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Adverse childhood events, substance abuse, and measures of affiliation
Addictive Behaviors 29 (2004) 1177 – 1181
Short communication
Adverse childhood events, substance abuse, and measures of affiliation Cheryl Zlotnicka,b,*, Tammy Tama, Marjorie J. Robertsona a
Alcohol Research Group-Public Health Institute, 2000 Hearst Avenue, Berkeley, CA 94709, USA Center for the Vulnerable Child, Children’s Hospital and Research Center at Oakland, 747 52nd Street, Oakland, CA 94609-1809, USA
b
Abstract Adverse childhood events may influence later behaviors, including adulthood substance use and social affiliation. Studies have noted high prevalence rates of adverse childhood experiences and adulthood substance abuse among homeless adults. Using an existing longitudinal, countywide probability sample of 397 homeless adults, we examine the relationships among adverse childhood events on adulthood substance use, and the relationship of these variables to affiliation. Almost 75% of the sample had experienced an adverse childhood event. Path analysis indicated adulthood substance abuse mediated the inverse relationship between adverse childhood events and two measures of adulthood affiliation. Thus, although there is a relationship between adverse childhood events and adulthood substance use, it is adulthood substance use that determines most aspects of affiliation. D 2004 Elsevier Ltd. All rights reserved. Keywords: Homelessness; Alcohol; Substance use; Foster care; Social affiliation
1. Introduction Substance abuse is a common problem among homeless adults that too often is associated with decreased social affiliation and abdication of social roles, such as worker, resulting in unemployment and as parent, resulting in loss of parental rights and foster care placement. Equally interesting is the repeated finding that a disproportionate number of homeless adult men and women have experienced adverse childhood events. Thus, we used an existing * Corresponding author. Alcohol Research Group-Public Health Institute, 2000 Hearst Avenue, Berkeley, CA 94709, USA. Tel.: +1-510-428-3783; fax: +1-510-601-3913. E-mail address: [email protected] (C. Zlotnick). 0306-4603/$ – see front matter D 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.addbeh.2004.01.005
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longitudinal data set to examine the temporal relationships among adverse childhood events on adulthood substance use, and the relationship of these variables to affiliation among homeless adults.
2. Methods This Study of Alameda County Homeless Residents (STAR) data set is an existing threewave longitudinal data set with a total of 397 homeless adults. The methodology used to sample and collect data for the STAR Project was described elsewhere in more detail (Zlotnick, Robertson, & Lahiff, 1999). Demographic data were collected at baseline. Duration of homelessness was measured by asking respondents at baseline to estimate the total days spent homeless since age 18. Adverse childhood events referred to the respondents’ experiences when they were under 18 years of age, including a history of the following: living in a foster care, group home, or other out-ofhome placement; sexual abuse; physical abuse; running away from home for seven nights or more; being arrested; homelessness; and early regular alcohol or drug use. A new variable was created to indicate the number of adverse childhood events that were reported by each respondent. The summed variable ‘‘adverse childhood events’’ was used in the path model. Substance-use disorders and major mental disorders were assessed at baseline using the Diagnostic Interview Schedule, Version III Revised (DIS-III-R). In addition, we created the variable ‘‘heavy, consistent substance abuse’’ to indicate whether respondents met either the alcohol severity criteria (drinking five or more drinks of alcohol every day for the past 30 days at all three waves) or the drug severity criteria (using any drug every day for the past 30 days at all three waves). Support from family and friends and social service use were assessed at all three waves and were subdivided into three areas: instrumental support from family and friends; perceived support; and contacts with family and friends. Each response referred to the 30-day period prior to that interview. The path model used responses from the third wave interview (completed at the 15-month follow-up) for each indicator of support. Social services received by respondents were measured by the following three items in each interview: (1) number of agencies where the respondent was being assisted by a counselor or advocate or case manager; (2) number of types of assistance the agencies or advocates provided; and (3) whether respondents received help applying for entitlements, including Aid to Families with Dependent Children, Supplemental Security Income or Social Security Disability Income, and General Assistance. Details on the creation of the composite score for support and social services are provided in a previous paper (Zlotnick, Tam, & Robertson, 2003).
