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A study of the relationship between child abuse and drug addiction in 178 patients: Preliminary results
Ch,ij .Abusr and h
1982
0l45-?l3~~82/~UO3R?-o~so3 Go0 Cop)nphl I‘ 199: Pergamon Pree Lid
A STUDY OF THE RELATIONSHIP BETWEEN CHILD ABUSE AND DRUG ADDICTION IN 178 PATIENTS: PRELIMINARY RESULTS FREDERICKS. COHEN AND JUDIANNEDENSEN-GERBER J.D.. Odyssey
lnsntute.
Inc..
656
Avenue
of the Americas.
New
York.
New
York
M.D.
10010
Abstract-Social histories and demographic data were collected on 178 patients101 in the United States and 77 in Austraiia-in treatment for drup,alcohol addiction. The purpose of the study was to determme the degree to which a correlation exists between child abuseineglect and the later onset of drug/alcohol addictIon patterns m the abuse victims. The questionnaire explored such Issues as family intactness. parental violence’abuselneglect. parental drug abuse. sibling relationships and personal physical. sexual abuse tnstories. Including incest and rape The study deterrmned that 84% of the sample reported a hlstov of child abuse:neglect. Rbum&Le materiel itudik consistait en I78 patients. IO1 venant des Etats-Unis et 77 d’Australie. trait& pour toxicomanie 21 des stupkfiants ou trait& pour I’alcoolisme. Le but de l’etude ttait de determiner jusqu‘g quel de@ il existe une corrkiation entre maltraltance ou t-kgligence B I’kgard d’enfants et le dkveloppement plus tard chez les victlmes de ces pratiques d’une toxicomame g hautes drogues ou g I’aicool. Le moyen utilise itait un questionnaire qui explorait des fairs tels que I’int+rite de la famille. la violence et la nC@ence par les parents. les usages de drogues par les parents. les relations entre f&es et soeurs et Ies anamneses d’inctdents phvslques et sexuels. y compris I’inceste et le ~101. L’etude a dimontre’ que 84% de ces I78 patients toxicomanes avaient & victimes de s&ices ou de nkgligence dans leur enfance.
BACKGROUND Odyssey
House
ODYSSEY HOUSE is a residential (in-patient) therapeutic community treatment model which provides drug free. psychiatrically based rehabilitation services to substance abusers in the United States and Australia. The opening of the first Odyssey program in 1966 was in large part a response to the growing. untreated population of adult heroin addicts in New York City. However. in 1969, Odyssey opened its first adolescent treatment center. and in 1971 the Parents Program was opened. The Parents Program treats drug abusers and their children (up to the age of five) in the same facility. Staff provide around-the-clock supervision to the young while observing the nurturing habits of the parents. The goal of the Parents Program is to teach nurturing skills to adults who, because of their addiction, would chronically neglect or physically abuse their children. In some with support services-and so instances it is not possible to reconstruct the family unit -even alternative child care arrangements must be made. Within the first year of the Parents Program’s openin,, 0 clinical staff posed the question: “what has happened to these adults that compromises their ability-or desire-to nurture their child(ren)?” Observations of parent/child interaction and a reviem t of their social histories revealed several answers: A. Chronic dren. Presented
alcoholism
at the Third
and/or drug addiction
International
Congress
on Child
creates neglectful/abusive
Abuse 383
and Neglect.
Amsterdam,
environments
The Netherlands.
for chi!-
April
1981
381
Frederick
S. Cohen and Judianne Densen-Gerber
B. Unplanned and/or unwanted children are often met with parental ambivalence or hostility. C. Single parents in isolating circumstances often lack the coping skiils to sustain the environmental stress created by the dependency needs of a child. D. Adults who, in their own childhoods, did not experience a nurturing relationship with their parents, find it difficult to be nurturing. There are, of course, many other circumstantial indicators in child abuse or neglect situations; but (D) raises innumerable questions on the multi-generational passage of family disruption. Children carry the physical and emotional scars of abuse/neglect into adulthood. Odyssey’s experiences at the Parents Program suggested the necessity of inquiring into the childhood experiences of patients in other Odyssey programs. Since 1973 Odyssey’s patient charts have revealed a high incidence of child sex abuse, violence, and neglect which seem to be primary factors in those patients who have resorted to drugs to minimize dysphoria, create euphoria. or simply help get them through the day. These observations are the subject of the following inquiry.
