CHILD ABUSE AND DRUGS

In the United States, on average, a child is abused every 13 seconds. Because of social awareness, reported child abuse has increased dramatically since the 1980s. Some states have experienced a 20 percent increase in reported child abuse between 1990 and 1991. The American Public Health Association (APHA) estimates that 1.7 million children are abused or neglected annually in the United States. This means that by 1992 a total of about 63.5 million (2.8%) of children under 18 years of age were abused.

Reported cases in the 1990 National Child Abuse and Neglect Data System totaled about half the APHA estimate, or only 893,856. This total comprised 227,057 victims of physical abuse; 403,430 victims of neglect; 138,357 victims of sexual abuse; 59,974 victims of emotional maltreatment; and 68,207 other. These figures represent only the reported cases—the proverbial tip of the iceberg. Research suggests that as many as 10 percent of children may be sexually abused and even more children physically abused or neglected. In addition, each year a higher percentage of U.S. children are being raised in poverty, often by over-stressed and drug-abusing parents.

INCIDENCE AND PREVALENCE OF DRUG ABUSE

Although the casual use of drugs is decreasing in the United States, reported drug abuse is increasing in women of child-bearing age. While it is believed that more children are being raised by alcohol-, tobacco-, or other drug (ATOD)-abusing parents, the scope of the problem is undetermined. Longitudinal studies of children of ATOD-abusing parents are currently underway by the U.S. Centers for Disease Control (CDC), the National Institute on Drug Abuse (NIDA), and the National Institute on Alcoholism and Alcohol Abuse (NIAAA). The Children of Alcoholics Foundation estimates that in the U.S. population about one in eight were raised in homes with one alcoholic parent. Studies suggest that as many as 11 percent of newborns are drug-exposed in utero. About six million women of childbearing age are marijuana users and 10,000 children per year are born to women using opiates. Polydrug use and frequent use of alcohol and other drugs by parents increases the difficulty of researching any causal relationships between a specific drug and child abuse.

The National Committee for the Prevention of Child Abuse (NCPCA) estimates that 10 million U.S. children are raised by ATOD-abusing parents or caretakers and at least 675,000 children every year are seriously abused by ATOD caretakers. ATOD-abusing women have higher fertility rates and more multiple births than non-ATOD-abusing women. Reasons for these repeated pregnancies in drug-abusing women may include lack of sex education and birth control, irregular menstruation, carelessness when using drugs, peer pressure and cultural norms, the desire to replace lost children, the need for increased welfare payments, the enjoyment of being pregnant (decreased depression), and having an infant to love them. These interesting findings should be studied further to determine their validity and related psychological, sociological, and biological causal mechanisms.

RELATIONSHIP OF CHILD MALTREATMENT AND ATOD ABUSE

Do addicted parents abuse their children more? Do both addicted and nonaddicted parents abuse their children more when using alcohol or drugs? Unfortunately, clear empirical research is lacking on the relationship of child abuse and alcohol abuse or child abuse and drug abuse. The validity of existing research is threatened by problems, such as unclear definitions of ATOD abuse, lack of control groups or longitudinal causal studies, and inappropriate statistical and research design techniques for separating causation and coincidence (Bays, 1990). Nevertheless, a relationship does exist between child abuse and ATOD abuse—and definitely between ATOD abuse and child neglect. Similar risk factors for child abuse exist for both child-abusing parents and substance-abusing parents, such as poor parenting skills, family disorganization, involvement in criminal activity, and a disproportionately high incidence of mental and physical illness. Several types of child abuse and neglect involving children of drug abusers are reviewed below.

Prenatal Drug Exposure.

