Maternal alcoholisM and childcare iMplications: a qualitative study

The aim of this qualitative research was to evaluate how alcoholic mother care for their children. In-depth interviews were conducted with 10 alcoholic mothers between December 2011 and January 2012, in two mental health care services in the municipality of Imperatriz, MA. The data were analyzed according to Bardim’s content analysis technique. The care provided by alcohol dependent mothers predisposes the children to vulnerable health, as the mother’s cognitive capacities and childcare skills are affected. The study shows the importance of this investigation by nurses in order to create strategies to deal with alcoholism and to exchange experiences on appropriate childcare together with alcoholic mothers.


Introduction
Alcoholism is a significant public health problem as it affects daily social and family life and more knowledge is needed in order to tackle it (1) .For a long time, alcoholism was linked with the male population, a sort of social bonding.However, recent years have seen an increase in female alcoholism all over the world (2) .
The panorama of alcoholism among women has doubled since 2001, reaching one female for every three male alcoholics, which shows women's growing susceptibility to alcohol use.Data from the II Brazilian Household Survey on Psychotropic Drugs, involving the 108 largest cities in the country, indicate that 6.9% of Brazilian women are alcohol dependent.Moreover, the number of women who seek treatment for alcoholism in the 47 Psychosocial Care Center for Alcohol and other Drugs -Centro de Atenção Psicossocial Álcool e outras Drogas (CAPS Ad) in Brazil gives an estimated figure of 3,000 women in this situation (3) .
Studies on alcohol use among women consider female alcoholism capable of affecting the process of expressing affection and emotional relationships, which may substantially compromise mother/child interaction, as the mother's health is essential in being able to care for the child (4)(5) .Thus, the maternal care given by alcoholic mothers may act as a negative predictor for the children's future health (5)(6) .
Maternal care is a comprehensive activity, spreading affection and love between the components that make up the family.Care is an art form, requiring the use of basic criteria such as affection, sensitivity and skill.Effective child care requires the mother to have cognitive functions intact and to be capable of offering appropriate care conditions, as well as attending to her child's needs, creating an atmosphere that encourages healthy development.When care does not occur in the expected way, the child may become depressed, psychologically incapable of relating to others, apathetic, even leading to death (7) .
Such research highlights the role of the health care professional in preventing and detecting problems related to the care given by alcoholic mothers, as it is a process that may make the child's development or even survival more difficult as it affects daily social and family life and affects the mother's capacity to care for the child.
This study is relevant due to the impact alcoholism has on the family, in the understanding that its existence has repercussions on the health of all its members, the care given by alcohol dependent mothers is a determining factor in the healthy development of the child.It is also justified as, among its possible uses, it contributes to guiding the body of nursing knowledge of maternal alcoholism.Thus, the aim of this study was to evaluate how childcare is provided by alcoholic mothers.

Method
This is a descriptive study using a qualitative approach, conducted in the Psychosocial Care Center for Alcohol and other Drugs (CAPS Ad) and in the Casa de Rute Treatment Community in the municipality of Imperatriz, Maranhão, Brazil.
The locations selected for this study are health care services that treat and prevent the use/abuse of alcohol and other drugs.The above mentioned institutions differ in their function: the Casa de Rute Treatment Community is a philanthropic institution providing shelter and care to drug addicted patients, receiving an average of a dozen individuals during the period in question.The CAPS Ad has a multi-professional weekly health care team, as well as structural and functional conditions for art therapy, music therapy, a teaching area, leisure area and meeting groups for patients and their family members.
The study participants were 10 alcoholic mothers who agreed to take part in the study, signing an informed consent form.The eligibility criteria were: being an alcoholic mother and receiving treatment and prevention of alcohol and drug use.
After participants had given their consent, in-depth interviews were conducted within the treatment areas of the respective services.Each mother was interviewed twice and the sessions were recorded using an MP4 device to be transcribed and analyzed.The average length of each interview varied between 10 and 15 minutes.The following semi-structured topics were used to guide the sessions: feeding, hygiene, preventing disease and education and upbringing.
The data were analyzed using Bardim's content analysis technique (8) which has three staged: pre-analysis; exploring the material and treating the results obtained.

Characterizing the research participants
The participants were 10 alcoholic mothers, in different age groups, varying between the lowest age of 22 and the oldest of 46.Concerning employment, four were unemployed, two were maids, one lived on a pension and three had informal employment.Three of the participants were married and the other were single and had, on average, between two and six children.The ages of the children varied between three and ten years old, three were in the 3-5-year-old age range and the rest were aged between 5 and 10 years old.It is worth noting that all participants in the study were in a phase of abstaining from alcohol.
Only two of the interviewees in this study made use of the CAPS Ad services, whereas eight regularly attended the Casa de Rute philanthropic institution, showing a gap in the care provided to alcoholic mothers by the CAPS Ad.
The role of the CAPS Ad in monitoring alcoholics is relevant, as it is a multi-professional institution based on a comprehensive care model that aims to move the view of the patients from sick individuals to citizens, promoting social re-insertion and inter-sectorial activities, such as adopting policies of minimizing harm and other principals of comprehensive, fair and equal care (10) .Thus, the study indicates the need to re-formulate the care the Unified Health Care System (SUS) provides to this public at an outpatient and domestic level, demonstrating the need to reform and renew public policies aimed at these service users.

