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Infants of drug addicts: At risk for child abuse, neglect, and placement in foster care
Neurotoxicology and Teratology, Vol. 9, pp. 315-319. ©PergamonJournals Ltd., 1987. Printed in the U.S.A.
0892-0362/87 $3.00 + .00
Infants of Drug Addicts: At Risk for Child Abuse, Neglect, and Placement in Foster Care DIANNE
O. R E G A N , S A U N D R A
M. E H R L I C H
AND LORETTA
P. F I N N E G A N
Jefferson Medical College o f Thomas Jefferson University Department o f Pediatrics, Philadelphia, P A
REGAN, D. O., S. M. EHRLICH AND L. P. FINNEGAN. Infants of drug addicts: At risk for child abuse, neglect and placement in foster care. NEUROTOXICOL TERATOL 9(4) 315--319, 1987.--In a methadone maintenance program for pregnant, drug dependent women, an investigation was undertaken (1) to study the occurrence of violence experienced by the women as children and as adults and (2) to learn whether those who report past violence/abuse are more likely to neglect and/or abandon their children to the care of others. Subjects included 178 drug dependent women who completed a Violence Questionnaire and 70 comparable, but drug-free women. Results revealed that a history of violence or abuse is related to drug abuse and also to the placement of one's own child(ren) in foster care. Infants of drug addicts Drug treatment programs
Childhood violence and drug abuse Drug addiction and parenting Sexual abuse and parenting Drug use and child neglect
M A T E R N A L drug and/or alcohol abuse is known to be one of the critical factors involved in the abuse, neglect and perhaps even the abandonment of children [1]. In addition to the chaotic lifestyle and physical discomforts of addiction which inevitably place the drug dependent women at highrisk for parenting problems, they must also cope with numerous financial, social and psychological difficulties. These include single parenthood, poor housing, inadequate income, lack of education and emotional problems. A history of having been physically and/or sexually abused during childhood is not uncommon among this group of women [7]. Even during pregnancy, drug dependent women are not immune to battering by a spouse or partner [7]. In fact, battering may acutally begin when the woman becomes pregnant, perhaps as a result of her partner or spouse's rage at feeling excluded, non-essential, or financially burdened. Thus, the safety and security of pregnant, female patients in drug treatment programs needs to be periodically evaluated, particularly if they reside with an alcoholic or drug-abusing partner. The following characteristics have been commonly reported in families where child abuse occurs [5]. Many of these characteristics are seen in the lives of drug dependent women: (1) When young themselves, one or both parents have been subjected to violence. (2) One or both parents have had an unhappy, disrupted and insecure childhood. (3) One or both parents are addicted to drugs, alcohol, or are psychotic. (4) There is a record of violence between the parents. (5) Another child in the family has already been abused,
or has suffered an unexplained death. (6) With the pregnancy unwanted, the baby was rejected at birth or soon thereafter. (7) Failure in early bonding. (8) Both parents are under 20 years of age, immature for their years, and socially isolated. (9) The family lives in poor housing and on a low income. (10) The family is suffering from multiple deprivations. The data from several studies regarding drug dependent women and parenting ability has proven interesting. In a 1985 study by Fiks [3] in New York City, 57 methadone maintained mothers and 31 matched drug-free controls were compared with regard to "their ability to provide adequate child care, capacity for satisfying interpersonal relationships and motivation for self-improvement." The study showed that, as a group, "methadone mothers require more assistance in parenting, are more socially isolated, and are less likely to pursue vocational and educational activities." The study reached the following conclusions: the interpersonal and environmental impact of poor parenting further compounds the effects of in-utero exposure to methadone and places these infants at high risk. In Fiks' study [3], 56% of the methadone women also used additional drugs. Our clinical experience at the Family Center's methadone maintenance program in Philadelphia has shown that it is not methadone alone, but the use of illicit drugs in addition to methadone, which increases the risk for neglect or abuse [4]. If a women is using additional drugs which have a soporific effect, she may neglect to feed her child on time or keep the infant clean and dry, and, if, at the same time, she is withdrawing, she may also be irritable and abusive. A factor which further decreases a woman's ability to
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REGAN, EHRLICH AND FINNEGAN
parent is the presence of depression, In a study of depressed women who were not drug addicted, Weissman et al. [11] found that, during an acute episode of depression, these women became less involved with their children, had impaired communication, increased friction, lack of affection and greater guilt and resentment. When with their children, they were overprotective, irritable, preoccupied, withdrawn, emotionally distant and/or rejecting. In the Family Center methadone program, 15% of women were severely depressed and 39% were found to have moderate levels of depression [8]. The results of the presence of depression in drug dependent women compare with data on 533 opiate dependent men and women in treatment in New Haven, CT [10]. Seventy percent of the opiate addicts had a psychiatric disorder at some time in their lives and 86.9% met the criteria for at least one psychiatric disorder other than drug abuse. The most common disorders found were major depressive disorders, alcoholism and antisocial personality. Rates of chronic minor mood disturbances and anxiety disorders were elevated in comparison to the community population. In this study, follow-up evaluations also indicated significant improvement in average levels of depression. Thus, symptoms of depression appeared to lessen after treatment for drug abuse. In a study in Philadelphia, significantly higher depression scores (as measured with the Beck Depression Inventory) were found among drug abusing women whose children were in foster placement or had been referred to a child welfare agency than in the women who were raising their own children [9]. Depression played a significant role in the placement of children. However, it is difficult to ascertain whether depression is an antecedent or consequential factor in placement. (Is a woman depressed because she has placed her child in foster care or has she placed the child as a result of her depression?) In addition to problems of drug abuse and depression, several other factors may place the drug dependent woman at risk for parenting problems. Many women who use illicit drugs support their habits by retail theft or prostitution. This may result in repeated incarcerations, with disruption of family functioning and possible placement of children in foster care or with relatives. Many drug dependent women come originally from chaotic backgrounds, in some cases due to parenatal substance abuse. All too frequently they recreate these chaotic conditions in their own families. In addition, these women, with their drug-using partners, are involved in chaotic relationships marked by conflict over drugs. Spouse abuse is not uncommon in this population. The use of welfare money to buy drugs can result in significant impoverishment of the family and leave no funds with which to purchase formula and diapers, thus placing the infant at considerable risk. Many of the women who are single parents reside in public housing located in areas of the city where drugs are sold openly and where frequent outbreaks of violence occur, exposing them and their children to further danger. Thus, additional risk for the infant can occur as a result of the general environment. FAMILY CENTER