DESCRIPTION The Odyssey House treatment model is a synthesis of various schools of behavioral science and psychiatry (e.g., Mifieu Therapy, Reality Therapy, Freud) with behavior modification techniques. Odyssey places its emphasis on the dual role of the trained professional clinician and the ex-addict role model working as a treatment team (medical model). Furthermore. it is the goal of Odyssey to return its patients to the community as drug-free, crime-free, productive citizensnot to remain in the safe, supportive structure of the treatment facility. Odyssey’s psychiatric thrust is more concerned with investigating addiction symptomatology than with addiction per se. resulting in a remarkable ability to rehabilitate a wide range of ethnic, religious, racial, geographic and diagnostic populations. This flexibility is the prime force behind the agency’s expansion throughout the United States and Australia. Odyssey’s adult treatment programs each serve 40-60 patients, except in Australia where larger facilities allow for a larger ~puiation. Selection for participation in the study was on a random basis, save only that ah were adults, at least 18 years of age. Each Odyssey program in the United States was to administer up tobut no more than-26 questionnaires to their existing patient population. For the two Australian programs, the upper limit on questionnaires was raised to 50 to elicit a larger sample size.
DESIGN An g-page questionnaire was administered Odyssey House programs, as follows: Australia: Melbourne Sydney United States: Louisiana Michigan New York Utah
-
31** 46**
-
2s 24 26 26
to 178 adult patients
**It was the original intent of the study to review 200 patients. been lost during transit.
However,
original
in residential
data on 23 Australian
treatment
patients has
at
Child abuse and drug addiction in 178 patients
385
The purpose of the questionnaire was to gather data on child abuse/neglect experiences of drug addicts and to attempt to determine the degree of correlation between child abuse/neglect and drug addiction.
RESULTS Before highlights of the study are discussed, * it is worthwhile to make a few general remarks on the locations from which the data was drawn: Australia: Racial composition is largely Caucasian. Minority groups include Aborigine and Southeast .4sian immigrants. Melbourne and Sydney are the most populous cities: both are modem and cosmopolitan. The most common drug of abuse is alcohol. Heroin addiction and other drug problems are a relatively new phenomena, due to general lack of availability prior to 1975. United States: New York (City)-heterogenous population; one of the highest levels of per capita drug addiction and violent crime in the nation. Michigan (Detroit)-primarily Black and Caucasian population; home of America’s automobile industry; high incidence of drug addiction, family violence. Louisiana (New Orleans)-unusual mix of Black, Caucasian and French/Spanish/Indian infiuences; highest per capita homicide rate in nation. Utah (Salt Lake City)-almost exclusively Caucasian; home of the Mormon Church, which has a great impact upon the city, discourages use of any drug (including alcohol and caffeine), and encourages family relationships; drug addicts tend to exhibit more psychopathology or social/cultural deviance. These comments were intended to draw attention to the diversity of environmental influences which characterize the four populations studied in the United States. The two Australian populations are much more homogeneous and so have not been presented individually. The demographic data (age, race, religion) is self-explanatory. It might be helpful to point out that in America males in treatment usually outnumber females on a three-to-one basis. in Australia, males outnumber females in treatment less than two-to-one. Seventeen questions focusing on the patient’s parents revealed: -Other than the New York sample? the incidence of adoption is unremarkable. -Divorce/separation figures are significant, though unremarkable. except for Utah where 54% of the sample had parental conflict (divorce/separation). -Although Australians report 27% parental divorce/separation, only 4% grew up in single parent homes. In America, Michigan reports 38% single parent homes. The next fourteen questions provide separate figures for the male and female parents, since it was anticipated that their behavior in these areas might significantly differ: -35% of the sample reported being physically abused by the male parent, 24% by the female parent; the physical abuse in Australia was 50% higher than in America. Michigan was the only sample to report greater abuse from mothers than from fathers. --In all instances, the female parent had no active role in sexual abuse, while in all but one sample the male parent was a sexual aggressor. Note the Utah figure of 8%-twice that of any other population. -Australian fathers were reported twice as often as mothers for neglect. American fathers
*For further reference. the questionnaire and the Data Summary are available from the authors.