3. Results All analyses were conducted using SPSS and Mplus. The proposed path model was tested using Mplus (Muthen & Muthen, 1998). Model v2 with degrees of freedom, root mean square
C. Zlotnick et al. / Addictive Behaviors 29 (2004) 1177–1181
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error of approximation (RMSEA), and comparative fit index (CFI) are reported to assess the model fit. Standardized b coefficients and standard errors are provided in the text. For bivariate analyses, significance was declared at P < .05. Of the 397 homeless persons who completed baseline and follow-up interviews, the majority were male (74.8%), over 35 years old (60.7%), had high school education (72.1%), were African American (66.5%), and were married at least once (52.6%). Almost threequarters of the sample had experienced at least one adverse childhood event. About one third had lived in an out-of-home placement, ran away from home for seven nights or more, had been arrested before age 18, or had substance abuse problems before age 18. The vast majority had reported recent heavy alcohol use or daily drug use during the 30-day period before at least one of the three interviews. When we examined the relationship between adverse childhood events and substance abuse, we found that consistent heavy alcohol use (i.e., for all three waves of data collection) was unrelated to adverse childhood events; however, a significant relationship was noted between consistent heavy drug use and adverse childhood events. In fact, 78.4% of consistent heavy drug users, compared to 55.1% who were not, had experienced at least one adverse childhood event ( P < .0001; not shown). To obtain a clearer view of relationships among measures of affiliation, recent heavy substance use, and selected demographic variables and childhood events, we constructed a path model. Illustrated in Fig. 1, the path model was specified based on the following hypotheses: (1) adverse childhood events and other demographic variables will be associated with heavy substance use; (2) the effect of adverse childhood events on adult affiliation (i.e., number of service contacts, number of contacts with family/friends, and level of perceived support) will be mediated by heavy adulthood substance use; and (3) over and above the mediating effects of adulthood substance use, adverse childhood events and other demographic characteristics (i.e., gender, age, chronic homelessness, marital status, and current
Fig. 1. Path model.
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substance use disorder) will have direct effects on measures of affiliation (as indicated by dotted arrows in Fig. 1). The path model demonstrated good fit (v2 = 22.32, df = 12, P=.034; RMSEA = 0.047; CFI = 0.942). The following significant ( P < .05) relationships were found. Adverse child events (Std b=.091, S.E. = 0.027), chronic homelessness (Std b=.161, S.E. = 0.095), age greater than 35 years (Std b=.146, S.E. = 0.101), and diagnosis of a current drug or alcohol use disorder (Std b=.351, S.E. = 0.093) were positively associated with current heavy alcohol or drug use over the three waves of data collection. Heavy alcohol or drug use over the three waves of data collection was negatively associated with number of service contacts (Std b = .136, S.E. = 0.013) and with level of perceived support (Std b = .119, S.E. = 0.369). Although not shown in Fig. 1, significant direct effects on contact with family and friends were found for: current drug or alcohol use disorder (Std b=.226, S.E. = 0.017), age of greater than 35 years (Std b = .139, S.E. = 0.016), and chronic homelessness (Std b = .151, S.E. = 0.016). Direct effects on number of service contacts were found with current drug- or alcohol-use disorder (Std b=.154, S.E. = 0.026); and direct effects on level of perceived support were found with marital status (Std b=.103, S.E. = 0.722) and female gender (Std b = .122, S.E. = 0.826).
4. Conclusions This study hypothesized that among homeless adults: (1) adverse childhood events will have a direct effect on heavy consistent adulthood substance abuse; (2) the effects of adverse childhood events on affiliation will be mediated by heavy consistent adulthood substance abuse; and (3) over and above the mediating effects of heavy consistent adulthood substance abuse, adverse childhood events will have direct effects on affiliation. For the first hypothesis, adverse childhood events were associated with heavy consistent adulthood substance abuse. Surprisingly, in the bivariate analysis, adverse childhood events were associated with adulthood drug abuse, but not adulthood alcohol abuse. As with the bivariate analyses using adulthood drug abuse, the path model indicated that adverse childhood events contributed to heavy consistent substance use (defined as either drug or alcohol use). This study adds to the current literature by demonstrating that this relationship exists among homeless sample as well as nonhomeless adults (Brabant, Forsyth, & LeBlanc, 1997). As hypothesized and consistent with other studies, adverse childhood events predicted consistent heavy adulthood substance abuse (Wilsnack, Vogeltanz, Klassen, & Harris, 1997). In addition, consistent heavy substance abuse was inversely related to contacts with service agencies and perceived support. However, consistent heavy substance abuse did not influence contacts with family or friends. This last relationship was unexpected and inconsistent with other studies (Grigsby, Baumann, Gregorich, & Roberts-Gray, 1990). Many substance abusers are characterized as avoiding former family or friends. A possible explanation for this study’s finding is that all contacts, even those involving substance use, were included.