Family Center is a comprehensive program which was established to provide obstetrical and psychosocial services and methadone maintenance for pregnant women addicted to opiates, alcohol or combinations of psychoactive drugs. Dur-
ing pregnancy, women are either self-referred or referred from other drug programs in the area. They may be admitted to Family Center at any time during pregnancy. Once admitted, they are routinely seen until delivery in the hospital's high-risk obstetrical clinic. All Family Center women are offered a full range of services as well as neonatal and pediatric care for their children. The staff includes full-time social workers, a health educator, nurse, pharmacist, developmental psychologist, and research personnel as well as a part-time obstetrician, neonataologist, and psychiatrist. Types of therapy provided are individual, group, couples, and family therapy. Research on the effects of drug use in the neonate and developing child is an ongoing component of the program. If addicted to opiates, the women are hospitalized for a minimum of three days and placed on methadone. A social worker and nurse are assigned during the hospital stay so that a solid therapeutic alliance is established. Following delivery, the women remain on the program from 3 months to 4 years, depending on individual circumstances. If opiate dependent, they are maintained on methadone; if dependent on non-opiate substances, an attempt at detoxification is made. Other drugs of abuse by Family Center patients include stimulants, tranquilizers, barbiturates and alcohol. Weekly urine toxicologies are collected from all patients on a random schedule. Urines are screened for methadone, morphine, codeine, quinine, stimulants such as cocaine and amphetamines, and glutethimide, propoxyphene, diazepam, barbiturates and alcohol. Within this unique group of women, who are both pregnant and drug dependent, the potential for severe problems in the mother and infant is great. The main objective of the program is to insure the short- and long-term welfare of infants born within the program. In response to the aforementioned concerns and the remarkably high incidence of drug dependent women at our University Hospital treatment program who frequently report being battered by husbands or partners, a Violence Questionnaire was developed by the staff as an aid in counselling and for research. When it became apparent from responses on the questionnaire that incidences of violence occur all too frequently in the lives o f drug dependent women, several studies examining violence and its effects on the women and their children were initiated. The present investigation was designed to (1) study the excessive occurrence of violence experienced by the drug dependent women, including acts of physical and sexual abuse during childhood and/or as an adult and (2) to learn whether women who report a history of violence and abuse are those more likely to abandon their children to foster care. Subjects
Participants in the study were drawn from women enrolled in Family Center. Subjects included 178 pregnant, drug and/or alcohol dependent women who completed a Violence Questionnaire during a 6 year period. A total of 56% of the women were black (n= 100), 39% were white (n=70), and the remaining 5% were Hispanic (n=8). Mean age on admission was 27.2 years, with mean age at menarche reported as 12.3 years. The majority of the women were from urban Philadelphia and greater than 95% of them listed welfare as their financial support. A separate group of women who also completed the Violence Questionnaire were used as a comparison. They included 70 pregnant, but drug-free women attending the same
I N F A N T S O F D R U G ADDICTS prenatal clinic of the hospital and comparable to the Family Center women in age, race, socioeconomic status, and prenatal care. The control group had the following ethnic distribution: 59% black, 34% white and 7% Hispanic.
317 TABLE 1 VIOLENCE QUESTIONNAIRE RESPONSES
Method The drug dependent women were admitted to Family Center during pregnancy, usually upon referral from other drug programs in the area. At intake, each woman was routinely evaluated by the Supervisor of Clinical Services, the psychiatrist and the obstetrician. At the time of the initial examination, a Violence Questionnaire was administered to all Family Center Women in addition to other measures which included the Beck Depression Inventory, Beck SelfConcept, and Profile of Mood States (POMS). The comparison group of 70 women also completed the Violence Questionnaire. They were selected from a similar group of drug-free clinic patients who volunteered to take part in the study. The Violence Questionnaire, which quantifies violent occurrences in the subject's past, was administered to both groups of women. There are 23 items, yielding a possible score from 0 to 35, with a high score indicating the occurence of more frequent and/or more severe episodes of violence. The questionnaire includes issues which relate to the occurence of childhood or adult physical assaults and by whom, sexual molestation, and the occurrence of rape at what age and by whom. The drug addicted and drug free women were compared with each other on these factors. W o m e n w h o placed their children in foster care and those who kept their children home with them to raise were also compared on these factors. Comparisons between these groups were analyzed using a chi-square (X2) test of association. Statistical differences were measured at or below the 0.05 level of significance. Anonymity and confidentiality were assured. Consent in the form of written permission was obtained from each mother and procedures were followed in accordance with the University Institutional Review Board and the National Institute on Drug Abuse, Rockville, MD. RESULTS
The results of this investigation revealed the following with regard to physical abuse and severe battering. Of the 178 pregnant, drug dependent women, 19% reported having been severely beaten during childhood, most frequently by their mother or father, (52% and 39% respectively). Seventy percent of the women were beaten as adults. Of these women, 86% were beaten by husbands and/or partners with smaller percentages having been beaten by other family members or friends. Pregnancy, it appears, offered no protection for the women and, in some cases, may even have precipitated the abuse. A subgroup of 94 women were questioned about molestation; 28% of these women reported having been molested as a child. Of these, 37% were by a close family member, 19% were by family friends, and 38% were by strangers. The remaining 6% were not reported. (Only 94 women completed the question " W e r e you molested as a child?" In 1982 this item was added to the Violence Questionnaire after 84 questionnaires had already been completed.) When asked to indicate whether or not they had ever been raped, at what age, and by whom, 15% or 27 of the 178 drug
Severely beaten as a child Severely beaten as an adult* Raped as a child* Raped as an adult* ~Molested as a child*
Family Center (n= 178)
Control (n=70)
19% 70% 15% 21% 28%
16% 17% 0% 4% 7%
*p=<0.01. 1Note: This item was added to the Violence Questionnaire during the latter half of the study. The data, therefore, is based on 94 of the 178 women respondents.