386
Frederick S. Cohen and Judianne Densen-Gerber
were reported only one-third more often than mothers for neglect. except in Utah where neglectful mothers out-numbered fathers and both parents were proportionately more neglectful than in the rest of the country. -All samples reported mothers to be more protective than fathers. -Fathers were reported violent more than twice as often as mothers. Michigan’s sample uniquely reported a higher percentage of violent mothers. -Parental criminal activity was fairly consistent, with fathers involved three times more often than mothers. -All samples report psychiatric problems with mothers more than with fathers. Utah reports a very high 50% of all mothers. ---In all samples, alcohol use by fathers was greater than by mothers. Significantly. Utah. where the Mormon Church exerts its greatest influence on the use of alcohol. reports the highest percentage of drinking parents. -For the entire sa.nple, use of prescription drugs is found approximately 50% more often amongst mothers than fathers. Utah reports high percentages of prescription use for both parents, particularly mothers. The next five questions on parental drug use reveal nothing noteworthy. However. it should be pointed out that the Utah sample consistently shows a higher percentage of drug use among mothers. Seven questions were asked about siblings: -Average number of siblings is 3. -Utah reports significantly higher alcohol use by siblings than the rest of the sample. -New York reports significantly higher marijuana use by siblings than the rest of the sample. -Reports of non-opiate use and opiate use are unremarkable. -Utah reports the highest percentage of criminal history among siblings. -Reports of psychiatric history among siblings shows Michigan-where levels of antisocial behavior are highest and require less devianceto be lowest: Utah is highest again suggesting more deviance from social norms. Ten questions relating to patient histories of child abuse and neglect were asked. Patients were asked to respond separately to trauma before twelve years of age and trauma after twelve to ascertain, in part, the role of the onset of puberty to sexual abuse: -Reports of neglect from 23% to 4676, with a significant average of 39% under twelve years of age. Neglect figures over twelve are not considered pertinent to this study. -As expected, reports of female sexual abuse (molestation. fondling, prostitution) were significant, with an average 33% reporting for the entire sample. Louisiana reports low, suggesting here as in other areas the presence of a more intact, extended family. Utah reports a remarkably high incidence of female sexual abuse. -As expected, reports of male sexual abuse were significantly lower than for females. -Reports of male incest were generally low, but significantly lower than for females. -Reports of male incest were generally low. but significantly higher in Australia than in the United States. -Reports of female incest averaged 28% of the sample. ranging from 5% in Louisiana to 50% in Utah. Incest after the age of 12 (puberty) generally stopped. -Reports of male rape were generally unremarkable. -Reports of female rape were as expected: three times higher after puberty and often reported by half the sample or more. -A larger percentage of the Australian patients reported physical violence but the average for the entire sample was high at 38%. -43% of the sample reported family violence under the age of 12 (corroborating the Strauss and Gelles studies).
Child
abuse and drug addiction
m I78 patients
387
-Generally. the sample’s report of non-family violence supported the responses for family violence. Two questions on relocation were asked to ascertain the extent of family disruption and uprootedness. These issues warrant further study. Nine questions about drug abuse w’ere asked to validate their presence in a treatment program and as a pre-requisite for participation in this study. Three questions about crime were asked. As would be expected of a drug abusing population, involvement in criminal activity was very high. Males were more frequently involved in crime than were females.
WEAKNESSES The greatest weakness in this study lies in the very nature of the information-gathering tool- the questionnaire. Inasmuch as the responses to questions are subjective. there is a risk that each person responding to “physical abuse” or “sexual abuse” will do so from a personal, statistically inconsistent, frame of reference. In order to reduce the chances of non-relevant responses. the questionnaires were administered by staff who defined for the participants the behavioral manifestation of physical and sexual abuse. i.e.: physical: beating, burning, slapping, shooting, stabbing. starvation, physical isolation, kicking sexual: fondling. molestation. penetration (anal/vaginal), oralipenital contact, masturbation, pornography, prostitution It was expected that this preparatory discussion would, to the extent possible. mitigate against non-relevent, subjective responses.
CONCLUSIONS Of a sample population of 178 adult patients in treatment for drug abuse 84% reported a history of child abuse. Therefore: even given obvious weaknesses in the study. it would be safe to conclude that if child abuse has a great bearing on the formation of adult coping mechanisms-the lack of such mechanisms in a complex. competitive urban environment would leave the individual easy prey to involvement with drugs.