Maternal alcoholism and the care process
The aspects of childcare analyzed, which may suffer from maternal alcoholism, are: feeding and hygiene, upbringing, love/attention given, the child's psychological and emotional character, difficulties in providing maternal care and health risks to the child.
Providing a continuous balanced diet, at appropriate intervals, in the presence of a motherfigure, is an essential factor in maintaining health growth and development in the child.However, insufficient provision of food may lead to physical and immunological weakness, triggering childhood illness.From this perspective, the diet is a privileged care dimension and it should provide adequate, age-appropriate food to meet the child's needs, thus avoiding the child falling ill (11) .
Because of their status as alcohol dependence, the alcoholic mothers' bonds can deteriorate and they may belittle the importance of nutritional care of the children, as can be seen in the following statements.The statements show the devastating repercussions of alcoholism in the family ambit, capable of affecting it and directly interfering in the responsibility to provide food and, thus, with direct implications for the child's health.
With regard to the lack of hygienic care of the child, carelessness is evident, according to Ruby's statement.

[...] I couldn't keep from drinking alcohol and I forgot about being a mother, children went to bed without taking a bath [...] (Ruby).
Beyond negligence, the statement also shows feelings of maternal remorse/guilt about the alcoholism, showing dysfunction in the mother's role of caring about her children's hygiene, a factor that can lead to the child getting a variety of diseases linked to dirt, as well as the offspring's lack of health and wellbeing.
In corroboration of this statement, authors have indicated the important of hygiene in upbringing, a basic need for maintain health and building healthy self-care habits.In this context, they also highlight that paying attention to hygiene in bringing up children is a necessary care domain for healthy child development (9,12) .
With the advance of alcohol dependence and lack of specific treatment, the alcoholic mother's symptoms are exacerbated and egocentrism increases, also disregard their children's upbringing, as emphasized by Pearl in her statement.

The children didn't have a good upbringing because of the kind of mother I was [...] The kid doesn't go to the beach or the country club, not even to visit relatives, because its mother's drunk (Pearl).
In the statement, we can observe a progressive loss of the mother/child binominal link.The lack of correct guidance can significantly compromise the child's nature and psychological side, which can lead to irreversible changes in behavior, even when linked to a lack or deficiency of family entertainment/leisure.
Various national and international studies have shown parental influence within the family to be a mechanism collaborating with the vulnerability of their children to alcohol dependence (12)(13) .
However, in the case of behavior alterations, it is worth pointing out that the children are a true reflection of the parents, they can internalize aggressive reactions and behavior, integrating their personality and having a kind of "domino effect" on future generations.Parents, then, are children's first reference, their first teachers, representing correct behavior to be followed (13) .
Aggressive or irrational behavior, as a consequence of the effects of alcohol, is also evident, as can be seen in the statements by Pearl and Sapphire, respectively.

I took the baby to the bar, sat it on a chair (Pearl). I used to take my daughter to bars. She slept on my lap and woke up when I spilled drink on her (Sapphire).
This absurdity in the children's upbringing, compromising their safety, is directly influenced by alcoholism, as the child may internalize the alcoholic mother's conduct and this may decisively influence the offspring's behavior in later life.
Implicit attitudes and public demonstrations of affection area essential, as they lead to the child feeling warmth, protection, serenity, happiness, gratification and wellbeing, as well as to reciprocal actions.From this perspective, this form of care is essential in strengthening the emotional and friendship bonds between mother and child.However, alcoholism produces recurring episodes of mutual aggression, minimizing the mother's provision of affection to the children, expending less time on the care they are in need of (13)(14) .
Alcohol dependence generates a sizeable egocentrism, so that efforts to maintain the link between the mother/alcohol dyad are sufficient to exacerbate the mother's individual "well-being", to the detriment of the child's emotional needs, as the statements below demonstrate.

I didn't give them any attention at all. I didn't even know if it was my child (Turquoise). I never gave any attention or affection. Someone who drinks doesn't know how to love a child (Sapphire).
Such statements show the abyss existing in the relationship between alcoholic mothers and their children, a factor that contributes to making the child vulnerable to disorders in general, especially behavioral or psychopathological disorders.
With respect to the psycho-emotional effects that can affect the child, daughter of an alcoholic mother, adversity can be reflected intensely, as is highlighted below.Faced with the statements cited above, we can see that the emotional maturity and emotional development of the son or daughter of an alcoholic mother suffer intense, often irreversible, deterioration responsible for behavior that may manifest themselves in the form of aggression, learning difficulties or difficulties relating to other people (14) .
With the existence of alcoholism and some associated comorbidities, such as depression, the maternal attributes of childcare and promoting healthy growth and development are compromised.According to the statements, difficulties providing maternal care can be translated, as shown below.