dependent women reported having been raped during childhood (defined as < 16 years of age). Of the 27 rapes, 7 were by relatives, 4 were by persons known to the victim and 16 by strangers. The mean age of rape as a child was 12.8 years for the drug dependent women with a model age of 13. Twenty-one percent or 37 women were raped as adults, with the average age of the rapes at 22.3 years. Fourteen of the 37 rapes were by men known to the women, and 23 were by strangers. Incest, which includes at least 8% of all rape victims, was also reported by the women. The results of the survey on the pregnant, drug-free comparison women (n=70) can be found in Table 1. The Family Center women are listed beside them for comparison. The amount of violence and abuse experienced by the drug dependent women (sexual and non-sexual) far exceeded that reported by the comparison group, with a greater percentage of these incidents occurring to the women both as children and as adults. To learn whether the same women who had experienced abuse, molestation or rape in childhood were also being victimized as adults, a more indepth analysis was done. Of the 34 (19%) women who reported having been beaten as children, 26 (76%) were also physically abused as adults. F o r the control women, this f~gure was far less; 30% of those beaten during childhood reported abuse as adults. Fifteen o f the 26 Family Center women (58%) molested during childhood were also raped as children and 7 (27%) reported being raped as adults. In comparison, none of the control subjects were raped as children and figures o f child molestation and adult rape were lower (4% and 7% respectively). Of the 178 Family Center women, 107 women were raising their children. However, 71 women or 40% had at least one child in some type of foster placement or with relatives (see Table 2). Some were voluntary placements while other were placed in foster care through legal intervention o f the Philadelphia Department of Human Services. We found that women with a reported history of sexual abuse, if it occurred in childhood or more than once, were more likely to have their children in foster care or placed with others rather than at home with them. Physical abuse in childhood or as adults (without the sexual trauma) did not appear to be a factor in child placement. DISCUSSION
These data suggest that (1) there is a relationship between
318
REGAN, E H R L I C H AND F I N N E G A N TABLE 2 VIOLENCE AND PLACEMENTOF CHILDREN IN FAMILY CENTER WOMEN
n=178
Percent of 178
Foster Care n =71 (40%)
27 37 14
(15%) (21%) (8%)
16 (0.59) 16 (0.44) 11 (0.77)
11 (0.41) 21 (0.56) 3 (0.23)
Beaten as a child Beaten as an adult Beaten as both, child and adult
33 124 26
(19%) (70%) (15%)
12 (0.35) 51 (0.41) 10 (0.38)
21 (0.65) 73 (0.59) 16 (0.62)
1Molested as a child*
26
(28%)
14 (0.54)
12 (0.46)
Violence Questionnaire Item Raped as a child* Raped as an adult Raped more than once*
With Mother n= 107 (60%)
*p=<0.01. 1Note: See bottom of Table 1.
the occurrence of violence/abuse during childhood and subsequent drug abuse and (2) childhood sexual trauma and the presence of drug abuse disrupts a woman's parenting ability. In several cases, we believe that drugs have been used to cope with the trauma, particularly in the occurrence of sexual abuse during childhood. What is surprising about these findings is the large proportion of rapes which were perpetrated by strangers. Although this is not consonant with much of the rape literature, it is consistent with the dangerous lifestyle in which these women live. A similar pattern was also noted in the women as children (< age 16). The majority of incidents of rape by stanger(s) occurred during the older years of childhood, ages 14 through 16, about the time their drug use and deviant lifestyle was beginning. Incidents of rape during the younger years were perpetuated, for the most part, by relatives or others known to the victims/children. The impact of childhood sexual abuse depends on a number of factors such as: the relationship of the victim to the offender, the reaction of parents and other family members to disclosure (if it is disclosed); the reaction of the Social Service System to the disclosure; whether force or coercion was used; the age of the victim; the age difference between the victim and the offender; the nature of the sexual activity and the nature of the abusive relationship [6]. However, there is evidence that sexually abused children are likely to develop depression, experience problems with sexual adjustments, and have troubled relationships as adults. Studies of adults who have experienced intrafamilial sexual abuse indicate that they are susceptible to depression, and self destructive behavior, including self-mutilation and drug and alcohol abuse [6]. An additional factor in childhood sexual or physical abuse is that some women who are physically or sexually abused in childhood are then subsequently raped or abused by spouses or others as adults. In this study, the mean age of rape as a child (12.8 years) is noteworthy since this trauma at so critical an age can overwhelm the victim who then may attempt to cope by the use of of drugs, school truancy or sexual acting out and subsequent pregnancy in adolescence. Women raped in childhood may, as children, have dealt with or may still be dealing with this trauma by the use of drugs and/or alcohol.