1982
0l45-?l3~~82/~UO3R?-o~so3 Go0 Cop)nphl I‘ 199: Pergamon Pree Lid
A STUDY OF THE RELATIONSHIP BETWEEN CHILD ABUSE AND DRUG ADDICTION IN 178 PATIENTS: PRELIMINARY RESULTS FREDERICKS. COHEN AND JUDIANNEDENSEN-GERBER J.D.. Odyssey
lnsntute.
Inc..
656
Avenue
of the Americas.
New
York.
New
York
M.D.
10010
Abstract-Social histories and demographic data were collected on 178 patients101 in the United States and 77 in Austraiia-in treatment for drup,alcohol addiction. The purpose of the study was to determme the degree to which a correlation exists between child abuseineglect and the later onset of drug/alcohol addictIon patterns m the abuse victims. The questionnaire explored such Issues as family intactness. parental violence’abuselneglect. parental drug abuse. sibling relationships and personal physical. sexual abuse tnstories. Including incest and rape The study deterrmned that 84% of the sample reported a hlstov of child abuse:neglect. Rbum&Le materiel itudik consistait en I78 patients. IO1 venant des Etats-Unis et 77 d’Australie. trait& pour toxicomanie 21 des stupkfiants ou trait& pour I’alcoolisme. Le but de l’etude ttait de determiner jusqu‘g quel de@ il existe une corrkiation entre maltraltance ou t-kgligence B I’kgard d’enfants et le dkveloppement plus tard chez les victlmes de ces pratiques d’une toxicomame g hautes drogues ou g I’aicool. Le moyen utilise itait un questionnaire qui explorait des fairs tels que I’int+rite de la famille. la violence et la nC@ence par les parents. les usages de drogues par les parents. les relations entre f&es et soeurs et Ies anamneses d’inctdents phvslques et sexuels. y compris I’inceste et le ~101. L’etude a dimontre’ que 84% de ces I78 patients toxicomanes avaient & victimes de s&ices ou de nkgligence dans leur enfance.
BACKGROUND Odyssey
House
ODYSSEY HOUSE is a residential (in-patient) therapeutic community treatment model which provides drug free. psychiatrically based rehabilitation services to substance abusers in the United States and Australia. The opening of the first Odyssey program in 1966 was in large part a response to the growing. untreated population of adult heroin addicts in New York City. However. in 1969, Odyssey opened its first adolescent treatment center. and in 1971 the Parents Program was opened. The Parents Program treats drug abusers and their children (up to the age of five) in the same facility. Staff provide around-the-clock supervision to the young while observing the nurturing habits of the parents. The goal of the Parents Program is to teach nurturing skills to adults who, because of their addiction, would chronically neglect or physically abuse their children. In some with support services-and so instances it is not possible to reconstruct the family unit -even alternative child care arrangements must be made. Within the first year of the Parents Program’s openin,, 0 clinical staff posed the question: “what has happened to these adults that compromises their ability-or desire-to nurture their child(ren)?” Observations of parent/child interaction and a reviem t of their social histories revealed several answers: A. Chronic dren. Presented
alcoholism
at the Third
and/or drug addiction
International
Congress
on Child
creates neglectful/abusive
Abuse 383
and Neglect.
Amsterdam,
environments
The Netherlands.
for chi!-
April
1981
381
Frederick
S. Cohen and Judianne Densen-Gerber
B. Unplanned and/or unwanted children are often met with parental ambivalence or hostility. C. Single parents in isolating circumstances often lack the coping skiils to sustain the environmental stress created by the dependency needs of a child. D. Adults who, in their own childhoods, did not experience a nurturing relationship with their parents, find it difficult to be nurturing. There are, of course, many other circumstantial indicators in child abuse or neglect situations; but (D) raises innumerable questions on the multi-generational passage of family disruption. Children carry the physical and emotional scars of abuse/neglect into adulthood. Odyssey’s experiences at the Parents Program suggested the necessity of inquiring into the childhood experiences of patients in other Odyssey programs. Since 1973 Odyssey’s patient charts have revealed a high incidence of child sex abuse, violence, and neglect which seem to be primary factors in those patients who have resorted to drugs to minimize dysphoria, create euphoria. or simply help get them through the day. These observations are the subject of the following inquiry.
