Faculty Affiliations and Disclosures
Ms. Shaw is a researcher in the Department of Psychiatry at the University of Iowa Roy J. and Lucille A. Carver College of Medicine in Iowa City. Mr. Forbush is a PhD candidate in the Department of Psychology at the University of Iowa College of Liberal Arts and Sciences. Ms. Schlinder is a researcher in the Department of Psychiatry at the University of Iowa Roy J. and Lucille A. Carver College of Medicine. Dr. Rosenman is in private practice in Las Vegas, Nevada. Dr. Black is professor in the Department of Psychiatry University of Iowa Roy J. and Lucille A. Carver College of Medicine.
Disclosures: Mses. Shaw, Forbush, and Schlinder and Dr. Rosenman do not have an affiliation with or financial interest in any organization that might pose a conflict of interest. Dr. Black receives research/grant support from Forest and Shire; is on the speaker’s bureau of Pfizer; and is a consultant to Forest.
Submitted for publication: May 8, 2007; Accepted for publication: July 18, 2007.
Please direct all correspondence to: Donald W. Black, MD, University of Iowa Carver College of Medicine, Psychiatry Research/2-126b MEB, Iowa City, IA 52242; Tel: 319-353-4431, Fax: 319-353-3003; E-mail: Donaldfirstname.lastname@example.org.
Pathological gambling (PG) is widely reported to have negative consequences on marriages, families, and children. Empirical evidence is only now accumulating but when put together with anecdotal information, the extent of these problems is clear. PG contributes to chaos and dysfunction within the family unit, disrupts marriages, leading to high rates of separation and divorce, and is associated with child abuse and neglect. Divorce rates are high, not surprising in light of reports that these marriages are often abusive. Research shows that the families of pathological gamblers are filled with members who gamble excessively, suffer from depressive or anxiety disorders, and misuse alcohol, drugs, or both. Families of persons with PG are also large, a variable independently related to family dysfunction. The authors review the evidence on the impact of PG on families, marriages, and offspring, and make recommendations for future research targeting these problems.
Pathological gambling (PG) is a serious health concern that significantly and adversely affects individuals and society. Yet, little attention has been directed to examining its collateral effects, a term referring to the negative consequences of PG on personal and social relationships. Collateral effects include divorce, domestic abuse, financial instability, friendship/family loss, and the psychological and educational development of the children included in those families.
Although the concept of collateral effects of PG is not new, therapeutic focus on the topic has been slow to evolve. For example, therapists, including Freud,1 have written anecdotally about the collateral effects of PG for many decades, and the founding in 1960 of Gamblers Anonymous (GA), an organization designed to support and educate families and friends of pathological gamblers, signaled the widespread recognition of the ill effects of PG on others. It was not until 1972 that the first research article on the impact of PG on marital and family functioning was published, suggesting a significant lag between early clinical observations and subsequent research. Twenty-four years later, the National Gambling Impact Study Commission, created by Congress and signed into law by United States President Bill Clinton, fully recognized the importance of studying the collateral effects of PG.2 It recommended that the National Institutes of Health revise their special program announcements for research applications on PG to include the effects on family members, such as divorce, spousal or child abuse, severe financial instability, and suicide. Darbyshire and colleagues3 observed: “These potentially devastating collateral effects of problem gambling suggest that in order to develop a more complete understanding of this problem, researchers need to study the experiences of all those who are likely to be affected.”
The purpose of this article is to review the literature concerning the collateral effects of PG involving families, marriages, and children, including both anecdotal and evidence-based material.
Family Histories of Individuals with Pathological Gambling
Family-history data provide insight into the make-up of the gambler’s immediate family. In evaluating published family-history data, Walters4 concluded that PG runs in families. Among the studies reviewed, Lesieur and Klein5 found that 5% of 892 high-school students surveyed reported that one or both parents gambled “too much”; 17% of those students showed signs of problem gambling themselves. In a survey of 702 adolescents, Winters and colleagues6 found that 8.7% reported problem gambling, and that 80% further reported that one or both parents gambled. Lesieur and colleagues7 found that in an inpatient group of persons with substance abuse or problem gambling, 39% of the sample reported that their fathers were pathological gamblers, and 3% reported that their mothers were.