C. Zlotnick et al. / Addictive Behaviors 29 (2004) 1177–1181
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The last hypothesis examined the direct effects of baseline characteristics, including adverse childhood events, on affiliation. We found no direct effect in the path model between adverse childhood events and affiliation that further highlights the important mediating effect that consistent heavy adulthood substance abuse has on the relationship between those two variables. Adverse childhood events were antecedents to and had an inverse relationship with consistent heavy substance abuse, which was a mediator to two of the three variables reflecting affiliation (i.e., perceived support and service use). In addition, we noted a significant association between adverse childhood events (of any type) and number of services or number of contacts with family or friends. Note that the data used in this study are based on self-reported and are subject to recall bias. Moreover, due to the sampling frame, findings may not generalize to homeless adults elsewhere.
Acknowledgements This work was supported by grants from the National Institute on Alcohol Abuse and Alcoholism (AA12019) and the National Institute of Mental Health (MH51651 and MH46104).
References Brabant, S., Forsyth, C. J., & LeBlanc, J. B. (1997). Childhood sexual trauma and substance misuse: A pilot study. Substance Use and Misuse, 32(10), 1417 – 1431. Grigsby, C., Baumann, D., Gregorich, S. E., & Roberts-Gray, C. (1990). Disaffiliation to entrenchment: A model for understanding homelessness. Journal of Social Issues, 46(4), 141 – 156. Muthen, L. K., & Muthen, B. (1998). Mplus users guide. Los Angeles: Muthen & Muthen. Wilsnack, S. C., Vogeltanz, N. D., Klassen, A. D., & Harris, T. R. (1997). Childhood sexual abuse and women’s substance abuse: National survey findings. Journal of Studies on Alcohol, 58, 264 – 271. Zlotnick, C., Robertson, M. J., & Lahiff, M. (1999). Getting off the streets: Economic resources and residential exits from homelessness. Journal of Community Psychology, 27(2), 209 – 224.. Zlotnick, C., Tam, T., Robertson, M.J. (2003). Disaffiliation, substance abuse and exiting homelessness. Substance Use and Misuse, 38(3-6), 577 – 599.
Short communication
Adverse childhood events, substance abuse, and measures of affiliation Cheryl Zlotnicka,b,*, Tammy Tama, Marjorie J. Robertsona a
Alcohol Research Group-Public Health Institute, 2000 Hearst Avenue, Berkeley, CA 94709, USA Center for the Vulnerable Child, Children’s Hospital and Research Center at Oakland, 747 52nd Street, Oakland, CA 94609-1809, USA
b
Abstract Adverse childhood events may influence later behaviors, including adulthood substance use and social affiliation. Studies have noted high prevalence rates of adverse childhood experiences and adulthood substance abuse among homeless adults. Using an existing longitudinal, countywide probability sample of 397 homeless adults, we examine the relationships among adverse childhood events on adulthood substance use, and the relationship of these variables to affiliation. Almost 75% of the sample had experienced an adverse childhood event. Path analysis indicated adulthood substance abuse mediated the inverse relationship between adverse childhood events and two measures of adulthood affiliation. Thus, although there is a relationship between adverse childhood events and adulthood substance use, it is adulthood substance use that determines most aspects of affiliation. D 2004 Elsevier Ltd. All rights reserved. Keywords: Homelessness; Alcohol; Substance use; Foster care; Social affiliation
1. Introduction Substance abuse is a common problem among homeless adults that too often is associated with decreased social affiliation and abdication of social roles, such as worker, resulting in unemployment and as parent, resulting in loss of parental rights and foster care placement. Equally interesting is the repeated finding that a disproportionate number of homeless adult men and women have experienced adverse childhood events. Thus, we used an existing * Corresponding author. Alcohol Research Group-Public Health Institute, 2000 Hearst Avenue, Berkeley, CA 94709, USA. Tel.: +1-510-428-3783; fax: +1-510-601-3913. E-mail address: [email protected] (C. Zlotnick). 0306-4603/$ – see front matter D 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.addbeh.2004.01.005
1178
C. Zlotnick et al. / Addictive Behaviors 29 (2004) 1177–1181
longitudinal data set to examine the temporal relationships among adverse childhood events on adulthood substance use, and the relationship of these variables to affiliation among homeless adults.