Alcohol held me back, I didn't know how to be a mother, it wouldn't let me be a mother (Pearl).
I felt like a failure, incapable of being a mother [...] I wanted to go back and be a real mother, a real wife, a real woman (Ruby).
The perceived difficulties in childcare are intrinsically related to being dependent on alcohol, which overrides vital human priorities.Thus, maternal alcoholism deteriorates maternal responsibility, translating into incapacity to work, to care for oneself and, above all, to be a mother (15) .
There are cases in which the children's loss of confidence in their mother is evident, as can be seen in the excerpt below.
When I'm running late, my children call to ask where I am.

I tell them I'm at work, but they don't believe me [...] (Pearl).
We cans see that, over time, the children come to substitute the mother in the capacity of being the mother and responsible carer and begin to see her as weak, irresponsible and incapable, losing confidence in her.
Familial support can alleviate this problem, subsidizing the provision of care (15)(16) .The family, in fact, should be willing and integrated within this activity, one that requires much effort and understanding on the part of all involved.
Certain conduct on the part of alcoholic mothers leaves the children vulnerable to severe morbidity and even mortality.The difficulties in giving up drinking in order to acquire the calmness needed to provide adequate childcare to the children, so as to guarantee their health, were noted in this study, in which, of the ten participants, seven referred to having abused alcohol since their teens, even continuing to drink whilst pregnant and breastfeeding, as in the statements below.

I was pregnant when I started drinking [...] (Ruby).
Drinking alcohol whilst pregnant may cause death in the mother or the child, whether through miscarriage, accidents or incidents with multiple causes, and can even cause fetal alcohol syndrome, among other factors that may impact on the health and survival of the newborn, with consequences such as intellectual disability, facial alterations typical of the syndrome and problems with growth, development and cognition (16) .
It is recommended not to consume alcohol whilst breastfeeding, as alcohol passes into the breast milk and is harmful to the child's psychomotor development, as well as altering the taste of the milk, minimizing episodes of feeding and affecting the nutrition process.Alcohol passes into breast milk from intake of 1g/kg/day.Thus, prolonged alcohol consumption during pregnancy/breast feeding may trigger alterations and effects in the fetus or newborn, harming learning capacity and memory and increasing childhood mortality (17)(18) .
Of the interviewees, four admitted striking their child when under the influence of alcohol, which can have disastrous physical and psychological effects.This situation can be observed in the following excerpt.
When I was drunk I would hit them for no reason (Turquoise).

I was very aggressive to my children (Emerald).
Aggressive maternal behavior due to alcohol demonstrates the lack of a mother-child bond, representing serious risk factors to the child's health, capable of affecting the essence of the mother/child relationship, as evinced below.
They would notice when I was drunk [...] My oldest son even stopped asking for my blessing (Turquoise).
Maternal alcoholism distances mother from child, thus affecting the interpersonal relationship.In this aspect, nursing interventions in the family ambit are a crucial action to be considered.The nurse can intervene in diverse problematic factors that make up the family's universe and affect the health of its members.Thus, the family is adopted as a care unit, taking into consideration its identity, as well as its particular dilemmas; the interpersonal components in the family sphere; evaluating the family's daily functioning, as well as the health risk factors of its members; conducting regular visits with a multi-professional team and NASF (Family Health Support Center -Núcleo de Apoio à Saúde da Família) support and proposing specific conditions to care for and treat the alcoholic mother and the other family members, especially when faced with maternal alcoholism (18) .
In line with the data presented, it can be seen that the participants were aware of the severity of their drinking habit in relation to caring for their children.It is, then, reasonable to recognize that this accentuates these women's suffering, their feelings of guilt and social marginalization.It is therefore imperative that health care professionals listen to and reflect on what these mothers say, welcome them and provide them with equal and impartial treatment.

Conclusion
Based on the results identified, a definition of maternal alcoholism can be drawn up, including how it affects the process of caring for children, compromises their emotional and psychosocial development and generated negative impacts for the child's health.
The conclusion of this study refers to the effects and repercussions of maternal alcoholism on the family environment and childcare, leading to the observation that alcoholism is a highly complex and damaging disease, of generalized activity, provoking illness not only in the child but in all family members, destroying the base from which it functions -the mother figure, predisposing the children to biological and mental morbi-mortality risks, compromising their emotional maturity and unbalancing the integrity of the home.
Historically, the female is blamed for errors in caring for and bringing up children, running the home and the family in general.However, this vision is flawed and prejudiced, as some factors are related to this situation in alcoholic mothers: deficient social support networks, socio-economic and cognitive vulnerability and, above all, lack of affection and understanding of the state in which they find themselves.
Comprehensive family support as well as increased emotional ties, supported by social networks, are essential as they facilitate the mother's re-establishment, raising adherence to treatment and improving quality of life for the family members.
[...] I didn't care about their food [...] The only thing I was interested in was drinking (Turquoise).My little ones often went to bed without any supper [...] (Ruby).
[...] the child absorbs the mother's annoyance.They started to treat other people the way I treated them [...] the child's future is anxiety, insecurity, that's what mu children have (Pearl).