Black and colleagues8 followed up these informal observations with systematically collected family history information. In their first study, 14 subjects with PG were interviewed regarding their first-degree relatives. Compared with information from 22 control subjects and their 162 first-degree relatives, the 75 PG relatives had a significantly increased lifetime prevalence of alcohol disorders (31% vs 4%), major depression (19% vs 7%), drug use disorders (5% vs 2%), antisocial personality disorder (5% vs 0%), and generalized anxiety disorder (8% vs 0%). They were also more likely to have “any psychiatric disorder” than control relatives (60% vs 11%). Nine percent of the PG relatives also had lifetime PG.
In their second study using a family study method,9 31 pathological gamblers and their 193 first-degree relatives were compared to 31 controls and their 142 first-degree relatives. They reported that the prevalence of PG and problem gambling combined (“any” gambling disorder) was significantly greater in the relatives of those with PG than in comparison relatives (12.4% vs 3.5%, respectively, P=.0099). Furthermore, PG relatives were at significantly greater risk for other psychiatric disorders, including alcohol disorders (29% vs 13%), “any substance use disorder” (33% vs 15%), antisocial personality disorder (5% vs 0%), and “any mental disorder” (53% vs 40%). Interestingly, the families of the pathological gamblers assessed in this study were larger than the families of the controls (6.6 individuals vs 4.6 individuals, respectively, P=.008). Larger family size has been associated with delinquency, crime, and violence.10
Linden and colleagues11 had earlier calculated morbidity risks of 17% for major mood disorders, and 18% for alcohol use disorders among 175 first-degree relatives of 25 persons with PG. Roy and colleagues12 had reported that 33% and 24% of the first-degree relatives of 24 pathological gamblers had mood disorders or alcohol abuse, respectively.
These studies strongly suggest that one source of family dysfunction stems from the excess burden of mental illness and addictive disorders found in the families of pathological gamblers. On the other hand, it could be that having a pathological gambler in the family induces psychiatric illness in others, in reaction to the gambler’s disturbed behavior. More likely, the presence of genetically transmitted illness (eg, depression, alcoholism), in combination with the pathological gambler’s behavioral problems (eg, impulsivity, antisocial behavior) contributes to dysfunctional family life. For example, the parent with PG or substance misuse may convey an attitude of acceptance or conventionality towards the behaviors to his children that could contribute to future gambling or addictive behaviors in offspring.
Effects of the Family of Origin on Pathological Gambling
Lesieur and Custer13 estimated that for each problem gambler, there were 10–15 other persons whose lives were adversely impacted by the gambler’s activities, be they spouses or partners, children, parents or siblings, employers, co-workers, distant relatives, or even strangers. Perhaps none are more greatly affected than the gambler’s immediate family. Along these lines, Bergh and Kuhlhorn14 found in a sample of 40 pathological gamblers that PG caused problems for at least one family member for 83% of their sample, mainly marital problems or having no time for children.
The parents of pathological gamblers, according to Heineman,15 typically fall into a “hard parent/soft parent” dichotomy, with fathers being the hard parent 80% of the time in the author’s sample of 126 parents. The hard parent is the one who says, “I have bailed you out several times, and either you don’t mean what you say or you are, for some reason, unable to keep your word. Whichever it is, I am not willing to bail you out anymore.” The mothers in this sample, the soft parents, moved emotionally closer to the gambler as the fathers distanced themselves. They were the ones to say, “I feel as a parent I am somehow responsible for all the pressures and problems you have today. Therefore, I cannot refuse your requests for help. It is my duty and obligation to help you. Regardless of its toll, I cannot desert you, for to do so would result in even greater feelings of guilt for me.” Out of this sense of duty, love, and guilt the soft parent may unwittingly enable the gambler to remain “in action.” The dichotomy between the parents brings more stress and discord into the family unit, more so as the gambler tends to manipulate and side with the soft parent.
