Codependency, Psychological Problems and Time of Exposure to Parents with a History of Psychoactive Substance Dependence: Appointments

The concept of codependency is controversial and related to psychological difficulties of family members of people with dependence of psychoactive substances, as well as covering family disorganization contexts not associated with this dependence. The study evaluated the correlation of codependency and internalizing and externalizing problems in adolescents, children of parents with a history of psychoactive substance dependence, according to gender, and a possible correlation between codependency and time of exposure to this family member, also according to gender. This study evaluated 30 adolescents, aged 13 to 18, of a city in the interior a city of the state of São Paulo, Brazil. Using the Spann-Fischer Codependency Scale and the Youth Self-Report, a strong correlation between codependency and psychological problems was observed among girls. Also, was found a strong positive correlation between codependency and the intermittent time of exposure to the family member when in use/abuse, in boys. For both genders there was no correlation between codependency and continuous time of exposure to the family member in that condition, which suggests that codependency transcends the mere presence of the person living together when using/abusing substances.


Introduction
The term codependency was first used in the late 1970s, when alcoholism and dependence on other drugs were called "chemical" dependencies. At first, codependency was related to wives' compulsive need to watch their alcoholic spouses and later to children of people with psychoactive substance dependence, as well as any individual who had closer relationship with them. According to Diehl, Silva and Bosso (2017), the concept of codependency involves several definitions, and may refer to: 1) a system of life that comes from the interaction with dysfunctional families; 2) an exacerbated reaction to the external environment concomitant with a low sensitivity to problem solution; 3) the behavior of a "normal" person who strives to deal with a problematic family member; 4) a stressful life event; or, 4) compulsive behaviors in an attempt to obtain safety and recognition. For these authors, sometimes codependency is also defined as a personality disorder.
This understanding variation indicates that there is no conceptual agreement about what it means to be codependent. On the other hand, there is some agreement regarding this phenomenon description. The characteristics that often define a person as codependent in research on the topic are: exaggerated care for others, need for control, low self-esteem, absence of a proper identity, focus on the other, inadequate management of emotions, difficulties in establishing limits, in addition to substance abuse -codependents may also become addicted to psychoactive substances, as well as to food or work, due to the fact that they still present personality disorders. A conceptual disagreement among researchers about codependency refers to its necessary association Codependency, psychological problems and time of exposure to parents with a history of psychoactive substance dependence: appointments __________________________________________________________________________________________ 726 Contextos Clínicos, v. 13, n. 3, set./dez. 2020 with psychoactive drug abuse in the family and although many understand that dependence on psychoactive substances in the family can be a factor for codependency in some of its members, the investigations on the subject do not explain how that occurs.
Under these conditions, researchers must explain their understanding on codependency in studies and interventions. In this article, codependency is understood from the perspective proposed by Bution and Wechsler (2016), which defines it as a problem associated with addictions without substance, sharing several similarities with other dependencies. So, in the same way that the dependent establishes a relationship with the drug (obsessively), the codependent creates a relationship with the other -both in an attempt to decrease their pain. The association between codependency and being the child of substance-dependent parents is still unclear. Investigations in this respect are incipient, since few studies can be found in international and national databases, a fact pointed out in a literature review on the topic by Bution and Wechsler (2016).
Authors such as McLaughlin, Campbell and McColgan (2016), suggest that children of dependent parents may be equally prone to substance abuse, which would function as an escape mechanism in the face of emotional difficulties, depression, feelings of stress, negligence, among others. In its turn, Brodski and Hutz (2016) suggested that, in general, the socio-emotional development throughout adolescence and into early adulthood could be predicted by stories of emotional abuse and neglection. This statement is in line with a research developed by Anaya Acosta, Fajardo Escoffié, Calleja and Rivera (2019) with 304 Mexican youths, between 14 and 18 years old, belonging to family contexts considered dysfunctional. By dysfunctional family, it was conceptualized in the study as one in which conflicts, misconduct and abuse occur continuously and regularly, leading other members to adjust and normalize such actions. The authors observed a strong positive correlation between co-dependency and family dysfunction, in order to conclude that family relationships influence the Contextos Clínicos, v. 13, n. 3, set./dez. 2020 prediction of models of co-dependent behaviors that adolescents use in other interpersonal relationships.
Considering organic and psychological transformations in adolescence, Fernandes and Oliveira-Monteiro (2016) argued that this can be a period of vulnerability for the development of emotional and behavioral problems. The authors, however, point out that this possible condition of vulnerability in this stage of life emerges from the interactions of the individual characteristics of adolescents with the various environments in which they are inserted, from the more proximal to the distal, but also from the historical and cultural moment that surrounds them.
According to Macalli, Torezan, Lessa and Almeida (2015), there are several definitions of emotional and behavioral problems in childhood and adolescence.
Achenbach and Rescorla (2010) present a classification of psychological problems by characterizing their symptomatic patterns into two types: internalizing (emotional) problems and externalizing (behavioral) problems. Internalizing problems are expressed in relation to the individual himself/herself, being focused on affections and on the more intimate psychological environment, such as anxiety and depression, sadness, shyness, somatic complaints and fear. Such emotional problems would be more related to mood (depression) and anxiety disorders. Externalizing problems would be those expressed in relation to others, to the outside world, as in the cases of hyperactivity, aggressive and antisocial behaviors -commonly linked to conduct disorders and oppositional defiant disorder (Achenbach & Rescorla, 2010). According to Fernandes and Oliveira-Monteiro (2016), there are gender differences concerning internalizing and externalizing problems of adolescents. The literature indicates that aggressive behavior and breaking of rules would be more related to male adolescents while internalizing problems, such as depression and anxiety disorders, would have higher prevalence among the female (Parco & Jó, 2015).
Codependency, psychological problems and time of exposure to parents with a history of psychoactive substance dependence: appointments __________________________________________________________________________________________ children of parents with a history of psychoactive substance dependence according to gender, and a possible correlation between codependency and time of exposure to this family member (when he/she was in the situation of use or abuse of psychoactive substances) , also according to gender.

