 1 or more psychiatric disorders in 12-months (OR=1.47, p<0.05) or over the life time (OR=2.00, p<0.05)(48). In the study by Foley et al (2001), it was revealed that paternal alcoholism alone is not significantly associated with psychiatric symptoms of children. However when it is comorbid with paternal or maternal depression, the risk of children developing increased levels of a number of diverse conditions, including separation anxiety, depression, conduct symptoms and oppositional defiant behavior is increased(67).
In a study by Keller et al (2008), it was revealed that the paternal alcoholism is indirectly associated with internalizing and externalizing problems. The data collections were done while the children were in kindergarten and in the following two years(53). In the study by Adkison et al (2013), it was revealed that the association between paternal alcoholism and poor self-regulatory strategies of children may re-emerge in early adolescence(38). In the study of Eiden Leonard and Morrisey (2001), sons of fathers with alcohol-problems demonstrated higher rates of non-compliance on four measures of compliance than the children without alcoholic fathers(50).
In a 15 year follow up study, Raitasalo et al (2018) concluded that, for both girls and boys, paternal alcohol use is associated with a higher likelihood of “mental and behavioral disorders” among children.(42). Similarly a higher proportion (10.6%) was “ever diagnosed” with mental-health problems compared to the no-problem drinking parent group (6.2%). Similarly 7.1% of the exposed group, compared to a 3.7% of the no-problem drinking category had a mental health problem diagnosed in the previous 12months (39)