Child maltreatment as a risk factor for opioid dependence: Comparison of family characteristics and type and severity of child maltreatment with a matched control group☆
Introduction
Child maltreatment is associated with a range of negative outcomes (Andrews et al., 2004, Fergusson et al., 1996a, Fergusson and Lynskey, 1997, Kendler et al., 2000a, Kessler et al., 1997, Nelson et al., 2006, Nelson et al., 2002, Oddone Paolucci et al., 2001). Child maltreatment is thought to disrupt normal development leading to problems of self-definition and emotion regulation and consequently, increased risk of mental disorder (Cicchetti and Lynch, 1995, Maughan and Cicchetti, 2002). Population estimates for sexual abuse range from 14 to 34% among women and 3–16% among men (Briere and Elliot, 2003, Molnar et al., 2001). In contrast, the prevalence of physical abuse appears to be similar for males and females, with 22% of males and 20% of females experiencing physical abuse in the US general population (Briere & Elliot, 2003). Population prevalence studies of neglect and emotional abuse are limited, however a study across four developed nations found prevalence of emotional abuse to be 12% and neglect to be 4% (Cohen et al., 2006). A national representative sample of young adults aged 18–24 years in the United Kingdom found the prevalence of emotional abuse was 4% among males and 8% among females. The rate of physical neglect was similar for males (6%) and females (7%).
The risk of problems associated with child maltreatment appears related to the characteristics of the abuse experienced. Numerous studies have shown greater severity and an earlier onset of child maltreatment is associated with poorer outcome (Bifulco et al., 2002a, Briere and Elliot, 2003, Clemmons et al., 2007, Lynskey and Fergusson, 1997, Molnar et al., 2001, Thornberry et al., 2001). Additionally, both the duration and frequency of child maltreatment have been shown to influence risk for negative outcome. For example, Briere and Elliot (2003) mailed questionnaires including the Trauma Symptom Inventory (TSI) to a random sample of US residents. They found higher TSI scores were associated with having experienced a greater number of incidents of sexual or physical abuse and being older when the last incident of sexual or physical abuse occurred (possibly suggesting longer duration of abuse). This is consistent with the idea that cumulative trauma is associated with incremental risk for mental disorder (Breslau et al., 1999, Kendler et al., 2000b, Kessler et al., 1997).
Related to this, there is a high degree of overlap among maltreatment types and consistent evidence of a dose-response relationship between multiple exposure and risk for later psychopathology (Bifulco et al., 2002a, Bolger and Patterson, 2001, Edwards et al., 2003, Higgins and McCabe, 2000, Mullen et al., 1996). While such evidence suggests the number of maltreatment types is important in conferring risk for adverse outcome, there is also evidence to suggest the risk for adverse outcome varies across the different types of child maltreatment. General population studies examining a range of outcomes confirm that sexual abuse imbues a general vulnerability for mental disorder (Andrews et al., 2004, Bulik et al., 2001) whereas the impact of physical abuse may be more specific (Fergusson & Lynskey, 1997). Additionally, some forms of child maltreatment appear to be stronger predictors of negative outcome. For example, compared to other forms of maltreatment, emotional abuse has been found to be independently associated with mood and anxiety disorders (Cohen et al., 2006, Gibb et al., 2001, Sullivan et al., 2006).
There is consistent evidence that child maltreatment and drug use problems are associated. Research on substance use disorders within the general population has revealed a higher prevalence among those with a history of child maltreatment (Molnar et al., 2001, Saunders et al., 1999). Twin studies examining sexual abuse have also demonstrated increased risk of drug use problems, over and above that construed by genetic and familial risk factors (Kendler et al., 2000a, Nelson et al., 2006, Sartor et al., 2007). High rates of child maltreatment have been documented among both community and treatment samples of drug users (Medrano et al., 2002, Simpson and Miller, 2002).
Studies examining child maltreatment among those with opioid dependence specifically are few. Among a psychiatric inpatient sample, a history of sexual and/or physical abuse was associated with opioid use (Heffernan et al., 2000). Opioid use was most common among those with sexual abuse and/or physical abuse, compared to those with a history of sexual abuse alone. In an Australian study examining posttraumatic stress disorder among opioid-dependent persons, 22% of males and 52% of females had experienced sexual abuse during childhood (Mills, Lynskey, Teeson, Ross, & Darke, 2005).
Bartholomew et al. (Bartholomew et al., 2005, Bartholomew et al., 2002) examined child maltreatment among a sample of opioid-dependent women commencing opioid replacement therapy (ORT). Women with a history of sexual abuse were significantly more likely to have also experienced physical and emotional abuse, had a higher prevalence of comorbid mental health problems, elevated rates of use of other depressant drugs (such as cannabis and benzodiazepines), and were more likely to report psychological reasons for using drugs compared to women without a history of sexual abuse.
