TIP 36: Substance Abuse Treatment for Persons with Child Abuse and Neglect Issues Short Contents | Full Contents Other books @ NCBI Search (: on) Checked This book (text) (: on) Unchecked All books (: on) Unchecked PubMed Navigation About this book SAMHSA/CSAT Treatment Improvement Protocols 36. TIP 36: Substance Abuse Treatment for Persons with Child Abuse and Neglect Issues Executive Summary and Recommendations Chapter 1 Working With Child Abuse and Neglect Issues Chapter 2 Screening and Assessing Adults For Childhood Abuse and Neglect AHCPR Archived reports, Put Prevention Into Practice and Minnesota Health Technology Advisory Committee SAMHSA/CSAT Treatment Improvement Protocols 36. TIP 36: Substance Abuse Treatment for Persons with Child Abuse and Neglect Issues Title Page Substance Abuse Treatment for Persons With Child Abuse and Neglect Issues Treatment Improvement Protocol (TIP) Series 36 Judy Howard, M.D. Consensus Panel Chair U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment Rockwall II, 5600 Fishers Lane Rockville, MD 20857 DHHS Publication No. (SMA) 00-3357 Printed 2000 Chapter 3 Comprehensive Treatment for Adult Survivors of Child Abuse and Neglect Chapter 4 Therapeutic Issues for Counselors Chapter 5 Breaking the Cycle: The Substance- Dependent Client as Parent/Caregiver Chapter 6 Legal Responsibilities and Recourse Chapter 7 Emerging and Continuing Issues Appendix B -Protecting Clients' Privacy Appendix C -Implications of Recent Federal Legislation for Clients in Treatment Appendix D Obtaining Screening and Assessment Tools Appendix E -Resources Related to Childhood Trauma Among Adults Link to the National Guideline Clearinghouse Disclaimer This publication is part of the Substance Abuse Prevention and Treatment Block Grant technical assistance program. All material appearing in this volume except that taken directly from copyrighted sources is in the public domain and may be reproduced or copied without permission from the Substance Abuse and Mental Health Services Administration's (SAMHSA) Center for Substance Abuse Treatment (CSAT) or the authors. Citation of the source is appreciated. This publication was written under contract number 270-95-0013 with The CDM Group, Inc. (CDM). Sandra Clunies, M.S., I.C.A.D.C., served as the CSAT government project officer. Rose M. Urban, L.C.S.W., J.D., C.C.A.S., served as the CDM TIPs project director. Other CDM TIPs personnel included Raquel Ingraham, M.S., project manager; Jonathan Max Gilbert, M.A., managing editor; Cara Smith, production editor; Kurt S. Olsson, former editor/ writer; Paul Seaman, former acting editor; Y-Lang Nguyen, former production editor; and MaryLou Leonard, former project manager. Special thanks go to consulting writers Tracy Simpson, Ph.D., and Christine Courtois, Ph.D., for their considerable contributions to this document. The opinions expressed herein are the views of the Consensus Panel members and do not reflect the official position of CSAT, SAMHSA, or the U.S. Department of Health and Human Services (DHHS). No official support or endorsement of CSAT, SAMHSA, or DHHS for these opinions or for particular instruments or software that may be described in this document is intended or should be inferred. The guidelines proffered in this document should not be considered as substitutes for individualized client care and treatment decisions. What Is a TIP? Treatment Improvement Protocols (TIPs) are best practice guidelines for the treatment of substance abuse, provided as a service of the Substance Abuse and Mental Health Services Administration's Center for Substance Abuse Treatment (CSAT). CSAT's Office of Evaluation, Scientific Analysis and Synthesis draws on the experience and knowledge of clinical, research, and administrative experts to produce the TIPs, which are distributed to a growing number of facilities and individuals across the country. The audience for the TIPs is expanding beyond public and private substance abuse treatment facilities as alcoholism and other substance abuse disorders are increasingly Appendix F -Resource Panelists Appendix G Field Reviewers Figures Appendix A -Bibliography recognized as major problems. The TIPs Editorial Advisory Board, a distinguished group of substance abuse experts and professionals in such related fields as primary care, mental health, and social services, works with the State Alcohol and Other Drug Abuse Directors to generate topics for the TIPs based on the field's current needs for information and guidance. After selecting a topic, CSAT invites staff from pertinent Federal agencies and national organizations to a Resource Panel that recommends specific areas of focus as well as resources that should be considered in developing the content of the TIP. Then recommendations are communicated to a Consensus Panel composed of non-Federal experts on the topic who have been nominated by their peers. This Panel participates in a series of discussions; the information and recommendations on which they reach consensus form the foundation of the TIP. The members of each Consensus Panel represent substance abuse treatment programs, hospitals, community health centers, counseling programs, criminal justice and child welfare agencies, and private practitioners. A Panel Chair (or Co-Chairs) ensures that the guidelines mirror the results of the group's collaboration. A large and diverse group of experts closely reviews the draft document. Once