The Violence and Addiction Equation

Theoretical and Clinical Issues in Substance Abuse and Relationship Violence

Christine Wekerle, Anne-Marie Wall, Christine Wekerle, Anne-Marie Wall

• Publisher: Routledge
• Year: 2004
• eBook ISBN: 9781135470692
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

The Violence and Addiction Equation is an empirically based book that bridges the relationship between violence and substance addiction with a focus on the overlap of issues. It is a groundbreaking collection of contributions by prominent clinicians in the field, and the timely chapter's include clinical commentary that identifies and elaborates on points of transfer from theory to clinical practice.

CHAPTER 1

Christine Wekerle
Anne-Marie Wall

Introduction: The Overlap between Relationship Violence and Substance Abuse

Most parents say they love their children; most husbands say they love their wives. Even so, children are most harmed by parents and women are most injured by partners. In 1997, over three million reports of child abuse were received by social service agencies (Wang & Daro, 1998); over 1,000 children died as a result of abuse or neglect (United States Department of Health and Human Services [USDHHS], 1998). Based on a survey of a nationally representative sample, nearly one million violent crimes were committed by partners against women (Rennison & Welchans, 2000). Results from the annual National Household Survey on Drug Abuse (NHSDA) indicate that in 1999 report approximately 10.3 million Americans (4.7%) age 12 or older were dependent on either alcohol or illicit drugs (Office of Applied Studies, 2000). It has been estimated that one in four children in the United States are exposed to parental alcohol dependence, alcohol abuse, or both (Grant, 2000), rendering this a prevalent concern. The presence of both substance abuse and aggressive tendencies in the perpetrator may be especially toxic, and the consequences for the child and adult female victims may be especially deleterious.

This chapter examines the extent to which alcohol and drug use, abuse, and dependence coexist with violence among intimates (parent-to-child and adult partner-to-partner). Understanding the true nature of the overlap between substance abuse and relationship violence, however, is an elusive endeavour. Variation in definitions and sampling methods necessitate a piecemeal approach to articulating prevalence, drawing upon epidemiological studies, forensic reports (e.g., child protective services, police reports), and data from self-selected clinical (e.g., addiction services and mental health clients) and community samples. The most general conclusion is that the prevalence of the overlap be tween substance abuse and relationship violence is generally high, and that this is most evident in high-risk samples (i.e., those that are positive on either relationship violence [e.g., maltreating parents] or substance abuse [e.g., addicted partners]). The specific estimate depends on many factors, including definitional criteria (e.g., diagnostic, legal), sampling procedures (e.g., self-referred, court-ordered), data-gathering method (e.g., interview, questionnaire), and information source (e.g., parent, partner, child, professional).

In attempting to integrate findings across diverse studies, a myriad of conceptual and methodological issues arise in assessing the violence and addiction overlap (see Leonard, 1993; Leonard & Jacob, 1988; Roizen, 1993, 1997). Vast differences exist in the degree of specificity with which abuse of substances and intimates is quantified; to date, no study has comprehensively assessed both constructs and their overlap simultaneously. A particular concern is the accuracy of estimates. Underestimation may arise when community surveys have small samples, low participation rate, and underreporting by respondents. Official reports may underestimate when reporting is deemed as of low benefit or as disruptive to families already receiving services. Further underestimation may stem from the absence of policies, training, and procedures for these dual problems within investigatory agencies (Wolock & Magura, 1996). Overall, there are indisputable factors deflating overlap estimates, including potential for legal ramifications (e.g., legal action concerning child custody, procuring and use of illicit drugs), social stigma (e.g., a double standard for female alcoholism), private nature of events (i.e., the secret of family violence; solitary use in chemical dependency), and individuals’ tendencies to deny or minimize substance and violence problems.

Conversely, other factors exist that may inflate the overlap between drug and intimate abuse. Official reports are widely thought to capture greater severity and, therein, may yield misleading estimates when considering the general population (Widom, 1993). Official reports reflect both a product (the illegal event) and a process (evaluating the probability of successful prosecution), and are subject to biases from professionals (e.g., selective reporting by ethnicity, gender, socioeconomic status [SES], multiproblem family status), clients (e.g., maltreating parents reporting greater substance abuse in an attempt to present a socially acceptable justification or mitigating circumstance), and agencies (e.g., priority to younger abused children, higher visibility problems). Considering these issues, it has been recommended that selected risk sample studies not be extrapolated to the general population, nor should the general population be considered the most suitable control group (Roizen, 1993, 1997). Both these data sources inform the violence and addiction equation.