These observations are partially consistent with the findings of Grant and Kim16 who reported a retrospective assessment on the family of origin in a group of 33 pathological gamblers participating in a clinical trial. They administered the Parental Bonding Instrument,17 which measures an individuals’ perception of his or her parents’ rearing practices up to 16 years of age. Subjects with PG had significantly lower maternal and paternal-care scores than control subjects. In terms of parental-bonding pattern, the pathological gamblers reported low rates of optimal parenting and high rates of neglectful parenting. Studies that have included normal controls have found rates of optimal bonding between 40% and 60%.18,19 Grant and Kim16 found the rate of optimal parenting for pathological gamblers to be only 17% to 30%; 39% to 43% of their sample reported neglectful parenting.
Problems are reported to exist within gamblers’ nuclear families as well. Ciarrocchi and Hohmann20 recruited 67 married male disordered gamblers (34 with alcohol dependence, 33 without) from treatment programs and had them complete the Family Environment Scale (FES),21 which measures an individual’s perception of his or her parent’s rearing practices. They compared the results with the data of 1,432 control families reported in the FES manual. Gamblers scored significantly lower on family commitment and support than the normative group; they also scored lower on independence within their families. Those in the disordered-gambling-only group reported a lower level of familial participation in intellectual activities, and the gamblers who were also alcohol-dependent reported a significantly higher level of expressed anger within the family. Both groups differed significantly from controls on six of the 10 FES subscales; this finding indicates that they had a greater number of family problems than did controls. Problems with the pathological gambler’s own children are discussed more fully in the next two sections.
Effects of Pathological Gambling on the Spouse or Partner
One of the most robust findings to emerge from studies of pathological gamblers is their high divorce rate. Both clinical studies and surveys show that the rate of divorce is consistently higher than that found in comparison groups. In the National Gambling Impact Study,2 the lifetime divorce rates for problem and pathological gamblers were 39.5% and 53.5%, respectively; the rate in non-gamblers was 18.2%. A typical and unfortunate example of the effect of PG on a marital relationship appeared in a California newspaper:
“Dorothy, a 70-year-old woman with PG, described how she treated her husband and time and time again spent all of their resources on gambling. She left him alone all night and lied about her whereabouts, sold his family jewelry, and spent their life savings and then blamed it all on him, even after he had passed away. ‘I loved him,’ she said ‘but he was in my way.’”22
High divorce rates are not hard to understand when, as Lesieur23 observed, the partners of persons with PG are put at serious financial risk, which may include huge credit-card debts, second or even third mortgages, illegal loans, formal and/or informal loans, loss of rent, or mortgage funds, resulting in homelessness or eviction or misuse of irreplaceable retirement funds or savings. Economic control, such as limiting or blocking access to family funds, can be a form of abuse that is used to conceal and maintain family members’ disordered gambling.
Despite the negative consequences, the individual with PG seldom desires, or is able, to cease gambling. The partner does not want the gambler to suffer, so to help the gambler quit, the partner may try to reduce the number of stresses and responsibilities the gambler faces. Although well-intentioned, this enabling behavior may spur additional gambling by giving the individual more free time and energy, presumably to gamble. Financial pressures from excessive gambling may lead some family members to want to “bail out” their gambler and hide the true cause of their distress from friends, creditors, employers, and other family members.24
Bailouts can be psychological as well as financial. A partner may at first believe the gambler’s rationalizations and denials. When the extent of the gambling problem is fully recognized for what it is, the partner may become angry with the gambler. According to Berman and Siegal,24 this “punishment” may absolve the gambler of his or her guilt, and prompt further gambling, this time guilt-free—with the added justification of escaping a scolding spouse. When the gambler is forgiven rather than scorned, this, too, condones the gambling and the gambler is left feeling justified in returning to gambling. Psychological bailouts, like financial ones, function as a means of removing the gambler from the repercussions of his or her gambling, yet it is a trap many partners fall into.
Ciarrocchi and Reinert20 ccompared married male members of Gamblers Anonymous (GA), married female members of GamAnon, and normal controls, and found that the GA and GamAnon members experienced significantly greater family life dissatisfaction than controls. GA, a 12-step program in which people with gambling problems share their experiences and through mutual support hope to cease gambling and/or maintain abstinence, is modeled after Alcoholics Anonymous. GamAnon, on the other hand, is a program for family members whose lives have been disrupted by a relative with disordered gambling behavior, patterned after Al-Anon, a program for relatives of alcoholic persons, With abstinence from gambling, men with PG improved in their views of family life, while wives continued to report significantly less satisfaction than controls for >2 years following the last gambling episode. In a qualitative study of the partners of pathological gamblers, Dickson-Swift and colleagues25 found that loss of trust was the salient feature, and that once a sense of trust was lost, it could never be fully restored.