Experiencing such violence as a child may well be a precursor not only to substance abuse but also to mental illness. This victim-to-patient process was described in a 1984 study by Carmen [2]. In a retrospective study of 188 male and female psychiatric patients, she reported the relationship between physical and sexual abuse and subsequent mental illness. Almost one-half of the psychiatric patients in Carmen's study described histories of physical and sexual abuse, 90% of which had been perpetrated by family members. In addition to their psychiatric diagnoses, some patients also had histories of alcohol and illicit drug use. The abused patients' responses to chronic victimization included difficulty in coping with anger and aggression, impaired self-esteem, and inability to trust [2]. We find these same characteristics in drug abusing women. Regarding the relationship between violence, particularly sexual violence and the subsequent placement of one's own children in the care of others, some interesting facts have emerged. In the present study, 40% of the women experienced placement of their children. Despite ongoing therapy, some of the current Family Center women still have difficulty coping with the demands of mothering as their children develop. Of the 70 women currently enrolled in our program, 30% have some or all of their children in placement with foster care agencies or with friends or relatives. As mentioned previously, several of these children have been voluntarily placed. Others were placed into foster care by the legal intervention of the Philadelphia Department of Human Services. In summary, the results of this study shows that the incidence of violence and/or abuse experienced by drug dependent women far exceeds that reported by a drug free comparison group. Drug dependent women were more often molested as children, raped as children and as adults, and beaten as adults. Most women were severely beaten as children by mother or father and, as adults, by husband or partner. Eight percent of childhood rape was reported as incest. The markedly high incidence of abuse and violence in the lives of pregnant drug dependent women places them at high risk for parenting. Since these women are the primary caretakers, this is a major problem for themselves and their children. In addition to their own drug use and chaotic lifestyles, further risk occurs if women live with alcoholic or drug abusing partners. They and their children become even more vulnerable to abuse. To further compound these problems, many of the infants born to drug dependent women undergo symptoms of drug withdrawal which often require long periods of hospitalization for treatment and can interfere with a mother's ability to attach to her n e w b o r n . . Our data and the data of others suggest that failure to resolve the conflicts and feelings resulting from childhood sexual trauma and/or the use of illicit drugs to cope with these feeling appears to disrupt the ability of women to parent their own children. The effects of violence toward women, particularly when they themselves were sexually abused as children, may have untoward and harmful effects upon their own children.
TREATMENTRECOMMENDATIONS Since affective states can lead to parenting failures possibly resulting in child neglect or child abuse, both social work and psychiatric intervention for the drug dependent woman at Family Center are geared toward the monitoring
INFANTS OF DRUG ADDICTS
319
and treatment of depression and states of confusion, the restoration of self-esteem, intervention in episodes of spouse or child abuse and group sessions to promote better parenting skills. Referral to the local Child Protection Agencies may be the sole alternative if women are not cooperative with regard to the services offered or if, despite measures of intervention, there remains evidence of child neglect or abuse. In addition, staff who work with these women should routinely question whether or not the woman is being battered by a spouse or a partner since violence can spread first from man to woman and then from her to her children. Drug addiction, per se, is not an indication for automatic removal of a child from parental custody in the State of Pennsylvania.
Instead, we must make every effort to involve the mother and father and/or extended family in services in order to enhance parenting and prevent neglect or abuse. The intergenerational transmission of abuse and nelect has long been recognized. Because of the numerous risk factors for parenting which exist in drug dependent women, treatment programs must include intervention procedures as a priority in the management of these women. It is vital that possible risk factors be evaluated and elminated as soon as possible after a woman is admitted to a treatment program. Failure to assess risk appropriately and provide social and community supports may place a further generation of children at risk.
REFERENCES 1. Black, R. and J. Mayer. Parents with special problems: Alcoholism and opiate addiction. In: The Battered Child, third edition, edited by H. Kempe and R. Heifer. Chicago: University of Chicago Press, 1981. 2. Carmen, E., P. Reiker and T. Mills. Victims of violence and psychiatric illnesses. Am J Psychiatry 141: 378--383, 1984. 3. Fiks, K., H. L. Johnson and T. S. Rosen. Methadone maintained mothers: 3 year follow-up of parental functioning, lnt J Addict 20: 651-660, 1985. 4. Finnegan, L. P., S. M. Oehlberg, D. O. Regan and M. E. Rudrauff. Evaluation of parenting, depression, and violence profiles in methadone maintained women. Child Abuse Negl 5: 267-273, 1981. 5. Frude, N. (Ed.). Psychological Approaches to Child Abuse. New Jersey: Rowman and Littlefield, 1981. 6. Marshall, L. The impact of childhood sexual abuse. J Social Work Process, 75th Anniversary Edition. Philadelphia, PA: University of Pennsylvania Press, 1985.
7. Regan, D. P., B. Leifer and L. P. Finnegan. The incidence of violence in the lives of pregnant drug dependent women. Abstract Proceedings of Infancy in a Changing World, 2nd World Congress on Infant Psychiatry. Cannes, France, April 1983. 8. Regan, D. O. B. Leifer, T. Matteucci and L. P. Finnegan. Depression in pregnant drug dependent women. In: Problems of Drug Dependence 1981, edited by R. C. Petersen. Washington, DC: U.S. Government Printing Office, 1981. 9. Regan, D. O., M. E. Rudrauff and L. P. Finnegan. Parenting abilities in drug dependent women: The negative effect of depression. Pediatr Res 15: 90, 1981. 10. Weissman, M., F. Slobetz, B. Prusoff, M. Mezritz and P. Howard. Clinical depression among narcotic addicts maintained on methadone in the community. Am J Psychiatry 133: 1434-1438, 1976. 11. Weissman, M., E. Paykel and G. Klerman. The depressed woman as a mother. Soc Psychiatry 7: 99--108, 1972.