2. Methods This Study of Alameda County Homeless Residents (STAR) data set is an existing threewave longitudinal data set with a total of 397 homeless adults. The methodology used to sample and collect data for the STAR Project was described elsewhere in more detail (Zlotnick, Robertson, & Lahiff, 1999). Demographic data were collected at baseline. Duration of homelessness was measured by asking respondents at baseline to estimate the total days spent homeless since age 18. Adverse childhood events referred to the respondents’ experiences when they were under 18 years of age, including a history of the following: living in a foster care, group home, or other out-ofhome placement; sexual abuse; physical abuse; running away from home for seven nights or more; being arrested; homelessness; and early regular alcohol or drug use. A new variable was created to indicate the number of adverse childhood events that were reported by each respondent. The summed variable ‘‘adverse childhood events’’ was used in the path model. Substance-use disorders and major mental disorders were assessed at baseline using the Diagnostic Interview Schedule, Version III Revised (DIS-III-R). In addition, we created the variable ‘‘heavy, consistent substance abuse’’ to indicate whether respondents met either the alcohol severity criteria (drinking five or more drinks of alcohol every day for the past 30 days at all three waves) or the drug severity criteria (using any drug every day for the past 30 days at all three waves). Support from family and friends and social service use were assessed at all three waves and were subdivided into three areas: instrumental support from family and friends; perceived support; and contacts with family and friends. Each response referred to the 30-day period prior to that interview. The path model used responses from the third wave interview (completed at the 15-month follow-up) for each indicator of support. Social services received by respondents were measured by the following three items in each interview: (1) number of agencies where the respondent was being assisted by a counselor or advocate or case manager; (2) number of types of assistance the agencies or advocates provided; and (3) whether respondents received help applying for entitlements, including Aid to Families with Dependent Children, Supplemental Security Income or Social Security Disability Income, and General Assistance. Details on the creation of the composite score for support and social services are provided in a previous paper (Zlotnick, Tam, & Robertson, 2003).
3. Results All analyses were conducted using SPSS and Mplus. The proposed path model was tested using Mplus (Muthen & Muthen, 1998). Model v2 with degrees of freedom, root mean square
C. Zlotnick et al. / Addictive Behaviors 29 (2004) 1177–1181
1179
error of approximation (RMSEA), and comparative fit index (CFI) are reported to assess the model fit. Standardized b coefficients and standard errors are provided in the text. For bivariate analyses, significance was declared at P < .05. Of the 397 homeless persons who completed baseline and follow-up interviews, the majority were male (74.8%), over 35 years old (60.7%), had high school education (72.1%), were African American (66.5%), and were married at least once (52.6%). Almost threequarters of the sample had experienced at least one adverse childhood event. About one third had lived in an out-of-home placement, ran away from home for seven nights or more, had been arrested before age 18, or had substance abuse problems before age 18. The vast majority had reported recent heavy alcohol use or daily drug use during the 30-day period before at least one of the three interviews. When we examined the relationship between adverse childhood events and substance abuse, we found that consistent heavy alcohol use (i.e., for all three waves of data collection) was unrelated to adverse childhood events; however, a significant relationship was noted between consistent heavy drug use and adverse childhood events. In fact, 78.4% of consistent heavy drug users, compared to 55.1% who were not, had experienced at least one adverse childhood event ( P < .0001; not shown). To obtain a clearer view of relationships among measures of affiliation, recent heavy substance use, and selected demographic variables and childhood events, we constructed a path model. Illustrated in Fig. 1, the path model was specified based on the following hypotheses: (1) adverse childhood events and other demographic variables will be associated with heavy substance use; (2) the effect of adverse childhood events on adult affiliation (i.e., number of service contacts, number of contacts with family/friends, and level of perceived support) will be mediated by heavy adulthood substance use; and (3) over and above the mediating effects of adulthood substance use, adverse childhood events and other demographic characteristics (i.e., gender, age, chronic homelessness, marital status, and current
Fig. 1. Path model.