Violence seems to be more frequent in couples in which one member of the dyad has disordered gambling. Muelleman and colleagues26 interviewed 286 women admitted to an emergency room and found that of the 61 women reporting partner violence, 14 (23%) had partners with PG; 10 partners (71%) also had a drinking problem. After adjusting for age, education, and ethnicity, Muelleman and colleagues26 concluded that a woman whose partner had problem gambling was 10.5 times more likely to be a victim of partner violence than if the partner did not have problem gambling; if the gambler was also a problem drinker, that likelihood was even greater (50.4 times more likely).
Lorenz and Shuttlesworth27 interviewed 144 spouses of persons with PG and reported that almost half had experienced physical or verbal abuse from the gambler. Tran’s28 findings indicated that approximately every two or three cases of family violence in Australia were gambling related and all the victims were women. In a survey of 30 pathological gamblers, 23% admitted to “hitting or throwing things more than once at [their] spouse or partner”.29 The National Gambling Impact Study2 found that of 10 communities, six experienced increases in reports of domestic violence following the introduction of casino gambling. The study also reported that requests for assistance at domestic violence shelters on the Mississippi’s Gulf Coast increased from 100% to 300% following the introduction of casino gambling. “I lived in fear daily due to his agitation and outbursts of violence, broken doors, overturned furniture, broken lamps, walls with holes in them. I haven’t the words to describe the hell my life became on a daily basis,” said one victim describing how her husband’s gambling problem affected their relationship. Lesieur30 found that 87% of problem gamblers ridiculed, insulted, embarrassed, or belittled their spouses in front of their children. Psychological control can be demonstrated by threats, abusive criticism, and unreasonably limiting freedom to family members.
While these studies confirm that physical abuse is found in many PG families, the reasons behind the violence are less clear. The violence could be linked to the gambler’s poor impulse control, to his low frustration tolerance, or to his aggressivity. Likewise, it could be related to the gambler’s antisocial behavior, mood disorder, or substance misuse. Clearly, the mixture of dysfunctional personality traits, mental and addictive disorders, and the complex social and financial problems found in these families fuels the volatile cycle of violence and abuse.
Mental and Physical Health
Lorenz and Yaffee31 surveyed 215 women belonging to GamAnon about their medical health, emotional health, and the health of their marital relationship. They were asked to recall the emotions and symptoms they experienced when their partner’s gambling was at its worst, that is, Custer’s32 “desperation” phase. Custer describes the progression of gambling addiction in three phases: the winning phase, the losing phase, and the desperation phase. In the desperation phase, there is a marked increase in the time spent gambling, blaming of others and alienating family and friends. The emotions most frequently endorsed by spouses were anger or resentment (74%), depression (47%), isolation (44%), and guilt about contributing to the gambling (30%). Physical complaints included chronic or severe headaches (41%) and stomach and bowel ailments (37%). Sexual relations were reported to be seriously disturbed as well. In 36% of the cases, the gambler wanted the spouse to join him in his gambling activities, and in most of these situations the spouse complied. Eighty-six percent of spouses contemplated leaving their gambling spouses, and 29% did so.
Lorenz and Yaffee33 surveyed 206 married GA respondents about their medical health, mental health, and the health of their marital relationship during the desperation phase of their illness and after a period of abstinence from gambling. During their desperation phase, 49% of the GA members indicated that their sexual relationship with their spouse was unsatisfactory, while 19% reported that their dissatisfaction continued even after they had abstained from gambling. Lorenz and Shuttlesworth27 found that 50% of the respondents indicated that their spouses lost interest in sex during periods of heavy gambling. Lorenz and Yaffee33 reported that 48% of their 206 married GA respondents stated they had seriously considered having an extramarital affair during the worst of their gambling period; 23% reported having done so. Fifty-nine percent indicated that they thought about separating from their spouses, and one third of the respondents eventually did separate.