0892-0362/87 $3.00 + .00
Infants of Drug Addicts: At Risk for Child Abuse, Neglect, and Placement in Foster Care DIANNE
O. R E G A N , S A U N D R A
M. E H R L I C H
AND LORETTA
P. F I N N E G A N
Jefferson Medical College o f Thomas Jefferson University Department o f Pediatrics, Philadelphia, P A
REGAN, D. O., S. M. EHRLICH AND L. P. FINNEGAN. Infants of drug addicts: At risk for child abuse, neglect and placement in foster care. NEUROTOXICOL TERATOL 9(4) 315--319, 1987.--In a methadone maintenance program for pregnant, drug dependent women, an investigation was undertaken (1) to study the occurrence of violence experienced by the women as children and as adults and (2) to learn whether those who report past violence/abuse are more likely to neglect and/or abandon their children to the care of others. Subjects included 178 drug dependent women who completed a Violence Questionnaire and 70 comparable, but drug-free women. Results revealed that a history of violence or abuse is related to drug abuse and also to the placement of one's own child(ren) in foster care. Infants of drug addicts Drug treatment programs
Childhood violence and drug abuse Drug addiction and parenting Sexual abuse and parenting Drug use and child neglect
M A T E R N A L drug and/or alcohol abuse is known to be one of the critical factors involved in the abuse, neglect and perhaps even the abandonment of children [1]. In addition to the chaotic lifestyle and physical discomforts of addiction which inevitably place the drug dependent women at highrisk for parenting problems, they must also cope with numerous financial, social and psychological difficulties. These include single parenthood, poor housing, inadequate income, lack of education and emotional problems. A history of having been physically and/or sexually abused during childhood is not uncommon among this group of women [7]. Even during pregnancy, drug dependent women are not immune to battering by a spouse or partner [7]. In fact, battering may acutally begin when the woman becomes pregnant, perhaps as a result of her partner or spouse's rage at feeling excluded, non-essential, or financially burdened. Thus, the safety and security of pregnant, female patients in drug treatment programs needs to be periodically evaluated, particularly if they reside with an alcoholic or drug-abusing partner. The following characteristics have been commonly reported in families where child abuse occurs [5]. Many of these characteristics are seen in the lives of drug dependent women: (1) When young themselves, one or both parents have been subjected to violence. (2) One or both parents have had an unhappy, disrupted and insecure childhood. (3) One or both parents are addicted to drugs, alcohol, or are psychotic. (4) There is a record of violence between the parents. (5) Another child in the family has already been abused,
or has suffered an unexplained death. (6) With the pregnancy unwanted, the baby was rejected at birth or soon thereafter. (7) Failure in early bonding. (8) Both parents are under 20 years of age, immature for their years, and socially isolated. (9) The family lives in poor housing and on a low income. (10) The family is suffering from multiple deprivations. The data from several studies regarding drug dependent women and parenting ability has proven interesting. In a 1985 study by Fiks [3] in New York City, 57 methadone maintained mothers and 31 matched drug-free controls were compared with regard to "their ability to provide adequate child care, capacity for satisfying interpersonal relationships and motivation for self-improvement." The study showed that, as a group, "methadone mothers require more assistance in parenting, are more socially isolated, and are less likely to pursue vocational and educational activities." The study reached the following conclusions: the interpersonal and environmental impact of poor parenting further compounds the effects of in-utero exposure to methadone and places these infants at high risk. In Fiks' study [3], 56% of the methadone women also used additional drugs. Our clinical experience at the Family Center's methadone maintenance program in Philadelphia has shown that it is not methadone alone, but the use of illicit drugs in addition to methadone, which increases the risk for neglect or abuse [4]. If a women is using additional drugs which have a soporific effect, she may neglect to feed her child on time or keep the infant clean and dry, and, if, at the same time, she is withdrawing, she may also be irritable and abusive. A factor which further decreases a woman's ability to
315
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REGAN, EHRLICH AND FINNEGAN
parent is the presence of depression, In a study of depressed women who were not drug addicted, Weissman et al. [11] found that, during an acute episode of depression, these women became less involved with their children, had impaired communication, increased friction, lack of affection and greater guilt and resentment. When with their children, they were overprotective, irritable, preoccupied, withdrawn, emotionally distant and/or rejecting. In the Family Center methadone program, 15% of women were severely depressed and 39% were found to have moderate levels of depression [8]. The results of the presence of depression in drug dependent women compare with data on 533 opiate dependent men and women in treatment in New Haven, CT [10]. Seventy percent of the opiate addicts had a psychiatric disorder at some time in their lives and 86.9% met the criteria for at least one psychiatric disorder other than drug abuse. The most common disorders found were major depressive disorders, alcoholism and antisocial personality. Rates of chronic minor mood disturbances and anxiety disorders were elevated in comparison to the community population. In this study, follow-up evaluations also indicated significant improvement in average levels of depression. Thus, symptoms of depression appeared to lessen after treatment for drug abuse. In a study in Philadelphia, significantly higher depression scores (as measured with the Beck Depression Inventory) were found among drug abusing women whose children were in foster placement or had been referred to a child welfare agency than in the women who were raising their own children [9]. Depression played a significant role in the placement of children. However, it is difficult to ascertain whether depression is an antecedent or consequential factor in placement. (Is a woman depressed because she has placed her child in foster care or has she placed the child as a result of her depression?) In addition to problems of drug abuse and depression, several other factors may place the drug dependent woman at risk for parenting problems. Many women who use illicit drugs support their habits by retail theft or prostitution. This may result in repeated incarcerations, with disruption of family functioning and possible placement of children in foster care or with relatives. Many drug dependent women come originally from chaotic backgrounds, in some cases due to parenatal substance abuse. All too frequently they recreate these chaotic conditions in their own families. In addition, these women, with their drug-using partners, are involved in chaotic relationships marked by conflict over drugs. Spouse abuse is not uncommon in this population. The use of welfare money to buy drugs can result in significant impoverishment of the family and leave no funds with which to purchase formula and diapers, thus placing the infant at considerable risk. Many of the women who are single parents reside in public housing located in areas of the city where drugs are sold openly and where frequent outbreaks of violence occur, exposing them and their children to further danger. Thus, additional risk for the infant can occur as a result of the general environment. FAMILY CENTER