DESCRIPTION The Odyssey House treatment model is a synthesis of various schools of behavioral science and psychiatry (e.g., Mifieu Therapy, Reality Therapy, Freud) with behavior modification techniques. Odyssey places its emphasis on the dual role of the trained professional clinician and the ex-addict role model working as a treatment team (medical model). Furthermore. it is the goal of Odyssey to return its patients to the community as drug-free, crime-free, productive citizensnot to remain in the safe, supportive structure of the treatment facility. Odyssey’s psychiatric thrust is more concerned with investigating addiction symptomatology than with addiction per se. resulting in a remarkable ability to rehabilitate a wide range of ethnic, religious, racial, geographic and diagnostic populations. This flexibility is the prime force behind the agency’s expansion throughout the United States and Australia. Odyssey’s adult treatment programs each serve 40-60 patients, except in Australia where larger facilities allow for a larger ~puiation. Selection for participation in the study was on a random basis, save only that ah were adults, at least 18 years of age. Each Odyssey program in the United States was to administer up tobut no more than-26 questionnaires to their existing patient population. For the two Australian programs, the upper limit on questionnaires was raised to 50 to elicit a larger sample size.
DESIGN An g-page questionnaire was administered Odyssey House programs, as follows: Australia: Melbourne Sydney United States: Louisiana Michigan New York Utah
-
31** 46**
-
2s 24 26 26
to 178 adult patients
**It was the original intent of the study to review 200 patients. been lost during transit.
However,
original
in residential
data on 23 Australian
treatment
patients has
at
Child abuse and drug addiction in 178 patients
385
The purpose of the questionnaire was to gather data on child abuse/neglect experiences of drug addicts and to attempt to determine the degree of correlation between child abuse/neglect and drug addiction.
RESULTS Before highlights of the study are discussed, * it is worthwhile to make a few general remarks on the locations from which the data was drawn: Australia: Racial composition is largely Caucasian. Minority groups include Aborigine and Southeast .4sian immigrants. Melbourne and Sydney are the most populous cities: both are modem and cosmopolitan. The most common drug of abuse is alcohol. Heroin addiction and other drug problems are a relatively new phenomena, due to general lack of availability prior to 1975. United States: New York (City)-heterogenous population; one of the highest levels of per capita drug addiction and violent crime in the nation. Michigan (Detroit)-primarily Black and Caucasian population; home of America’s automobile industry; high incidence of drug addiction, family violence. Louisiana (New Orleans)-unusual mix of Black, Caucasian and French/Spanish/Indian infiuences; highest per capita homicide rate in nation. Utah (Salt Lake City)-almost exclusively Caucasian; home of the Mormon Church, which has a great impact upon the city, discourages use of any drug (including alcohol and caffeine), and encourages family relationships; drug addicts tend to exhibit more psychopathology or social/cultural deviance. These comments were intended to draw attention to the diversity of environmental influences which characterize the four populations studied in the United States. The two Australian populations are much more homogeneous and so have not been presented individually. The demographic data (age, race, religion) is self-explanatory. It might be helpful to point out that in America males in treatment usually outnumber females on a three-to-one basis. in Australia, males outnumber females in treatment less than two-to-one. Seventeen questions focusing on the patient’s parents revealed: -Other than the New York sample? the incidence of adoption is unremarkable. -Divorce/separation figures are significant, though unremarkable. except for Utah where 54% of the sample had parental conflict (divorce/separation). -Although Australians report 27% parental divorce/separation, only 4% grew up in single parent homes. In America, Michigan reports 38% single parent homes. The next fourteen questions provide separate figures for the male and female parents, since it was anticipated that their behavior in these areas might significantly differ: -35% of the sample reported being physically abused by the male parent, 24% by the female parent; the physical abuse in Australia was 50% higher than in America. Michigan was the only sample to report greater abuse from mothers than from fathers. --In all instances, the female parent had no active role in sexual abuse, while in all but one sample the male parent was a sexual aggressor. Note the Utah figure of 8%-twice that of any other population. -Australian fathers were reported twice as often as mothers for neglect. American fathers
*For further reference. the questionnaire and the Data Summary are available from the authors.