Effects of Pathological Gambling on Offspring
Jacobs and colleagues34 conservatively estimate that there are >2.5 million young people affected by their parents’ gambling behavior in the US. Given this large number of children, it is surprising that there has been so little research to examine how living with a pathological gambler affects the emotional, physical, and educational lives of these children.
As more and more women gamble (and presumably many mothers) the effects of gambling on children are likely to increase. In one study,35 women pathological gamblers stated that their gambling resulted in stress, guilt, mood swings, a sense of isolation, and neglectful behavior, all of which negatively impacted their children.
Children of pathological gamblers often experience role conflicts, including taking on the role of peacemaker, being caught in the middle of family tensions, serving as scapegoat and/or taking the blame for family difficulties stemming from the problem gambling. They often experience disappointment due to broken promises.36 Lesieur and Rothschild37 noted that these children typically experienced a great deal of inconsistency in their relationships with their parents, at times being “doted” upon and at other times being “ignored”. Note how similar these complaints over differing parenting roles are to those experienced by gamblers reporting on their families of origin in an earlier section.
Jacobs and colleagues34 took the self-rating measures of 52 children in the ninth through 12th grades who described one or both of their parents as having “compulsive gambling problems” and compared them to a group of students who reported no gambling problems among their parents. The measures assessed general health, quality of life, school, and work adjustment; involvement with potentially addictive substances and behaviors; and indications of psychosocial maladjustment, including difficulties with the law and suicide attempts. Their findings suggest that offspring of the compulsive gambling parents were at much greater risk for health-threatening behaviors, such as smoking and alcohol or drug use; psychosocial problems, such as an unhappy childhood, or having a “broken home”; educational difficulties; and emotional disorders, including dysphoria and suicidal behavior. An unfortunate finding from many studies is that adolescent gambling is strongly associated with parental gambling,5,38-40 and could be as much as four times more likely than among youth whose parents do not gamble.41
Lesieur and Rothschild37 developed a questionnaire using a modification of Jacob’s Health Survey and gave it to 105 children of married GA members throughout the US and Canada. They found that, when compared with nationally normed samples from intact families, the GA children were more likely to have been subjected to parental physical violence and abuse. When asked about their feelings concerning their parents’ gambling, 44% of the children said they felt angry most or all of the time and 26% said they felt angry <50% the time. Sixty-eight percent reported feeling sad, 60% felt emotionally hurt, 56% were depressed, 59% were confused, while 46% felt pity for their parents’ gambling. They also said they felt hateful (45%), shameful (44%), helpless (42%), isolated (34%), abandoned (31%), and guilty (26%) concerning their parents’ gambling. Seventeen percent said they felt happy about their parents’ gambling at least some of the time.
Darbyshire and colleagues3 conducted a qualitative study to explore children’s experience of living with a parent with a gambling problem. The most notable finding was the experience of “pervasive loss” (ie, a sense of loss encompassing physical and existential aspects of their lives) including their “parent(s), relationships, trust, security, sense of home, and material goods.” As one 13-year-old put it: “She doesn’t care about anybody else but herself. And she, she won’t stop it. She knows she can get rid of it, but she just won’t, she likes it too much. She likes it better than what she likes us.” Again, note the similarity between this and the pathological gambler’s high ratings of their parents’ “neglectful parenting” reported by Grant and Kim.16
“Children of the pathological gambler are probably the most victimized by the illness. Usually underage, emotionally and financially dependent upon the gambler during the worst of the illness, it is the children who are the most helpless. They hear the arguments, recriminations, apologies, broken promises, insults, lies, and fights. They hear their mother arguing with their father about not having money for food, clothes, or school items for the children... The children of pathological gamblers, growing up in an atmosphere of emotional deprivation, isolation, parental abuse, rejection, poor role modeling, and emphasis on money, are very likely to have equally problem-ridden lives.”
Treatment for Families
Research on methods for helping families cope with the stress of living with a pathological gambler in their midst is limited. Much work has focused on how treatment affects the behavior of the gambler rather than on the well-being of the spouse or family. For example, Johnson and Nora43 found that GA members whose spouses participated in GamAnon did better than those whose spouses did not, but the difference was not significant. Likewise, Zion and colleagues44 studied GA members to determine whether or not spousal participation in GamAnon had any effect on the gamblers’ relapse into gambling behavior. No significant difference was found in relapse rates for those gamblers with or without a spouse in GamAnon. The authors conclude that other family impacts, such as improved family functioning or increased assertiveness on the part of the spouse, warrant further study.