Family Center is a comprehensive program which was established to provide obstetrical and psychosocial services and methadone maintenance for pregnant women addicted to opiates, alcohol or combinations of psychoactive drugs. Dur-
ing pregnancy, women are either self-referred or referred from other drug programs in the area. They may be admitted to Family Center at any time during pregnancy. Once admitted, they are routinely seen until delivery in the hospital's high-risk obstetrical clinic. All Family Center women are offered a full range of services as well as neonatal and pediatric care for their children. The staff includes full-time social workers, a health educator, nurse, pharmacist, developmental psychologist, and research personnel as well as a part-time obstetrician, neonataologist, and psychiatrist. Types of therapy provided are individual, group, couples, and family therapy. Research on the effects of drug use in the neonate and developing child is an ongoing component of the program. If addicted to opiates, the women are hospitalized for a minimum of three days and placed on methadone. A social worker and nurse are assigned during the hospital stay so that a solid therapeutic alliance is established. Following delivery, the women remain on the program from 3 months to 4 years, depending on individual circumstances. If opiate dependent, they are maintained on methadone; if dependent on non-opiate substances, an attempt at detoxification is made. Other drugs of abuse by Family Center patients include stimulants, tranquilizers, barbiturates and alcohol. Weekly urine toxicologies are collected from all patients on a random schedule. Urines are screened for methadone, morphine, codeine, quinine, stimulants such as cocaine and amphetamines, and glutethimide, propoxyphene, diazepam, barbiturates and alcohol. Within this unique group of women, who are both pregnant and drug dependent, the potential for severe problems in the mother and infant is great. The main objective of the program is to insure the short- and long-term welfare of infants born within the program. In response to the aforementioned concerns and the remarkably high incidence of drug dependent women at our University Hospital treatment program who frequently report being battered by husbands or partners, a Violence Questionnaire was developed by the staff as an aid in counselling and for research. When it became apparent from responses on the questionnaire that incidences of violence occur all too frequently in the lives o f drug dependent women, several studies examining violence and its effects on the women and their children were initiated. The present investigation was designed to (1) study the excessive occurrence of violence experienced by the drug dependent women, including acts of physical and sexual abuse during childhood and/or as an adult and (2) to learn whether women who report a history of violence and abuse are those more likely to abandon their children to foster care. Subjects
Participants in the study were drawn from women enrolled in Family Center. Subjects included 178 pregnant, drug and/or alcohol dependent women who completed a Violence Questionnaire during a 6 year period. A total of 56% of the women were black (n= 100), 39% were white (n=70), and the remaining 5% were Hispanic (n=8). Mean age on admission was 27.2 years, with mean age at menarche reported as 12.3 years. The majority of the women were from urban Philadelphia and greater than 95% of them listed welfare as their financial support. A separate group of women who also completed the Violence Questionnaire were used as a comparison. They included 70 pregnant, but drug-free women attending the same
I N F A N T S O F D R U G ADDICTS prenatal clinic of the hospital and comparable to the Family Center women in age, race, socioeconomic status, and prenatal care. The control group had the following ethnic distribution: 59% black, 34% white and 7% Hispanic.
317 TABLE 1 VIOLENCE QUESTIONNAIRE RESPONSES
Method The drug dependent women were admitted to Family Center during pregnancy, usually upon referral from other drug programs in the area. At intake, each woman was routinely evaluated by the Supervisor of Clinical Services, the psychiatrist and the obstetrician. At the time of the initial examination, a Violence Questionnaire was administered to all Family Center Women in addition to other measures which included the Beck Depression Inventory, Beck SelfConcept, and Profile of Mood States (POMS). The comparison group of 70 women also completed the Violence Questionnaire. They were selected from a similar group of drug-free clinic patients who volunteered to take part in the study. The Violence Questionnaire, which quantifies violent occurrences in the subject's past, was administered to both groups of women. There are 23 items, yielding a possible score from 0 to 35, with a high score indicating the occurence of more frequent and/or more severe episodes of violence. The questionnaire includes issues which relate to the occurence of childhood or adult physical assaults and by whom, sexual molestation, and the occurrence of rape at what age and by whom. The drug addicted and drug free women were compared with each other on these factors. W o m e n w h o placed their children in foster care and those who kept their children home with them to raise were also compared on these factors. Comparisons between these groups were analyzed using a chi-square (X2) test of association. Statistical differences were measured at or below the 0.05 level of significance. Anonymity and confidentiality were assured. Consent in the form of written permission was obtained from each mother and procedures were followed in accordance with the University Institutional Review Board and the National Institute on Drug Abuse, Rockville, MD. RESULTS
The results of this investigation revealed the following with regard to physical abuse and severe battering. Of the 178 pregnant, drug dependent women, 19% reported having been severely beaten during childhood, most frequently by their mother or father, (52% and 39% respectively). Seventy percent of the women were beaten as adults. Of these women, 86% were beaten by husbands and/or partners with smaller percentages having been beaten by other family members or friends. Pregnancy, it appears, offered no protection for the women and, in some cases, may even have precipitated the abuse. A subgroup of 94 women were questioned about molestation; 28% of these women reported having been molested as a child. Of these, 37% were by a close family member, 19% were by family friends, and 38% were by strangers. The remaining 6% were not reported. (Only 94 women completed the question " W e r e you molested as a child?" In 1982 this item was added to the Violence Questionnaire after 84 questionnaires had already been completed.) When asked to indicate whether or not they had ever been raped, at what age, and by whom, 15% or 27 of the 178 drug
Severely beaten as a child Severely beaten as an adult* Raped as a child* Raped as an adult* ~Molested as a child*
Family Center (n= 178)
Control (n=70)
19% 70% 15% 21% 28%
16% 17% 0% 4% 7%
*p=<0.01. 1Note: This item was added to the Violence Questionnaire during the latter half of the study. The data, therefore, is based on 94 of the 178 women respondents.