Participants
The participants were adolescents (from 12 years old to 18 years and 11 months) whose parents (mother or father) had a history of addiction to psychoactive substances.
The families in situation of social vulnerability benefited from the Serviço de Proteção e Atendimento Integral à Família (PAIF -Comprehensive Service and Care to Families), had to be benefited by at least one service in the Social Assistance Reference Center (CRAS) in a medium-sized municipality in the state of São Paulo, Brazil. We considered as exclusion criteria: non-literate adolescents, those who presented serious cognitive/mental impairment or had a history of dependency (according to the evaluation of the researcher).
The sample consisted of 30 adolescents, 19 boys (63%) and 11 girls (37%). Among the boys, 79% had the father as the family member with a history of addiction to psychoactive substances, present in 46% among the girls (Costa & Oliveira-Monteiro, no prelo). 21% of boys had father and mother as the family member with a history of addiction, while 36% of girls also had this feature. All adolescents of the sample, except for a boy, belonged to families in C1, C2 and D economic classes according to the Associação Brasileira de Empresas de Pesquisa (2014) classification.
Codependency, psychological problems and time of exposure to parents with a history of psychoactive substance dependence: appointments __________________________________________________________________________________________

Instruments
We used the following instruments for data collection: 1) Sociodemographic Questionnaire; 2) Spann-Fischer Codependency Scale and; 3) Youth Self Report. The sociodemographic questionnaire has been prepared specifically for the study to collect information regarding the family member with a history of addiction (if it was the father, the mother, both, or more members of the nuclear family). This instrument was also used for the data collection on time exposed to this family member (when he/she was using/ abusing of these substances) or, to collect information regarding the continuous or intermittent exposure time simultaneously, in the case of an adolescent who have been through situations where the contact with the family member with a history of addiction has been discontinued in a given period (for example, in situations of temporary marriage separation, or hospitalization of the family member).
The Spann-Fischer Codependency Scale, used for verifying the indexes of codependency in the sample, has 16 items with statements like: "it's hard for me to say no" and "I often put the needs of others before my own", to which the respondent must assign a value of 1 to 6 points, where 1 corresponds to "strongly disagree" and 6 "strongly agree". The final score ranges from 16 to 96, meaning the higher the number, the higher the codependency level. The cut score to determine presence of codependency is 52 points. The instrument had its reliability and validity examined by Fischer and Spann (1991)  Contextos Clínicos, v. 13, n. 3, set./dez. 2020 In the Biscarra, Brandariz and Cremonte (2009) study, internal consistency of the scale was satisfactory (Cronbach's alpha = 0.81), and its dimensionality was verified by means of the Exploratory Factor Analysis with four factors that retain 60% of the variance. These results coincide with those reported by Fischer and Spann (1991) indicating the multidimensionality of the instrument, and providing empirical support for the conceptual definition of codependency. Although the Spann-Fischer Codependency Scale is not validated for the brazilian population, for the present study, the scale was translated from the Biscarra's argentine survey (from Spanish to Portuguese) by the authors of the present manuscript. The Youth Self Report (YSR), a self-applied questionnaire for adolescents, from ASEBA (Achenbach & Rescorla, 2010), to evaluates internalizing and externalizing problems, is designed for youths aged 11 to 18. The YSR has 123 items that refer to aspects of the adolescent's