Early conceptualizations characterized the emotional tribulation experienced by the spouse as personality flaws inherent within the spouse.45,46 A newer framework, the stress and cope model, suggests that the emotional distress experienced by the spouse is brought on by the repeated, frustrated efforts to cope with the problems brought on by the gambling rather than a personality defect.47
Three studies have focused on teaching the spouse or concerned significant other (CSO) coping skills. In the first, Rychtarik and McGillicudy47 randomized 23 CSOs to either coping skills training or a delayed treatment condition. The CSOs assigned to the coping skills training received 10-weekly individual sessions of manualized treatment based on the stress and coping model and geared toward improving the person’s own functioning. The CSOs were provided education about gambling, the stress and cope model, cognitive-behavioral theory and techniques, problem solving, and communication skills. Coaching, rehearsal, role playing, and homework were integral parts of the sessions. At the end of the 10 weeks, the researchers of this preliminary study found that the CSOs in the coping skills were less anxious and depressed compared with the control group.
In the second study, Makarchuk and coworkers48 randomized CSOs to receive by mail either a standard resource information packet or a self-help manual modeled after the Community Reinforcement and Family Training (CRAFT) approach developed for CSOs of alcoholics.49 The CRAFT program was designed to teach skills to engage the pathological gambler in treatment as well as to improve the CSO’s own functioning. At the end of 3 months, a decrease in the CSOs’ psychological distress was found in both groups with only a small and nonsignificant difference between the two conditions.
The last study builds on the preceding one. Hodgins and colleagues50 investigated the efficacy of minimal-treatment interventions for CSOs of pathological gamblers by randomizing 186 subjects into three groups: the first minimal-treatment group received the CRAFT workbook previously mentioned and the second minimal-treatment group received the CRAFT workbook along with telephone support by certified gambling counselors. The control-condition group received a resource-information packet. Participants from all three conditions reported significant improvement in their personal and relationship functioning at the at the 3- and 6-month follow up, although subjects receiving one of the interventions experienced greater improvement.
This review demonstrates that PG has serious repercussions for families, marriages, and offspring. Data from a variety of sources converge to paint a picture of the pathological gambler’s family as disturbed and chaotic. The pathological gambler’s close relatives frequently suffer from mental health or addictive disorders, and the families themselves are large. High rates of separation and divorce are well documented. The pathological gambler’s retrospective report of their family of origin suggests a personal history of parental abuse and neglect. These effects appear to carry on to the next generation, as the pathological gambler’s own nuclear families are often the target of abuse and neglect. Spouses of gamblers and their children bear the brunt of the stress within the family, experiencing emotional and physical turmoil. Lastly, the children are at risk for developing PG, continuing the cycle of abuse and neglect into the next generation.
Research on the collateral effects of pathological gambling and its treatment is in its infancy, yet is an area that demands greater attention. The problem of collateral effects will only grow as PG becomes more entrenched in our society as gambling opportunities continue to expand. Data suggest that interventions for PG need to take into account the individual’s marital and family dynamics. To ignore the needs of the family does a disservice to all involved. The person with PG cannot be fully understood without gaining a better understanding of the environment from which he came and the environment in which he lives.
Future studies of PG need to address the intimate relationships and family unit, and preferably include direct interviews of spouses/partners, and offspring. Epidemiologic studies can help determine the extent of the problem and its risk factors, while clinical studies can focus on the family unit itself. Because substance misuse plays such a large role in marital and family related problems in these patients, an important task for researchers will be to separate the effects of PG from those of substance misuse. This could be accomplished by using a group of substance abusers and their spouses/partners and children as a control group. Follow-up studies can help to track the emergence and subsidence of marital and family problems over time, and to correlate evidence of dysfunction with gambling frequency and intensity. These studies can also help make clear why some PG families thrive despite the presence of the gambler in their midst; these so-called “resilience” factors are important to understand.