With the above concerns as a caveat, this chapter considers literature reviews and recent work with improved methodology. First, the overlap between child abuse and parental substance use and abuse is presented, followed by a discussion of the contribution of child abuse to adult addiction. Next, the role of alcohol and drugs in domestic violence is examined. Finally, conclusions regarding the overlap between substance and intimate abuse and directions for future work are considered.

Child Abuse and Substance-Abusing Parents

Children are vulnerable. Historically, demonstrable child physical injury from parents labeled the “battered-child syndrome,” was noted by formal health systems in the 1960s (Kempe, Silverman, Steele, Droegemueller, & Silver, 1962). Subsequently, researchers have highlighted that various forms of child abuse (physical, sexual, emotional abuse, and neglect) overlap substantially with each other (Wekerle & Wolfe, 1996), with exposure to marital violence (Straus & Gelles, 1990), and with pediatric populations such as child accidental injury (Peterson & Brown, 1994) and failure-to-thrive infants (Benoit, 1993). One consistent contextual factor to all these forms of child abuse is parental substance abuse.

The general definition of child abuse involves the “physical or mental injury, sexual abuse or exploitation or maltreatment of a child under the age of eighteen… by a person… who is responsible for the child’s welfare” (The Child Abuse Prevention and Treatment Act, 1984). Physical abuse refers to behaviors such as striking, shaking, or scalding that leave some evidence of physical injury (e.g., bruising, bleeding, burns). Sexual abuse ranges from adult-to-child exposure (of body, pornography, etc.) to more invasive assaults such as fondling, oral sex, and penetration. Neglect represents a range of acts of omission, including failure to provide the child with basic health care, nutrition, education, and protection from danger and injury. Emotional abuse includes such behaviors as verbal and emotional assaults (e.g., rejection, ridicule, isolation), as well as inappropriate confinement (e.g., physical restraint); it is commonly thought to coincide with other forms of abuse (Wekerle & Wolfe, 1996).

Parental substance abuse, alone, is not considered child abuse and, consequently, is not generally a cause in and of itself for mandatory protective services intervention (Wolock & Magura, 1996). Many states have laws requiring the reporting of drug- or alcohol-exposed infants. In some states, prenatal exposure itself constitutes neglect and is grounds for removing children from the custody of their parents (US General Accounting Office, 1997; USDHHS, 1994). Further, many chemically-involved parents remain invisible to child welfare agencies. This may be due to perceived greater overall functioning (e.g., nonsubstance-abusing spouse, employment of substance-abusing parent, “parentified” children, family and friend support) that may dampen immediate risk concerns. As a result of a parent’s preoccupation with substances, however, a child’s health and safety may be so seriously jeopardized as to capture the attention of child protective services (CPS). Child neglect may be a function of depletion of household budget on drugs and alcohol that would otherwise cover a child’s basic needs. Abuse and neglect may be related to a parent’s disappearance for hours or days, or a drug-related reduced emotional and physical availability and cognitive capacity (e.g., impaired judgment, reduced behavioral inhibition, reduced monitoring and supervising capacity). Further, exposure to criminal activity (e.g., drug or sex trade to obtain funds, manufacture or distribution of illicit drugs) to dangerous persons and high levels of household traffic increase child risk.

CPS reports are a valuable data source for considering the general question of the overlap between parental substance abuse and child abuse in that specified criteria (for child abuse) are applied. It provides unique information from community surveys and clinicbased studies, given that the majority of referrals are other-report, particularly professional report. For example, in 1996, two thirds of official reports were from professional sources; while 77% of perpetrators were parents, less than 7% were reporters to CPS (USDHHS, 1998). While CPS-based statistics and empirical studies move away from self-report biases such as social desirability, they remain subject to the biases of other-report. For instance, children in families with annual incomes below $15,000/year were 25 times more likely to have been noted by community professionals as being abused, as compared to those in families with annual incomes above $30,000 (USDHHS, 1996). Clearly, poverty overlaps with formal system entry. Nonetheless, it is widely regarded that national rates of reported child abuse are conservative, if not dramatic underestimates, given the data from cross-sectional and retrospective surveys (McCurdy & Daro, 1994). This is thought to be due, in part, to underreporting of professionals to CPS, a necessary reliance on evidenciary criteria to classify cases as “confirmed,” and that silence enforced by the per petrators is more often than not a successful strategy. Also, differing statistics are recorded by agencies, which complicates making any determination concerning the number of child victims versus incidents (McCurdy & Daro, 1994).