everyday life, such as school performance, number of friends, The YSR was validated in Brazil by Rocha (2012) in a study with 3,356 adolescents from four regions of the country (after its extensive use in international studies), aged 11 to 18 years old. Results indicated good model fit indexes for the Brazilian population (Root Mean Square Error of Approximation [RMSEA] = 0.032). As for internal consistency, this was tested using Cronbach's alpha coefficient: for the sample of adolescents not referred to the mental health service, the alpha values ranged from 0.545 (Anxiety Problems) to 0.924 (Total Scale of Emotional/Behavioral Problems) and for the Codependency, psychological problems and time of exposure to parents with a history of psychoactive substance dependence: appointments __________________________________________________________________________________________ sample sent for care in mental health services, the values ranged between 0.533 (Anxiety Problems) and 0.935 (Total Emotional/Behavioral Problems Scale). In addition, the instrument also presented good discriminate capacity for Problem scales. Country region and socioeconomic status had low impact on the results. Taken together, the results indicate the validity and reliability of the YSR for the Brazilian population, and indicate the appropriate norms for the use of the questionnaire in this country.

Procedures
The project had the approval of the Research Ethics Committee of Federal University of São Paulo (CEP 0823/2015 Opinion 1,282,132).

Data collection
The data collection was conducted in the CRAS mentioned, after approval by the team of local servers. We selected registers of families in the institution, where one of the researchers acted as a psychologist. These registers were chosen by respecting a priori the inclusion criteria (families with an adolescent son/daughter of father and/or mother with a history of addiction to psychoactive substances). The sampling was not probabilistic, with convenience and accessibility criteria. The contact was established with 40 adolescents and/or their families via telephone and/or in person, of whom 35 showed up in the interview accompanied by the responsible in the selection stage.
After the evaluation made by the researcher, through interview, 33 participants were selected. Three of them gave up, and the final sample consisted of 30 adolescents.
For those responsible for the adolescents, the Informed Consent Form (ICF) was presented and for the selected adolescents, the Consent Form (on the day of the selection). Later there was the first meeting, where information about the sample characteristics were obtained, as well as how long the adolescent had been exposed to the family member with a history of dependency when in use/abuse on psychoactive substances and the Spann-Fischer Codependency Scale were also applied. On the second meeting, YSR was applied with minimum interval of 15 days and a maximum of 30 days.

Data analysis
The data collected by YSR were submitted to the Assessment Data Manager Program (ADM), a specific software for the correction of this instrument. The codependency variables, internalizing and externalizing problems, were distributed by gender and described in terms of scoring variation, mean and standard deviation.
Likewise, the continuous or intermittent time of exposure of the adolescent to the family member with a history of dependency when in use/abuse on psychoactive substances were described.
To verify differences between boys and girls, a differential analysis of internalizing and externalizing problems, Student's t-test was used for unrelated samples. The premises of the distributions of the variables were verified using the Shapiro-Wilk test. Finally, to investigate possible correlation between the same variables and indexes of codependency present in the sample, according to the gender of the participants, the Pearson correlation coefficient was used. For all analysis, the significance level of 5% was considered. R Core Team software (2016) was used.