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substance use disorder) will have direct effects on measures of affiliation (as indicated by dotted arrows in Fig. 1). The path model demonstrated good fit (v2 = 22.32, df = 12, P=.034; RMSEA = 0.047; CFI = 0.942). The following significant ( P < .05) relationships were found. Adverse child events (Std b=.091, S.E. = 0.027), chronic homelessness (Std b=.161, S.E. = 0.095), age greater than 35 years (Std b=.146, S.E. = 0.101), and diagnosis of a current drug or alcohol use disorder (Std b=.351, S.E. = 0.093) were positively associated with current heavy alcohol or drug use over the three waves of data collection. Heavy alcohol or drug use over the three waves of data collection was negatively associated with number of service contacts (Std b = .136, S.E. = 0.013) and with level of perceived support (Std b = .119, S.E. = 0.369). Although not shown in Fig. 1, significant direct effects on contact with family and friends were found for: current drug or alcohol use disorder (Std b=.226, S.E. = 0.017), age of greater than 35 years (Std b = .139, S.E. = 0.016), and chronic homelessness (Std b = .151, S.E. = 0.016). Direct effects on number of service contacts were found with current drug- or alcohol-use disorder (Std b=.154, S.E. = 0.026); and direct effects on level of perceived support were found with marital status (Std b=.103, S.E. = 0.722) and female gender (Std b = .122, S.E. = 0.826).
4. Conclusions This study hypothesized that among homeless adults: (1) adverse childhood events will have a direct effect on heavy consistent adulthood substance abuse; (2) the effects of adverse childhood events on affiliation will be mediated by heavy consistent adulthood substance abuse; and (3) over and above the mediating effects of heavy consistent adulthood substance abuse, adverse childhood events will have direct effects on affiliation. For the first hypothesis, adverse childhood events were associated with heavy consistent adulthood substance abuse. Surprisingly, in the bivariate analysis, adverse childhood events were associated with adulthood drug abuse, but not adulthood alcohol abuse. As with the bivariate analyses using adulthood drug abuse, the path model indicated that adverse childhood events contributed to heavy consistent substance use (defined as either drug or alcohol use). This study adds to the current literature by demonstrating that this relationship exists among homeless sample as well as nonhomeless adults (Brabant, Forsyth, & LeBlanc, 1997). As hypothesized and consistent with other studies, adverse childhood events predicted consistent heavy adulthood substance abuse (Wilsnack, Vogeltanz, Klassen, & Harris, 1997). In addition, consistent heavy substance abuse was inversely related to contacts with service agencies and perceived support. However, consistent heavy substance abuse did not influence contacts with family or friends. This last relationship was unexpected and inconsistent with other studies (Grigsby, Baumann, Gregorich, & Roberts-Gray, 1990). Many substance abusers are characterized as avoiding former family or friends. A possible explanation for this study’s finding is that all contacts, even those involving substance use, were included.
C. Zlotnick et al. / Addictive Behaviors 29 (2004) 1177–1181
1181
The last hypothesis examined the direct effects of baseline characteristics, including adverse childhood events, on affiliation. We found no direct effect in the path model between adverse childhood events and affiliation that further highlights the important mediating effect that consistent heavy adulthood substance abuse has on the relationship between those two variables. Adverse childhood events were antecedents to and had an inverse relationship with consistent heavy substance abuse, which was a mediator to two of the three variables reflecting affiliation (i.e., perceived support and service use). In addition, we noted a significant association between adverse childhood events (of any type) and number of services or number of contacts with family or friends. Note that the data used in this study are based on self-reported and are subject to recall bias. Moreover, due to the sampling frame, findings may not generalize to homeless adults elsewhere.
Acknowledgements This work was supported by grants from the National Institute on Alcohol Abuse and Alcoholism (AA12019) and the National Institute of Mental Health (MH51651 and MH46104).
References Brabant, S., Forsyth, C. J., & LeBlanc, J. B. (1997). Childhood sexual trauma and substance misuse: A pilot study. Substance Use and Misuse, 32(10), 1417 – 1431. Grigsby, C., Baumann, D., Gregorich, S. E., & Roberts-Gray, C. (1990). Disaffiliation to entrenchment: A model for understanding homelessness. Journal of Social Issues, 46(4), 141 – 156. Muthen, L. K., & Muthen, B. (1998). Mplus users guide. Los Angeles: Muthen & Muthen. Wilsnack, S. C., Vogeltanz, N. D., Klassen, A. D., & Harris, T. R. (1997). Childhood sexual abuse and women’s substance abuse: National survey findings. Journal of Studies on Alcohol, 58, 264 – 271. Zlotnick, C., Robertson, M. J., & Lahiff, M. (1999). Getting off the streets: Economic resources and residential exits from homelessness. Journal of Community Psychology, 27(2), 209 – 224.. Zlotnick, C., Tam, T., Robertson, M.J. (2003). Disaffiliation, substance abuse and exiting homelessness. Substance Use and Misuse, 38(3-6), 577 – 599.