Elsevier

Child Abuse & Neglect

Volume 33, Issue 6, June 2009, Pages 343-352
Child Abuse & Neglect

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

https://doi.org/10.1016/j.chiabu.2008.09.009Get rights and content

Abstract

Objective

To examine the prevalence, characteristics and risk factors for child maltreatment among opioid-dependent persons compared to a community sample of similar social disadvantage.

Method

The study employed a case-control design. Cases had a history of opioid pharmacotherapy. Controls were frequency matched to cases with regard to age, sex and unemployment and were restricted to those with a lifetime opioid use of less than five times. The interview covered child maltreatment, family environment, drug use and psychiatric history.

Results

This study found a high prevalence of child maltreatment among both cases and controls. Despite the elevated prevalence among controls, opioid-dependent males had a higher prevalence of physical and emotional abuse; female cases had a higher prevalence and greater severity of sexual abuse. The prevalence of neglect was similar for both groups. Early parental separation was more prevalent among female cases compared to female controls; otherwise the prevalence of the risk factors was comparable for both groups. The risk factors significantly associated with child maltreatment were also similar for both cases and controls.

Conclusions

Given the documented association between child maltreatment and adult mental disorder, child maltreatment may be an important antecedent of current psychological distress in persons presenting to treatment for opioid dependence. Apart from a possible association between early parental separation and sexual abuse among female cases, the increased prevalence of child maltreatment associated with opioid dependence did not appear to be related to differences in early childhood risk factors considered in this paper. Other risk factors may be more pertinent for those with opioid dependence.

Practice implications

The high prevalence of child maltreatment among the opioid-dependent sample has implications for the assessment and treatment of clients presenting with opioid dependence. Assessment of child maltreatment history could help inform the development of individual treatment plans to better address those factors contributing to the development and maintenance of opioid dependence. Specifically, management of co-morbid mental disorder associated with child maltreatment could be the focus of relapse prevention programmes and also have a positive influence on treatment retention.

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:

  • (a)

    Collectively examining four types of child maltreatment.

  • (b)

    The use of detailed, objective questioning to ascertain child maltreatment.

  • (c)

    Separate analysis of the prevalence and risk factors for child maltreatment among males and females; and

  • (d)

    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.

References (71)

  • K. Heffernan et al.

    Childhood trauma as a correlate of lifetime opiate use in psychiatric patients

    Addictive Behaviors

    (2000)
  • M. Lynskey et al.

    Factors protecting against the development of adjustment difficulties in young adults exposed to childhood sexual abuse

    Child Abuse & Neglect

    (1997)
  • W. McGuigan et al.

    The predictive impact of domestic violence on three types of child maltreatment

    Child Abuse & Neglect

    (2001)
  • K. Mills et al.

    Post-traumatic stress disorder among people with heroin dependence in the Australian Treatment Outcome Study (ATOS): Prevalence and correlates

    Drug and Alcohol Dependence

    (2005)
  • P. Mullen et al.

    The long-term impact of the physical, emotional and sexual abuse of children: A community study

    Child Abuse & Neglect

    (1996)
  • C. Scher et al.

    Prevalence and demographic correlates of childhood maltreatment in an adult community sample

    Child Abuse & Neglect

    (2004)
  • T. Simpson et al.

    Concomitance between childhood sexual and physical abuse and substance use problems: A review

    Clinical Psychology Review

    (2002)
  • H. Swanston et al.

    Further abuse of sexually abused children

    Child Abuse & Neglect

    (2002)
  • S. Tate et al.

    Context of relapse for substance-dependent adults with and without comorbid psychiatric disorders

    Addictive Behaviors

    (2004)
  • N. Vogeltanz et al.

    Prevalence and risk factors for childhood sexual abuse in women: National survey findings

    Child Abuse & Neglect

    (1999)
  • S. Wilson et al.

    Patterns of maternal behaviour among neglectful families: Implications for research and intervention

    Child Abuse & Neglect

    (2005)
  • G. Andrews et al.

    Child sexual abuse

  • C. Bagley et al.

    Prediction of sexual, emotional and physical maltreatment and mental health outcomes in a longitudinal cohort of 290 adolescent women

    Child Maltreatment

    (2000)
  • R. Bailey et al.

    Influences affecting maintenance and cessation of narcotics addiction

    The Journal of Drug Issues

    (1994)
  • N.G. Bartholomew et al.

    Sexual abuse among women entering methadone treatment

    Journal of Psychoactive Drugs

    (2002)
  • J. Belsky

    Etiology of child maltreatment: A developmental-ecological analysis

    Psychological Bulletin

    (1993)
  • A. Bifulco et al.

    Exploring psychological abuse in childhood. II. Association with other abuse and adult clinical depression

    Bulletin of the Menninger Clinic

    (2002)
  • A. Bifulco et al.

    Childhood adversity, parental vulnerability and disorder: Examining inter-generational transmission of risk

    Journal of Child Psychology and Psychiatry

    (2002)
  • Black, E., Roxburgh, A., & Degenhardt, L. (2007). NSW drug trends 2006: Findings from the illicit drug reporting system...
  • K. Bolger et al.

    Developmental pathways from child maltreatment to peer rejection

    Child Development

    (2001)
  • N. Breslau et al.

    Previous exposure to trauma and PTSD effects of subsequent trauma: Results from the Detroit Area Survey of Trauma

    American Journal of Psychiatry

    (1999)
  • E. Bromet et al.

    Risk factors for DSM-III-R posttraumatic stress disorder: Findings from the National Comoribidity Survey

    American Journal of Epidemiology

    (1998)
  • C. Bulik et al.

    Features of childhood sexual abuse and the development of psychiatric and substance use disorders

    British Journal of Psychiatry

    (2001)
  • D. Cicchetti et al.

    Failures in the expectable environment and their impact on individual development: The case of child maltreatment

  • D. Cicchetti et al.

    Transactional ecological systems in developmental psychology

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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.

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