A number of states legally define in utero exposure to alcohol and other drugs as child abuse. States with excessively punitive laws requiring child removal are rapidly changing these laws. For example, in California, the law mandating that infants be removed from detected drug-abusing mothers at birth has been modified; in San Francisco, a positive urine toxicology alone cannot be the only reason for removal. In many states, medical or social-services personnel are mandated to report such cases to protective-services workers; this can result in the avoidance of prenatal care by ATOD-abusing pregnant women. For this reason, social-services employees may hesitate to notify authorities. Additionally, notification of authorities can appear to be (and may in some cases be) racially biased and discriminatory if more poor women of color are referred. In one Florida study only one percent of white but ten percent of African-American drug-abusing pregnant women were reported to child-protective services.

Alcohol and other drugs can cause teratogenic effects—resulting in abnormalities in the fetus. Isolating the specific effects of individual drugs has been complicated by the large proportion of women who are polydrug abusers and by additional factors of poor nutrition, disease, stress, and lack of prenatal care. Alcohol and tobacco are the drugs most commonly used by women during pregnancy; as many as 1 percent of births may be affected by Fe-Tal Alcohol Syndrome (FAS). Some researchers assert that FAS may be the major cause of mental retardation. Characteristics of FAS include facial anomalies, retarded growth, and abnormalities of the heart, kidneys, ears, and skeletal system. The long-term effects of FAS are still being studied but appear to include reduced intelligence, attention deficits, learning disorders, hyperactivity, impulsivity, and more antisocial behaviors than the norm.

The perinatal and long-term effects of other drugs have been studied—such as Cocaine, Meth-Amphetamine, Marijuana, Opiates, and Phencyclidine (PCP). Although a number of immediate problems are apparent, including drug withdrawal and developmental delays, with good postnatal environments many of these children can overcome their in utero exposure if structural damage is not severe. Some researchers have reported that even when cocaine-exposed infants were reared in adoptive homes from birth, some showed neurological deficits. Significant central nervous system (CNS) damage occurs with cocaine exposure. The major effects at birth of most drugs, however, including alcohol and tobacco, are preterm deliveries of low-birthweight infants, indicative of growth retardation that may affect both brain and physical development. Sudden infant death syndrome (SIDS) is also two to twenty times higher in infants exposed to cocaine and opiates.

Few longitudinal studies have tracked the impact of drug exposure on children. The longest follow-up study is of prenatal opiate-exposed children evaluated at ten years of age, and it is very difficult to separate the impact of a poor postnatal environment from prenatal drug exposure (unless the children are adopted). The few longitudinal studies conducted of prenatal drug-exposed infants have found almost no long-term developmental problems directly related to their drug exposure. A few cross-sectional studies of children of drug abusers have found clinically significant negative impacts on their emotional, academic, and behavioral status. These studies suggest that the greater the degree of maternal drug abuse, the greater the negative impact on the child's mental and behavioral status as measured by standardized clinical measures.

The quality of the infant's postnatal environment as actively constructed by the mother or care-giver appears to be the most significant factor in determining the impact of drugs on the drug-ex-posed or nondrug-exposed infant. Studies find that children born to drug-abusing mothers can look normal or be resilient to their in utero exposure to drugs if they are provided a nurturing environment that includes responsiveness to their needs, stimulation, and early childhood education.

Postnatal Exposure to Drugs.

Children can be hurt by ingesting or inhaling alcohol, tobacco, and other drugs. In 1978, PCP was the second most common cause of poisoning in young children at Los Angeles Children's Hospital. Four major ways exist for children to become intoxicated: passive inhalation, accidental self-ingestion, being given drugs by a minor, and deliberate poisoning by an adult. In addition, infants can ingest alcohol, nicotine, and other drugs through breast milk. Passive inhalation of tobacco is recognized as a health hazard to children; however, passive inhalation of Crack (freebase cocaine), PCP, marijuana, or hashish also has negative effects. Children living with parents who manufacture synthetic Designer Drugs in their homes, such as methamphetamine, are exposed to hazardous toxic chemicals. Some ATOD-abusing parents allow their children to drink alcohol or use the drugs they find lying around the house. Some parents deliberately give their children alcohol or other drugs (i.e., tincture of opium) to reduce their crying, sedate them, or to induce intoxication to amuse the parents. any relatively healthy child with unexplained neurological symptoms, seizures, or death may have been exposed to drugs.

