ReviewEffects of parental alcohol rules on risky drinking and related problems in adolescence: Systematic review and meta-analysis
Introduction
Risky drinking is a leading contributor to the global disease burden for adolescents (Gore et al., 2011, Patton et al., 2012). Risky drinking, defined as consuming ≥5 standard drinks on a single occasion at least monthly (Gore et al., 2011, Hill and Chow, 2002, National Institute on Alcohol Abuse and Alcoholism, 2016, Patton et al., 2012), is a cause of non-communicable disease, injury and sexually transmitted infection (Gore et al., 2011, Hill and Chow, 2002, Patton et al., 2012, Rehm et al., 2009). In the USA, approximately 14% of 12–20 year-old young people reported risky drinking in the last month (Center for Behavioral Health Statistics and Quality, 2015), and this age group required 188,706 emergency room visits because of alcohol-related injuries and disorders in 2011 (Substance Abuse and Mental Health Services Administration, 2013).
The rules parents set about alcohol may affect adolescent risky drinking, as parents are among the main agents of socialization of alcohol use during early adolescence (Abar and Turrisi, 2008, Jackson and Dickinson, 1999, Wood et al., 2004). It has been well-documented that parenting practices in general (e.g., support, monitoring, and parent-child attachment) are inversely related to adolescent risky drinking (Barnes et al., 1994, Danielsson et al., 2011, Kaynak et al., 2013, Kopak et al., 2012, Van Der Vorst et al., 2006). However, these broader parenting practices do not explain how parents respond to children’s drinking, such as by implementing rules specific to their acquisition and use of alcohol. Alcohol-specific rules refer to clear, distinct instructions concerning alcohol use, expressed approval or disapproval of adolescent drinking, as well as consistency in the use of penalties for violating those rules (Chun et al., 2008, Janssen et al., 2014, Koning et al., 2012, Van Der Vorst et al., 2005, Van Zundert et al., 2006).
Evidence regarding the association between parental alcohol rules and adolescent risky drinking is conflicting. Some longitudinal studies find that lenience (e.g., parental approval or permissiveness of alcohol use) is associated with a higher likelihood of risky drinking in adolescence (Ennett et al., 2016, Loveland-Cherry et al., 1999). However, others do not find such an association (Fairlie et al., 2012, Reifman et al., 1998, Varvil-Weld et al., 2014). Some cross-sectional studies find that strict rules are associated with a lower likelihood of adolescent risky drinking (Habib et al., 2010, Van Der Vorst et al., 2005), while others find that adolescents are less likely to be involved in risky drinking and alcohol-related problems when they are permitted to drink at home under parental supervision (Bellis et al., 2007, Wells et al., 2005). This approach may teach adolescents to drink moderately and generalize to contexts where alcohol is available without adult supervision (Donovan and Molina, 2008). Conversely, by allowing adolescents to drink in any social context, parents may be communicating a permissiveness that extends unhelpfully to unsupervised environments (Van Der Vorst et al., 2010). Adolescents may assume that apparent permissiveness amounts to overt approval of their drinking (Van Der Vorst et al., 2006) and this may facilitate experimentation (Kaynak et al., 2014). These cross-sectional studies do not, of course, establish a temporal relation between exposure and outcome. Moreover, several studies did not adjust estimates of association for likely confounders [e.g., parent drinking (Maimaris and McCambridge, 2014, Viner et al., 2012)]. Therefore, the true association between parental alcohol rules and later adolescent risky drinking remains unclear.
To date, no reviews have synthesized longitudinal studies to investigate associations between prospectively measured parental alcohol rules and subsequent adolescent risky drinking. We aimed to critically investigate longitudinal studies and conduct a meta-analysis to address the question: “Do the rules parents make about alcohol affect the likelihood that their adolescent children become risky drinkers?”
Section snippets
Selection and eligibility criteria
We used the PRISMA guidelines (Moher et al., 2015) and formulated eligibility criteria using the PICO (P – Populations/People/Patient/Problem, I – Intervention(s), C – Comparison, O – Outcome) worksheet and search strategy (Table 1) (Sackett, 1997).
We systematically reviewed prospective longitudinal studies including prospective cohort studies, randomized trials, and non-randomized trials, while excluding cross-sectional and retrospective studies. We specified a lag between exposure and outcome
Results
From the initial database searches, we identified 1740 records and exported them to Endnote X7 reference management software (Thomson Reuters Endnote). We identified three further articles from backward and forward searches, removed 620 duplicate articles, and screened the remaining articles by reading titles and abstracts. We excluded articles that did not meet inclusion criteria for full-text review, i.e., conference abstracts, review articles, cross-sectional or retrospective studies,
Discussion
Our meta-analysis suggests that parental rules concerning alcohol use may decrease the odds of risky drinking later in adolescence. However, there is a fair possibility that the pooled estimate is compromised by confounding bias, attrition bias, and limitations in trial design. Pooled estimates should not be considered generalizable as the I2 statistic and p-value suggest considerable heterogeneity across studies.
The strengths of this review and meta-analyses include the explicit and
Conclusion
This systematic review and meta-analysis suggest that parental rules concerning alcohol decrease the likelihood of risky drinking later in adolescence. However, we judged that the studies have a high risk of bias and the true association may be over-estimated. Inferences about the association are limited by the small number of studies suggesting further longitudinal studies are needed, in different cultural settings, and with designs and methods that minimize the risk of bias.
Role of funding source
The research was funded by an Australian Research Council Discovery Project (DP106668), an Australian Rotary Health Research Grant, and the Foundation for Alcohol Research & Education. Sonia Sharmin received a PhD scholarship from University of Newcastle, Australia, and Australian Rechabite Foundation. Kypros Kypri’s contribution was funded by a National Health & Research Council Senior Fellowship (APP1041867).
Contributors
Mrs. Sharmin and Prof. Kypri conceptualized the study, interpreted results and critically reviewed the article. Mrs. Sharmin completed initial database searches, and with Dr. Khanam independently screened articles, extracted data and assessed risk of bias. Prof. Kypri assessed included articles as to whether they met inclusion criteria. Dr. Holliday and Ms. Palazzi provided advice on data analysis and critically revised the manuscript. Mrs. Sharmin performed data analysis and prepared the
Conflict of interest
No conflict declared.
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