In 1990, child abuse was identified by the U.S. Advisory Board on Child Abuse and Neglect as an emergency. In 1996, close to one million children were identified by CPS as abuse and neglect victims in the United States, either substantiated or indicated (i.e., reasonable grounds, but insufficient evidence for prosecution) (USDHHS, 1998). The national rate of maltreatment was 15 victims per 1, 000 children in the population. Neglect emerged as the most prevalent form (52% of children), and is the major reason for child removal from parent substance-abusing homes, as these children suffer more injuries and poisonings than those in the general population (Bijur, Kurzon, Overpeck, & Scheidt, 1992). Neglect is predominantly committed by adult females (69%). Victimization decreases with child age (the majority of victims are under age 8) and with similar proportions of male and female children. To a lesser extent than neglect, are physical abuse (23%) and sexual abuse (14%). While similar proportions of males and females are represented in both the perpetrators and victims of physical abuse, males predominantly perpetrate sexual abuse (82%), with females being predominantly victimized (77%). Emotional abuse is a rarer cause for reporting (approximately 6% of cases).

State child welfare records indicate that substance abuse is one of the top two problems in 81% of reported families; among confirmed cases, 40% involve the use of alcohol or other drugs (USDHHS, 1996). Substance abuse by the primary caretaker represented 26% of families on the open child welfare caseloads in 1994; of these, 23% were not offered substance abuse treatment services (Westat, 1997). These overall figures, though, mask variations in different locales; for example, the proportion of previously reported child welfare cases involving substance abuse were 50% in Illinois, 80% in Washington, D.C., and 64% in Boston (Feig, 1990). One study found that children in alcohol-abusing families were approximately four times more likely to be maltreated overall, five times more likely to be physically neglected, and ten times more likely to be emotionally neglected than children in nonalcohol-abusing families (USDHHS, 1993). Although parental substance abuse has been implicated in child abuse-related fatalities, it does not appear to be more prevalent than in nonfatal child abuse cases. Based on data available from 11 states, parental substance abuse was linked to 19% of child abuse fatalities (McCurdy & Daro, 1994).

While parental substance abuse represents a significant proportion of official child abuse reports, there are other issues to be addressed. For instance, it is not clear what percentage of specific types of child abuse is related directly to a substance-abusing parent, as compared to an indirect relationship through exposure to greater vulnerability. The risk to the child likely increases when there is no supporting adult to diffuse parental stress and occupy the parental role abdicated by the substance-abusing single parent. Also, the contribution of maternal and paternal substance abuse to reported child abuse across types remains unclear. For instance, research indicates that mothers who are classified as problem drinkers are more likely to be married to problem drinking fathers, and their children are at highest risk of serious physical injury (head injuries, fractures), as compared to problem drinking single mothers (Bijur et al., 1992). Also, epidemiological research with women randomly selected from the community found that for those women who reported child sexual abuse (i.e., perpetrator five years older than victim and coercive actions ranging from fondling to intercourse), having an alcoholic mother or father was a significant predictor. When child abuse was categorized by perpetrator, extrafamilial child sexual abuse was predicted by having an alcoholic mother, while familial sexual abuse was predicted by having an alcoholic father (Fleming, Mullen, & Bammer, 1997).

Further, substance use and abuse tends to be assessed globally in CPS investigations, without referencing quantity, frequency, and type of substance to the specific child abuse behavior. One report that did consider this issue found that among substance-abusing child welfare families, alcohol was dominant, with a substantial number of parents using marijuana, cocaine, crack, and, to a much lesser extent, heroin. According to caseworker reports, 65% of children with substance-abusing perpetrators were maltreated while the perpetrator was intoxicated (Westat, 1992, as cited in Magura & Laudet, 1996). In addition to acute intoxication, it is important to assess lifetime substance abuse (i.e., chronicity and cumulative problems that may persist even beyond recovery) and withdrawal effects, as all may have a negative impact (e.g., irritability, depression, impaired judgment) on the parent and may facilitate child abuse and neglect.

Moving from CPS statistics to empirical studies, early reviews of the research on alcoholism and child abuse (Hamilton &...

Table of contents

• Cover Page
• Half Title Page
• Title Page
• Copyright Page
• Contents
• Contributors
• Preface
• Chapter 1 Introduction The Overlap between Relationship Violence and Substance Abuse
• I Theoretical Frameworks
• II Relationship Violence and Addiction Across the Lifespan
• III Clinical Issues in Intervention for Intimate Violence and Addiction Problems
• Index