Research efforts should examine existing treatment models, such as the cope and stress model for spouses and concerned significant others, while working to develop new ones to specifically address the needs of the gamblers’ children. The goal of this work should be to help create a family environment less conducive to the perpetuation of gambling, one that is safer and less stressful for all family members, and, finally, one that reduces the likelihood of a continuous intergenerational cycle whereby PG passes from one generation to the next.
1. Freud S. Dostoyevsky and parracide. In: Strachey J, ed. The Standard Edition of the Complete Psychological Works of Sigmund Freud. vol 21. London, England: Hogarth Press; 1928:177-121.
2. National Opinion Research Center at the University of Chicago (NORC). Gambling Impact and Behavior Study: Report to the National Gambling Impact Study Commission. Chicago, Ill: 1999.
3. Darbyshire P, Oster C, Carrig H. Children of parent(s) who have a gambling problem: a review of the literature and commentary on research approaches. Health Soc Care Community. 2001;9:185-193.
4. Walters GD. Behavior genetic research on gambling and problem gambling: a preliminary meta-analysis of available data. J Gambl Stud. 2001;17:255-227.
5. Lesieur HR, Klein R. Pathological gambling among high school students. Addict Behav. 1987;12:129-135.
6. Winters KC, Stinchfield R, Fulkerson J. Patterns and characteristics of adolescent gambling. J Gambl Stud. 1993;9:371-386.
7. Lesieur HR, Blume SB, Zoppa RM. Alcoholism, drug abuse, and gambling. Alcohol Clin Exp Res. 1986;10:33-38.
8. Black DW, Moyer T, Schlosser S. Quality of life and family history in pathological gambling. J Nerv Ment Dis. 2003;191:124-126.
9. Black DW, Monahan PO, Temkit M, Shaw M. A family study of pathological gambling. Psychiatry Res. 2006;141:295-303.
10. Ellis L. The victimful-victimless crime distinction and seven universal demographic correlates of criminal behavior. Pers Individ Dif. 1988;9:525-548.
11. Linden R, Pope H, Jonas J. Pathological gambling and major affective disorder: preliminary findings. J Clin Psychiatry. 1986;47:201-203.
12. Roy A, Adinoff B, Roehrich L, et al. Pathological gambling: a psychobiological study. Arch Gen Psychiatry. 1988;45:369-373.
13. Lesieur HR, Custer RL. Pathological gambling: roots, phases, and treatment. Ann Acad Poll Soc Sci. 1984;474:146-156.
14. Bergh C, Kuhlhorn E. Social, psychological and physical consequences of pathological gambling in Sweden. J Gambl Stud. 1994;10:275-285.
15. Heineman M. The parents of male compulsive gamblers: clinical issues/treatment approaches. J Gambl Behav. 1989;5:321-332.
16. Grant JE, Kim SW. Parental bonding in pathological gambling disorder. Psychiatr Q. 2002;73:239-246.
17. Parker G, Tupling H, Brown LB. A parental bonding instrument. Br J Med Psychol. 1979;52:1-10.
18. Leon CA, Leon A. Panic disorder and parental bonding. Psychiatr Ann. 1990;20:503-508.
19. Torgerson S, Alnaes R. Differential perception of parental bonding in schizotypal and borderline personality disorder patients. Compr Psychiatry. 1992;33:34-38.
20. Ciarrocchi JW, Reinert DF. Family environment and length of recovery for married male members of Gamblers Anonymous and female members of GamAnon. J Gambl Stud. 1993;9:341-352.
21. Moos RH, Moos BS. Family Environment Scale Manual. Palo Alto, Calif: Consulting Psychologists; 1984.
22. Brooke W. Losing to addiction. San Diego Union–Tribune. March 6, 2005.
23. Lesieur H. Costs and treatment of pathological gambling. Ann Am Acad Pol Soc Sci. 1998;556:153-171.
24. Berman L, Siegel M. Behind the 8-ball: A Recovery Guide for the Families of Gamblers. Lincoln, Neb: Authors Choice Press; 1998.
25. Dickson-Swift VA, James EL, Kippen S. The experience of living with a problem gambler: spouses and partners speak out. J Gambl Issues. 2005;13:1-22.
26. Muelleman RL, DenOtter T, Wadman MC, Tran TP, Anderson J. Problem gambling in the partner of the emergency department patient as a risk factor for intimate partner violence. J Emerg Med. 2002;23:307-312.