Results
Boys presented a score variation of 36-78 for codependency (47% of them overpassed the cutoff point). Among girls, the scores varied between 50-89 points (75% of them overpassed the cutoff point). The descriptive measures for internalizing problems and externalizing problems are shown in Table 1, in terms of score variation, averages and standard deviations obtained, for the boys and the girls in the sample.
Codependency, psychological problems and time of exposure to parents with a history of psychoactive substance dependence: appointments __________________________________________________________________________________________ Among the girls, 25% declared intermittently exposed to the family member with a history of dependency when in use/abuse on psychoactive substances (mean = 6.3 ± 7.6 years), and, among boys, 31% (mean = 5.8 ± 4.9 years). As for continuous exposure, 75% of the girls stated that kind of exposure (mean = 9.4 ± 6.8 years) and 74% of the boys in the sample (mean = 6.9 ± 5 years). In Table 2

Discussion
In this study, the use of the Student's t-test pointed to a significant difference between boys and girls regarding the internalizing and the externalizing problems was indicated, and for these two modes, the highest rates were also observed for the girls.
As mentioned in the Introduction of this article, Fernandes and Oliveira-Monteiro (2016) and Parco and Jó (2015) pointed gender differences concerning internalizing and externalizing problems, with girls/women presenting higher levels for internalizing types of problems and boys/men more related to higher levels of externalizing types of problems. The difference here is that the girls had both problems at higher levels, with scores interestingly higher than for boys. Maybe the strong and very strong correlations found between the degree of codependency and, respectively, internalizing and externalizing problems in the girls of the sample may help us explain the higher scores of those problems in the girls especially when compared to boys, who did not show a correlation between problems and codependency.
For both genders, there was no correlation between codependency and continuous time of exposure to the family member with a history of psychoactive substance dependency when in use/abuse on psychoactive substances, while on the Codependency, psychological problems and time of exposure to parents with a history of psychoactive substance dependence: appointments __________________________________________________________________________________________ other hand, for the boys, there was strong positive correlation between codependency and the intermittent time of exposure to the family member in that condition. Such finding suggests that sporadic contact with the family member on can be more damaging, than if this occurred more frequently. This sporadic contact may indicate flaws in the stability of the presence of this family member with the adolescent, a result that contradicts previous research in which it was stated that codependency can be more strongly associated with other variables, and not directly associated with time of exposure to the family member with a history of dependency on psychoactive substances (Panaghi, Ahmadabadi, Khosravi, Sadeghi & Madanipour, 2016). Still regarding the adolescent's time of exposure to the family member, a question would fit: would be a stable presence of a parental figure (even with the characteristic limitations to the condition from use /abuse) more protective than experiences of its absence (which may suggest abandonment)?
It is noted that most of the sample was composed by adolescents who had their father as member family wtih of dependency on psychoactive substances and as mentioned, even under such condition, the indications that the presence of the father figure would offer protection to the adolescent highlights the importance of the suggested actions directed to men, also for the reason that they could cooperate to a greater support in the exercise of fatherhood. Furthermore, such results can serve as a parameter for directed actions to men (in relative terms to health care), considering that they are most affected by addiction to psychoactive substances than women (Seleghim, Galera & Oliveira, 2016). These activities with parents become more important as they can also improve children's mental health.

Final Considerations
This study sought to evaluate the correlation of codependency and internalizing and externalizing problems in adolescents affected by parental substance abuse, Contextos Clínicos, v. 13, n. 3, set./dez. 2020 according to gender, and a possible correlation between codependency and time exposed to this situation (dependent person using regularly psychoactive substances), also according to gender. Girls presented higher scores of internalizing and the externalizing problems than boys (with significant difference between them). Also, strong and very strong correlations were found between the degree of codependency and, respectively, internalizing and externalizing problems in the girls of the sample.
For the boys, very strong correlation was found between the degree of codependency and the intermittent time of exposure to the chemically dependent. Whereas the study dealt with a small group -30 adolescents, children of parents with a history of addiction to psychoactive substances -, it is not feasible to come to major conclusions.
However, it was possible to explore some variables supposedly involved in the phenomenon of codependency. Time of continued exposure to the member family with a history of dependence on psychoactive substances when in use/abuse was not shown correlated to codependency. This suggests that codependency transcend the mere presence of a person with a history of dependency in the family, living with. Still, it is suggested that subsequent researches can study larger and diverse samples of addict's children, with the possibility of approaching other models of family structure, and a control group consisting of families who do not have members with a history of psychoactive substance dependency in their composition.