Physical Abuse.

Until recently, child-welfare agencies did not routinely screen for alcohol and drug abuse in caregivers of abused children. Because only about 40 percent of public child-welfare agencies and 71 percent of private child-welfare agencies even inquire about caregiver substance use, little is known about the incidence of substance abuse in child abuse cases. The Child Welfare League of America (CWLA) reported, after a 1990 survey of its 547 member agencies, that 37 percent of the children served by state agencies and 57 percent of children served by private agencies were estimated to be affected by ATOD family problems. A review of the literature found five studies suggesting a strong overlap between physical abuse and parental alcoholism. Physical and sexual abuse has been reported in 27 percent of alcoholic families and 19 percent of opiate-addicted families. Serious neglect was even more common (30.5%). Overall, 41 percent of children of addicts were found to be physically abused or neglected. In 1987, 50 percent of all reported child abuse and neglect cases in New York City were associated with parental drug abuse and 64 percent of cases were associated with parental alcohol and drug abuse. Of all child fatalities, 25 percent had related to a positive child drug toxicology (an overdose, OD).

ATOD abuse is frequently implicated when the courts remove a child from the home. A 1986 Illinois study indicated that 50 percent of all outplacements were from substance-abusing families and 68 percent of these parents refused ATOD treatment. Children growing up in abusive environments have increased, unfulfilled dependency needs, low self-esteem, distrust of others, and problems with aggression and anxiety.

Child Sexual Abuse.

A high percentage of drug abusers report that they were sexually abused as children. Child molesters are often intoxicated when the abuse occurs. Alcohol's influence on the brain allows a disinhibition of socially proscribed behaviors, including incest and the sexual molestation of children. A 1986 review of the research suggests that alcohol is involved in about 30 to 40 percent of child sexual-abuse cases, particularly when girls are abused. A 1988 study found 48 percent of fathers who had committed incest were alcoholic but 63 percent of fathers were drinking at the time of the abuse. Because of the high heritability rate of male-limited alcoholism (the most severe type of alcoholism associated with early drinking and antisocial behavior in males), sexually molested children may be more genetically vulnerable to ATOD-abused antisocial behavior. Thus, the cycle of childhood sexual abuse is perpetuated over generations, because of the overlap between the two types of abuse.

Childhood sexual abuse is a major risk factor for greater psychological distress, dissociative experiences, depression, eating disorders, relationship, trust, and intimacy difficulties, post-traumatic stress response, psychotic disorder, and heavy drug abuse. A very high percentage of drug abusers at inpatient and residential treatment programs report being sexually abused as children. When direct questions were asked of the clients, men's reports of childhood sexual abuse increased from four percent to 16 percent for adult males, and to 42 percent for adolescent males. Reports by women increased from 20 percent to 75 percent of adult women, and to a high of 90 percent for adolescent women. Other studies indicate that between 25 and 44 percent of female drug abusers report childhood sexual abuse compared to 15 percent of nonaddicted women.

Psychological conflicts arising from childhood sexual abuse are often a hidden factor contributing to drug abuse and relapse. Sexually molested children are reported to experience boundary inadequacy, resulting in difficulty establishing and enforcing the personal, psychological, or social boundaries necessary to maintain a sense of the self that is separate from other people. Hence, survivors of childhood sexual assault often do not see themselves as individuals separate from the desires or demands of others. The concept of refusing another person access to their bodies (and in later life, to their privacy, time, physical space, and possessions) has not been incorporated into their sense of identity. This leaves the survivors vulnerable to subsequent violations or coercive tactics throughout their lives. It could also lead adult survivors to become perpetrators who abuse their own or other children because of their own boundary inadequacies.

Risk Factors for Child Abuse by Substance Abusers.