27. Lorenz VC, Shuttlesworth DE. The impact of pathological gambling on the spouse of the gambler. J Community Psychol. 1983;11:67-76.
28. Tran D. Asian Gambling...Family Losses: A Study of Gambling Related Violence in the Vietnamese Community. Richmond, Va: Jesuit Social Services; 1999.
29. Bland RC, Newman SC, Orn H, Stebelsky G. Epidemiology of pathological gambling in Edmonton. Can J Psychiatry. 1993;38:108-112.
30. Lesieur HR. Current research into pathological gambling and gaps in the literature. In: Shaffer HJ, Gambino SA, Cummings TM, eds. Compulsive Gambling: Theory, Research and Practice. Toronto, Canada: Lexington Books; 1989:225-248.
31. Lorenz VC, Yaffee RA. Pathological gambling: psychosomatic, emotional and marital difficulties as reported by the spouse. J Gambling Behav. 1988;4:13-26.
32. Custer RL. Gambling and addiction. In: Craig R, Baker S, eds. Drug Dependent Patients: Treatment and Research. Springfield, Ill: Charles C. Thomas; 1982:367-381.
33. Lorenz VC, Yaffee RA. Pathological gambling: psychosomatic, emotional and marital difficulties as reported by the gambler. J Gambling Behav. 1986;2:40-49.
34. Jacobs DF, Marston AR, Singer RD, Widsman K, Little T, Veizades J. Children of problem gamblers. J Gambling Behav. 1989;5:261-268.
35. Brown S, Coventry L. Queen of Hearts: The Needs of Women with Gambling Problems. Melbourne, Australia: Financial and Consumer Rights Council; 1997.
36. Franklin J, Thoms DR. Clinical observations of family members of compulsive gamblers. In: Shaffer HJ, Gambino SA, Cummings TM, eds. Compulsive Gambling: Theory, Research and Practice. Toronto, Canada: Lexington Books; 1989:135-146.
37. Lesieur HR, Rothschild J. Children of Gamblers Anonymous members. J Gambling Behav. 1989;5:269-281.
38. Ladouceur R, Dube D, Bujold A. Gambling among primary school students. J Gambl Stud. 1994;10:363-370.
39. Fisher SE. Gambling and pathological gambling in British adolescents. Eur Addict Res. 1993;7:509-538.
40. Griffiths MD. Adolescent Gambling. London, England: Routledge Press; 1995.
41. Abbott DA, Sheran LC, Sherrets SD. Pathological gambling and the family: practical implications. Fam Soc. 1995;76:213-219.
42. Lorenz VC. Family dynamics of pathological gamblers. In: Galski T, ed. The Handbook of Pathological Gambling. Springfield, Ill: Charles C. Thomas; 1987:83-84.
43. Johnson EE, Nora RM. Does spousal participation in Gamblers Anonymous benefit compulsive gamblers? Psychol Rep. 1992;71:914.
44. Zion MM, Tracy E, Abell N. Examining the relationship between spousal involvement in Gam-Anon and relapse behaviors in pathological gamblers. J Gambl Stud. 1991;7:117-131.
45. Boyd W, Bolen DW. The compulsive gambler and spouse in group psychotherapy. Int J Group Psychother. 1970;20:77-90.
46. Tepperman JH. The effectiveness of short-term group therapy upon the pathological gambler and wife. J Gambl Behav. 1985;1:119-130.
47. Rychtarik RG, McGillicuddy NB. Preliminary evaluation of a coping skills training program for those with a pathological-gambling partner. J Gambl Stud. 2006;22:165-178.
48. Makarchuk K, Hodgins DC, Peden N. Development of a brief intervention for concerned significant others of problem gambling gamblers. Addict Disord. 2002;1:126-134.
49. Meyers RJ, Smith JE. Clinical Guide to Alcohol Treatment: The Community Reinforcement Approach. New York, NY: Guilford Press; 1995.
50. Hodgins DC, Toneatto T, Makarchuk K, Skinner W, Vincent S. Minimal treatment approaches for concerned significant others of problem gamblers: a randomized controlled trial. J Gambl Stud. 2007;23:215-230.