dependent women reported having been raped during childhood (defined as < 16 years of age). Of the 27 rapes, 7 were by relatives, 4 were by persons known to the victim and 16 by strangers. The mean age of rape as a child was 12.8 years for the drug dependent women with a model age of 13. Twenty-one percent or 37 women were raped as adults, with the average age of the rapes at 22.3 years. Fourteen of the 37 rapes were by men known to the women, and 23 were by strangers. Incest, which includes at least 8% of all rape victims, was also reported by the women. The results of the survey on the pregnant, drug-free comparison women (n=70) can be found in Table 1. The Family Center women are listed beside them for comparison. The amount of violence and abuse experienced by the drug dependent women (sexual and non-sexual) far exceeded that reported by the comparison group, with a greater percentage of these incidents occurring to the women both as children and as adults. To learn whether the same women who had experienced abuse, molestation or rape in childhood were also being victimized as adults, a more indepth analysis was done. Of the 34 (19%) women who reported having been beaten as children, 26 (76%) were also physically abused as adults. F o r the control women, this f~gure was far less; 30% of those beaten during childhood reported abuse as adults. Fifteen o f the 26 Family Center women (58%) molested during childhood were also raped as children and 7 (27%) reported being raped as adults. In comparison, none of the control subjects were raped as children and figures o f child molestation and adult rape were lower (4% and 7% respectively). Of the 178 Family Center women, 107 women were raising their children. However, 71 women or 40% had at least one child in some type of foster placement or with relatives (see Table 2). Some were voluntary placements while other were placed in foster care through legal intervention o f the Philadelphia Department of Human Services. We found that women with a reported history of sexual abuse, if it occurred in childhood or more than once, were more likely to have their children in foster care or placed with others rather than at home with them. Physical abuse in childhood or as adults (without the sexual trauma) did not appear to be a factor in child placement. DISCUSSION
These data suggest that (1) there is a relationship between
318
REGAN, E H R L I C H AND F I N N E G A N TABLE 2 VIOLENCE AND PLACEMENTOF CHILDREN IN FAMILY CENTER WOMEN
n=178
Percent of 178
Foster Care n =71 (40%)
27 37 14
(15%) (21%) (8%)
16 (0.59) 16 (0.44) 11 (0.77)
11 (0.41) 21 (0.56) 3 (0.23)
Beaten as a child Beaten as an adult Beaten as both, child and adult
33 124 26
(19%) (70%) (15%)
12 (0.35) 51 (0.41) 10 (0.38)
21 (0.65) 73 (0.59) 16 (0.62)
1Molested as a child*
26
(28%)
14 (0.54)
12 (0.46)
Violence Questionnaire Item Raped as a child* Raped as an adult Raped more than once*
With Mother n= 107 (60%)
*p=<0.01. 1Note: See bottom of Table 1.
the occurrence of violence/abuse during childhood and subsequent drug abuse and (2) childhood sexual trauma and the presence of drug abuse disrupts a woman's parenting ability. In several cases, we believe that drugs have been used to cope with the trauma, particularly in the occurrence of sexual abuse during childhood. What is surprising about these findings is the large proportion of rapes which were perpetrated by strangers. Although this is not consonant with much of the rape literature, it is consistent with the dangerous lifestyle in which these women live. A similar pattern was also noted in the women as children (< age 16). The majority of incidents of rape by stanger(s) occurred during the older years of childhood, ages 14 through 16, about the time their drug use and deviant lifestyle was beginning. Incidents of rape during the younger years were perpetuated, for the most part, by relatives or others known to the victims/children. The impact of childhood sexual abuse depends on a number of factors such as: the relationship of the victim to the offender, the reaction of parents and other family members to disclosure (if it is disclosed); the reaction of the Social Service System to the disclosure; whether force or coercion was used; the age of the victim; the age difference between the victim and the offender; the nature of the sexual activity and the nature of the abusive relationship [6]. However, there is evidence that sexually abused children are likely to develop depression, experience problems with sexual adjustments, and have troubled relationships as adults. Studies of adults who have experienced intrafamilial sexual abuse indicate that they are susceptible to depression, and self destructive behavior, including self-mutilation and drug and alcohol abuse [6]. An additional factor in childhood sexual or physical abuse is that some women who are physically or sexually abused in childhood are then subsequently raped or abused by spouses or others as adults. In this study, the mean age of rape as a child (12.8 years) is noteworthy since this trauma at so critical an age can overwhelm the victim who then may attempt to cope by the use of of drugs, school truancy or sexual acting out and subsequent pregnancy in adolescence. Women raped in childhood may, as children, have dealt with or may still be dealing with this trauma by the use of drugs and/or alcohol.