Child-welfare authorities consider parental substance abuse to be a major risk factor for child abuse. Under the influence of alcohol and other drugs, adults are less inhibited and have reduced judgement and emotional control. Uppers (stimulants such as cocaine, methamphetamine, PCP, and amphetamines) can cause anxiety, irritability, paranoia, and aggressiveness. Downers (depressants such as alcohol, opiates, sedatives, and barbiturates) have also been related to depression, irritability, and loss of control while disciplining children. It has been suggested that organic brain damage, hypoglycemia, and sleep disturbances caused by alcohol exacerbates child abuse by alcoholics. ATOD-abusing parents are often irritable and angry because of neurochemical imbalances caused by persistent drug abuse. Some researchers attest that these neurochemical imbalances can last for several years after detoxification. Furthermore, neurotransmitter imbalances, which can be either biologically inherited or lifestyle-induced, may precede parental drug abuse and lead to self-medication with drugs. For example, excessively aggressive adolescent human and monkey males have been found to have lower levels of serotonin. Alcohol and carbohydrates increase brain levels of serotonin. Low levels of serotonin are associated with depression and eating disorders. Doctors prescribe serotonin-uptake inhibitors, such as fluoxetine (Prozac), to reduce mental disorder like depression and bulimia.

Psychosocial risk factors for child abuse include the following:

1. Modeling Physical and Sexual Abuse and Violence as seen in the child's home as enacted by adults or the abuser's friendship groups, or as portrayed in popular media (movies, television, radio). Drug abusers often belong to subcultures where violence is common. Children raised in violent homes are more likely to become abusers as adults, thus perpetuating the cycle of violence.
2. Family Violence and Conflict. High levels of family conflict found in drug-abusing families can lead to family violence. Absence of empathy and support among family members in the home environment increases the risk of child abuse and family violence. Ironically, women who are victimized by their spouses have pregnancy rates 2.3 times higher than national averages. Children growing up in abusive homes experience increased anxiety, powerlessness, and self-deprecation, which may lead to ATOD abuse and, in turn, to aggression, conflict, and physical/sexual abuse of others.
3. Poor Parenting Skills. Drug-abusing parents or caretakers have been found to have less adequate parenting skills, spend less time with their children, have unrealistic developmental expectations that can lead to excessive punishment, and lax, overly severe, or inconsistent discipline. Verbal abuse in the form of threatening, chastising, belittling, and criticizing are common. Studies have found that drug-abusing parents, whether in recovery or not, are able to increase their parenting skills after participating in a 14-week parent-training program (The Strengthening Families Program).
4. Poverty and Stress. Many children of drug-abusing parents or caretakers are raised in poverty. Money that would normally be available for food, clothing, transportation, medical and dental care, and to provide social and educational opportunities for the children is often diverted into purchases of tobacco, alcohol, and drugs. Crack-addicted parents sometimes use food stamps and welfare checks to purchase crack. Lack of money to handle daily crises elevates the usual level of life stressors and increases parental anger and irritability. Unemployment, which frequently results in low self-esteem, can lead to increased child abuse.
5. Mental Disorders. Approximately 90 percent of drug abusers have other mental disorders, such as depression, bipolar-affective disorder, narcissism, Antisocial Personality, organic brain disease, and psychosis. Mental disorders of this nature can have a severe impact on a person's ability to parent and can lead to child abuse. Parents suffering from antisocial personality and narcissism are less empathic toward their children's suffering. It is harder to decenter from their own perspective, needs, and emotions in order to consider the child's feelings. Depression, bipolar disorder, and psychosis can cause parents to become angry, irrational, and abusive. Parents with personality disorders are less likely to internalize societal taboos against child abuse and sexual abuse.
6. Physical Illness and Handicaps. Physical illness and physical handicaps can reduce the patience parents need to handle the stress inherent in dealing with children. Physical illness is more common in ATOD-abusing families because of their lifestyle and lack of preventive health care. Intravenous drug abusers and their children have higher rates of common infections, as well as increased exposure to diseases transmitted through the blood (HIV/AIDS and hepatitis), sexually transmitted diseases (syphilis, gonorrhea, and herpes), and tuberculosis.
7. Criminal Involvement. Drug-abusing parents are at high risk for criminal involvement by nature of their use alone or by the need to obtain considerable sums of money to support their habit. Prostitution, theft, and drug dealing are reported in about half of all drug-abusing parents. Arrest and incarceration may increase the stress on the family and can reduce inhibitions to sexual abuse upon reunification of the family.