386
Frederick S. Cohen and Judianne Densen-Gerber
were reported only one-third more often than mothers for neglect. except in Utah where neglectful mothers out-numbered fathers and both parents were proportionately more neglectful than in the rest of the country. -All samples reported mothers to be more protective than fathers. -Fathers were reported violent more than twice as often as mothers. Michigan’s sample uniquely reported a higher percentage of violent mothers. -Parental criminal activity was fairly consistent, with fathers involved three times more often than mothers. -All samples report psychiatric problems with mothers more than with fathers. Utah reports a very high 50% of all mothers. ---In all samples, alcohol use by fathers was greater than by mothers. Significantly. Utah. where the Mormon Church exerts its greatest influence on the use of alcohol. reports the highest percentage of drinking parents. -For the entire sa.nple, use of prescription drugs is found approximately 50% more often amongst mothers than fathers. Utah reports high percentages of prescription use for both parents, particularly mothers. The next five questions on parental drug use reveal nothing noteworthy. However. it should be pointed out that the Utah sample consistently shows a higher percentage of drug use among mothers. Seven questions were asked about siblings: -Average number of siblings is 3. -Utah reports significantly higher alcohol use by siblings than the rest of the sample. -New York reports significantly higher marijuana use by siblings than the rest of the sample. -Reports of non-opiate use and opiate use are unremarkable. -Utah reports the highest percentage of criminal history among siblings. -Reports of psychiatric history among siblings shows Michigan-where levels of antisocial behavior are highest and require less devianceto be lowest: Utah is highest again suggesting more deviance from social norms. Ten questions relating to patient histories of child abuse and neglect were asked. Patients were asked to respond separately to trauma before twelve years of age and trauma after twelve to ascertain, in part, the role of the onset of puberty to sexual abuse: -Reports of neglect from 23% to 4676, with a significant average of 39% under twelve years of age. Neglect figures over twelve are not considered pertinent to this study. -As expected, reports of female sexual abuse (molestation. fondling, prostitution) were significant, with an average 33% reporting for the entire sample. Louisiana reports low, suggesting here as in other areas the presence of a more intact, extended family. Utah reports a remarkably high incidence of female sexual abuse. -As expected, reports of male sexual abuse were significantly lower than for females. -Reports of male incest were generally low, but significantly lower than for females. -Reports of male incest were generally low. but significantly higher in Australia than in the United States. -Reports of female incest averaged 28% of the sample. ranging from 5% in Louisiana to 50% in Utah. Incest after the age of 12 (puberty) generally stopped. -Reports of male rape were generally unremarkable. -Reports of female rape were as expected: three times higher after puberty and often reported by half the sample or more. -A larger percentage of the Australian patients reported physical violence but the average for the entire sample was high at 38%. -43% of the sample reported family violence under the age of 12 (corroborating the Strauss and Gelles studies).
Child
abuse and drug addiction
m I78 patients
387
-Generally. the sample’s report of non-family violence supported the responses for family violence. Two questions on relocation were asked to ascertain the extent of family disruption and uprootedness. These issues warrant further study. Nine questions about drug abuse w’ere asked to validate their presence in a treatment program and as a pre-requisite for participation in this study. Three questions about crime were asked. As would be expected of a drug abusing population, involvement in criminal activity was very high. Males were more frequently involved in crime than were females.
WEAKNESSES The greatest weakness in this study lies in the very nature of the information-gathering tool- the questionnaire. Inasmuch as the responses to questions are subjective. there is a risk that each person responding to “physical abuse” or “sexual abuse” will do so from a personal, statistically inconsistent, frame of reference. In order to reduce the chances of non-relevant responses. the questionnaires were administered by staff who defined for the participants the behavioral manifestation of physical and sexual abuse. i.e.: physical: beating, burning, slapping, shooting, stabbing. starvation, physical isolation, kicking sexual: fondling. molestation. penetration (anal/vaginal), oralipenital contact, masturbation, pornography, prostitution It was expected that this preparatory discussion would, to the extent possible. mitigate against non-relevent, subjective responses.
CONCLUSIONS Of a sample population of 178 adult patients in treatment for drug abuse 84% reported a history of child abuse. Therefore: even given obvious weaknesses in the study. it would be safe to conclude that if child abuse has a great bearing on the formation of adult coping mechanisms-the lack of such mechanisms in a complex. competitive urban environment would leave the individual easy prey to involvement with drugs.