Experiencing such violence as a child may well be a precursor not only to substance abuse but also to mental illness. This victim-to-patient process was described in a 1984 study by Carmen [2]. In a retrospective study of 188 male and female psychiatric patients, she reported the relationship between physical and sexual abuse and subsequent mental illness. Almost one-half of the psychiatric patients in Carmen's study described histories of physical and sexual abuse, 90% of which had been perpetrated by family members. In addition to their psychiatric diagnoses, some patients also had histories of alcohol and illicit drug use. The abused patients' responses to chronic victimization included difficulty in coping with anger and aggression, impaired self-esteem, and inability to trust [2]. We find these same characteristics in drug abusing women. Regarding the relationship between violence, particularly sexual violence and the subsequent placement of one's own children in the care of others, some interesting facts have emerged. In the present study, 40% of the women experienced placement of their children. Despite ongoing therapy, some of the current Family Center women still have difficulty coping with the demands of mothering as their children develop. Of the 70 women currently enrolled in our program, 30% have some or all of their children in placement with foster care agencies or with friends or relatives. As mentioned previously, several of these children have been voluntarily placed. Others were placed into foster care by the legal intervention of the Philadelphia Department of Human Services. In summary, the results of this study shows that the incidence of violence and/or abuse experienced by drug dependent women far exceeds that reported by a drug free comparison group. Drug dependent women were more often molested as children, raped as children and as adults, and beaten as adults. Most women were severely beaten as children by mother or father and, as adults, by husband or partner. Eight percent of childhood rape was reported as incest. The markedly high incidence of abuse and violence in the lives of pregnant drug dependent women places them at high risk for parenting. Since these women are the primary caretakers, this is a major problem for themselves and their children. In addition to their own drug use and chaotic lifestyles, further risk occurs if women live with alcoholic or drug abusing partners. They and their children become even more vulnerable to abuse. To further compound these problems, many of the infants born to drug dependent women undergo symptoms of drug withdrawal which often require long periods of hospitalization for treatment and can interfere with a mother's ability to attach to her n e w b o r n . . Our data and the data of others suggest that failure to resolve the conflicts and feelings resulting from childhood sexual trauma and/or the use of illicit drugs to cope with these feeling appears to disrupt the ability of women to parent their own children. The effects of violence toward women, particularly when they themselves were sexually abused as children, may have untoward and harmful effects upon their own children.
TREATMENTRECOMMENDATIONS Since affective states can lead to parenting failures possibly resulting in child neglect or child abuse, both social work and psychiatric intervention for the drug dependent woman at Family Center are geared toward the monitoring
INFANTS OF DRUG ADDICTS
319
and treatment of depression and states of confusion, the restoration of self-esteem, intervention in episodes of spouse or child abuse and group sessions to promote better parenting skills. Referral to the local Child Protection Agencies may be the sole alternative if women are not cooperative with regard to the services offered or if, despite measures of intervention, there remains evidence of child neglect or abuse. In addition, staff who work with these women should routinely question whether or not the woman is being battered by a spouse or a partner since violence can spread first from man to woman and then from her to her children. Drug addiction, per se, is not an indication for automatic removal of a child from parental custody in the State of Pennsylvania.
Instead, we must make every effort to involve the mother and father and/or extended family in services in order to enhance parenting and prevent neglect or abuse. The intergenerational transmission of abuse and nelect has long been recognized. Because of the numerous risk factors for parenting which exist in drug dependent women, treatment programs must include intervention procedures as a priority in the management of these women. It is vital that possible risk factors be evaluated and elminated as soon as possible after a woman is admitted to a treatment program. Failure to assess risk appropriately and provide social and community supports may place a further generation of children at risk.
REFERENCES 1. Black, R. and J. Mayer. Parents with special problems: Alcoholism and opiate addiction. In: The Battered Child, third edition, edited by H. Kempe and R. Heifer. Chicago: University of Chicago Press, 1981. 2. Carmen, E., P. Reiker and T. Mills. Victims of violence and psychiatric illnesses. Am J Psychiatry 141: 378--383, 1984. 3. Fiks, K., H. L. Johnson and T. S. Rosen. Methadone maintained mothers: 3 year follow-up of parental functioning, lnt J Addict 20: 651-660, 1985. 4. Finnegan, L. P., S. M. Oehlberg, D. O. Regan and M. E. Rudrauff. Evaluation of parenting, depression, and violence profiles in methadone maintained women. Child Abuse Negl 5: 267-273, 1981. 5. Frude, N. (Ed.). Psychological Approaches to Child Abuse. New Jersey: Rowman and Littlefield, 1981. 6. Marshall, L. The impact of childhood sexual abuse. J Social Work Process, 75th Anniversary Edition. Philadelphia, PA: University of Pennsylvania Press, 1985.
7. Regan, D. P., B. Leifer and L. P. Finnegan. The incidence of violence in the lives of pregnant drug dependent women. Abstract Proceedings of Infancy in a Changing World, 2nd World Congress on Infant Psychiatry. Cannes, France, April 1983. 8. Regan, D. O. B. Leifer, T. Matteucci and L. P. Finnegan. Depression in pregnant drug dependent women. In: Problems of Drug Dependence 1981, edited by R. C. Petersen. Washington, DC: U.S. Government Printing Office, 1981. 9. Regan, D. O., M. E. Rudrauff and L. P. Finnegan. Parenting abilities in drug dependent women: The negative effect of depression. Pediatr Res 15: 90, 1981. 10. Weissman, M., F. Slobetz, B. Prusoff, M. Mezritz and P. Howard. Clinical depression among narcotic addicts maintained on methadone in the community. Am J Psychiatry 133: 1434-1438, 1976. 11. Weissman, M., E. Paykel and G. Klerman. The depressed woman as a mother. Soc Psychiatry 7: 99--108, 1972.