Child maltreatment is multiply determined (Belsky, 1993, Cicchetti and Lynch, 1995). Some of the risk factors identified by previous research include social disadvantage (Gillham et al., 1998, Knutson et al., 2004, Shook Slack et al., 2004), parental substance use (Fergusson and Lynskey, 1997, Fergusson et al., 1996b, Kelleher et al., 1994, Vogeltanz et al., 1999), poor parent-child relationships (Fergusson et al., 1996b, Fleming et al., 1997, Howes and Cicchetti, 1993, McLaughlin et al., 2000), lack of a confidante during childhood and adolescence (Bromet et al., 1998, Fleming et al., 1997, Mullen et al., 1996), conflict between caregivers (Bagley and Mallick, 2000, Gaudin et al., 1996, McGuigan and Pratt, 2001), and household composition (Fergusson and Lynskey, 1997, Stiffman et al., 2002, Swanston et al., 2002).
The above risk factors are also highly prevalent in the early family environment of persons who have developed opioid dependence (Bailey et al., 1994, Glavak et al., 2003, Vaillant, 1966). It is plausible to contend that differences in the prevalence of child maltreatment among general population and problematic substance use samples may be driven by differences in the prevalence of these early environmental risk factors. Moreover, as the impact of child maltreatment is an ongoing transaction between the individual and their physical and social environments, these risk factors may also exert significant influence on the sequelae of child maltreatment (Cicchetti and Toth, 1997, Higgins et al., 2003, Zielinski and Bradshaw, 2006).
Opioid dependence is a significant concern in Australia: over 30,000 persons were in ORT for heroin dependence as at June 2005 (Black, Roxburgh, & Degenhardt, 2007). Clients typically present to treatment with extensive social problems and high comorbidity of psychiatric disorders (Ross et al., 2005) that contribute to poor retention and treatment outcome (Tate, Brown, Unrod, & Ramo, 2004). Child maltreatment may be an important antecedent to the complex presentations in this population: clients with a history of child maltreatment have greater psychiatric comorbidity upon presentation to treatment (Bartholomew et al., 2002, Ouimette et al., 2000).
Most research on child maltreatment and substance dependence has tended to focus on sexual and physical abuse, to the exclusion of the less well-specified types of neglect and emotional abuse. This is an important limitation, particularly when long-term outcomes are being considered, as there is a substantial degree of overlap in the experience of different types of child maltreatment (Edwards et al., 2003, Higgins and McCabe, 2000, Scher et al., 2004). Although there is a general consensus regarding the types of behaviors that constitute sexual and physical abuse, research has been impeded by differences in the way in which these forms of maltreatment have been operationalized. Both the depth and phrasing of the assessment appear to be important drivers in the disparate prevalence estimates found across studies.
This study aims to document the prevalence, characteristics and risk factors of four types of child maltreatment (sexual abuse, physical abuse, neglect, and emotional abuse) among an Australian sample of opioid-dependent persons and additionally, to compare their experience of child maltreatment to a community sample of similar social disadvantage. This study extends previous research by:
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Collectively examining four types of child maltreatment.
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The use of detailed, objective questioning to ascertain child maltreatment.
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Separate analysis of the prevalence and risk factors for child maltreatment among males and females; and
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Comparison of findings with a control group of similar social disadvantage and matched for age, gender and employment.
Section snippets
Design
This study is part of a larger project examining the interaction between genes and the environment in the development of opioid dependence. It employs a matched case-control design where nonopioid-dependent controls are frequency matched to opioid-dependent cases on age, gender and employment status. Given that social disadvantage is a significant risk factor for child maltreatment, associations between child maltreatment and opioid dependence may simply reflect the highly disadvantaged early
Results
The prevalence of sexual abuse, physical abuse, emotional abuse and neglect among opioid-dependent cases and nonopioid-dependent controls is shown in Table 1. Categorical variables were analyzed using logistic regression and results reported in terms of odds ratios and 95% confidence intervals; continuous variables were analyzed using linear regression and results reported in terms of t-values. All analyses were adjusted for demographic variables and dependence on alcohol and other illicit
Discussion
To our knowledge, this is the largest and most comprehensive study of child maltreatment among an opioid-dependent sample. The rate of child maltreatment in the present study was high: 72% of opioid-dependent females had experienced sexual abuse and 68% of opioid-dependent males had a history of neglect. Opioid-dependent cases experienced greater severity of some types of child maltreatment—sexual abuse among female cases was typically severe, chronic, and perpetrated by someone known to them.
Conclusion
This study demonstrated a significant relationship between some types of child maltreatment and opioid dependence, even when the comparison group was a socially disadvantaged control group. By additionally controlling for the prevalence of other substance dependence among cases and controls, the findings of this study suggest some types of maltreatment may be specifically associated with opioid dependence. The pattern of risk associated with the four types of maltreatment differed for males and
Acknowledgements
The authors thank the agencies and individuals who provided support with this study; we also thank Michelle Torok, Caitlin McCue, Elizabeth Maloney, Fiona Shand, and Cherie Kam for assistance with data collection.
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This research was funded by the grant number DA17305 (ECN) from the US National Institute of Drug Abuse. The National Drug and Alcohol Research Centre is funded by the Australian Department of Health and Ageing.