Children of ATOD abusers frequently are more difficult to parent because of the increased prevalence of Attention Deficit Disorder (ADD), hyperactivity, Conduct Disorders, and learning disorders. Some of these difficult temperament characteristics are caused by in utero exposure to drugs, some by genetic inheritance, and others by lack of nurturing and inconsistent parenting. Regardless of the cause, children of ATOD-abusing parents are frequently the most difficult to raise, even if they are raised by unstressed, happy, healthy, non-ATOD-abusing parents.

PROPOSED RESPONSES

Reasonable evidence exists to indicate that children who are raised by ATOD-abusing parents are at increased risk of abuse and neglect, as well as of subsequent addiction and delinquent behaviors. Additional research is needed on the long-term effects of reported physical or sexual abuse. Because of the high overlap between child abuse and drug abuse, ATOD treatment agencies should routinely ask their clients if they have been or are being physically or sexually abused. It is also important that child-welfare agencies routinely determine whether caregiver or family member ATOD abuse is contributing to the maltreatment of children.

Because it is not possible to remove all children from risky family environments, additional research is needed on ways to protect children. Caregivers and professionals can help maltreated children to avoid abuse or become more psychologically resilient to future ATOD abuse. Some children are resilient to negative outcomes, even though they were exposed to drugs in utero or lived with drug-abusing parents. Some of these children were really never exposed to the same degree of negative influences because they were sheltered by a caring adult who addressed their needs. The emerging literature on resiliency processes and mechanisms should be reviewed and used to inform resiliency research with children of drug abusers and to make prevention interventions more effective.

Negative outcomes primarily appear to be related to the physical and emotional abuse and neglect typically endured by children of drug-abusing parents. Even children of drug-addicted mothers can be resilient to their high-risk environments if their mothers realize the negative impact of their chaotic street lives on their infants and work to improve their parenting skills. This may include finding external supports to learn parenting skills, such as parent-and-family-skills training programs, locating good early-childhood education for the child and outside child care, and possibly even considering foster care or adoption. Research has shown more positive outcomes for drug-exposed infants if the mothers were willing to use whatever external social supports were necessary to provide the best opportunities for learning and emotional growth for the child. Such mothers clearly were able to understand and empathize with their children's needs and were willing to separate from their infants for short or long periods, if necessary, for the welfare of their children.

(See also: Childhood Behavior and Later Drug Use ; Coping and Drug Use ; Family Violence and Substance Abuse ; Poverty and Drug Use )

BIBLIOGRAPHY

Adams, E. H., Gfroerer, J. C., & Rouse, B. A. (1989). Epidemiology of substance abuse including alcohol and cigarette smoking. Annals of the New York Academy of Science, 562, 14.

Burgess, A. (Ed.). (1985). Rape and sexual assault: A research handbook. New York: Garland.

CWLA North American Commission on Chemical Dependency and Child Welfare. (1992). Children at the front: A different view of the war on alcohol and drugs. Washington, DC: Child Welfare League of America.

Conte, J. R., & Berliner, L. (1988). The impact of sexual abuse on children: Empirical findings. In L. E. A. Walker (Ed.), Handbook of sexual abuse of children. New York: Springer.

Finkelhor, D. (1984). Child sexual abuse: New theory and research. New York: Free Press.

Finkelhor, D. (1986). A Sourcebook on child sexual abuse. Beverly Hills: Sage.

Rutter, M. (1990). Psychosocial resilience and protective mechanisms. In J. E. Rolf et al. (Eds.), Risk and protective factors in the development of psychopathology. New York: Cambridge University Press.

Karol L. Kumpfer

Jan Bays