the changes recommended by these field reviewers have been incorporated, the TIP is prepared for publication, in print and online. The TIPs can be accessed via the Internet on the National Library of Medicine's home page at the URL: http://text.nlm.nih.gov. The move to electronic media also means that the TIPs can be updated more easily so they continue to provide the field with state-ofthe- art information. Although each TIP strives to include an evidence base for the practices it recommends, CSAT recognizes that the field of substance abuse treatment is evolving and that research frequently lags behind the innovations pioneered in the field. A major goal of each TIP is to convey "front line" information quickly but responsibly. For this reason, recommendations proffered in the TIP are attributed to either Panelists' clinical experience or the literature. If there is research to support a particular approach, citations are provided. This TIP, Substance Abuse Treatment for Persons With Child Abuse and Neglect Issues, examines treatment issues for both adult survivors of child abuse or neglect and adults in treatment who may be abusing or neglecting their own children. Chapters 1 through 3 focus primarily on adult survivors of child abuse and neglect. Chapter 1 defines child abuse and neglect, provides rates of child abuse and neglect both in the general population and among those in substance abuse treatment, and reviews the literature on links between childhood abuse and subsequent substance abuse. Chapter 2 describes screening and assessment tools that can be used to determine whether a client has a history of childhood abuse or neglect; Chapter 3 presents guidelines on treating clients with histories of child abuse or neglect and referring them to mental health care treatment when necessary. Chapter 4 discusses the personal issues counselors may encounter (e.g., countertransference) when working with clients with histories of abuse or neglect and offers suggestions for addressing them. In Chapters 5 and 6, the focus shifts to adults in treatment who may be abusing or neglecting their own children. Chapter 5 shows how alcohol and drug counselors can identify whether their clients are at risk of or are currently abusing or neglecting their children. It discusses what alcohol and drug counselors can do to break the cycle of child abuse and neglect, including how to work with child protective service agencies within the child welfare system. Chapter 6 is an overview of the legal issues that counselors should be aware of as mandated reporters. The TIP concludes with an overview in Chapter 7 of continuing and emerging trends, such as fast-track adoption and welfare reform, that counselors will need to follow in the coming years. Other TIPs may be ordered by contacting SAMHSA's National Clearinghouse for Alcohol and Drug Information (NCADI), (800) 729-6686 or (301) 4682600; TDD (for hearing impaired), (800) 487-4889. Editorial Advisory Board Karen Allen, Ph.D., R.N., C.A.R.N. Professor and Chair Department of Nursing Andrews University Berrien Springs, Michigan Richard L. Brown, M.D., M.P.H. Associate Professor Department of Family Medicine University of Wisconsin School of Medicine Madison, Wisconsin Dorynne Czechowicz, M.D. http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.63145 (4 of 9)08/01/2006 7:32:55 AM Associate Director Medical/Professional Affairs Treatment Research Branch Division of Clinical and Services Research National Institute on Drug Abuse Rockville, Maryland Linda S. Foley, M.A. Former Director Project for Addiction Counselor Training National Association of State Alcohol and Drug Abuse Directors Washington, D.C. Wayde A. Glover, M.I.S., N.C.A.C. II Director Commonwealth Addictions Consultants and Trainers Richmond, Virginia Pedro J. Greer, M.D. Assistant Dean for Homeless Education University of Miami School of Medicine Miami, Florida Thomas W. Hester, M.D. Former State Director Substance Abuse Services Division of Mental Health, Mental Retardation and Substance Abuse Georgia Department of Human Resources Atlanta, Georgia James G. (Gil) Hill, Ph.D. Director Office of Substance Abuse American Psychological Association Washington, D.C. Douglas B. Kamerow, M.D., M.P.H. Director http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.63145 (5 of 9)08/01/2006 7:32:55 AM Office of the Forum for Quality and Effectiveness in Health Care Agency for Health Care Policy and Research Rockville, Maryland Stephen W. Long Director Office of Policy Analysis National Institute on Alcohol Abuse and Alcoholism Rockville, Maryland Richard A. Rawson, Ph.D. Executive Director Matrix Center and Matrix Institute on Addiction Deputy Director, UCLA Addiction Medicine Services Los Angeles, California Ellen A. Renz, Ph.D. Former Vice President of Clinical Systems MEDCO Behavioral Care Corporation Kamuela, Hawaii Richard K. Ries, M.D. Director and Associate Professor Outpatient Mental Health Services and Dual Disorder Programs Harborview Medical Center Seattle, Washington Sidney H. Schnoll, M.D., Ph.D. Chairman Division of Substance Abuse Medicine Medical College of Virginia Richmond, Virginia Consensus Panel Chair Judy Howard, M.D. Professor of Pediatrics http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.63145 (6 of 9)08/01/2006 7:32:55 AM Developmental Studies Program Department of Pediatrics School of Medicine University of California at Los Angeles Los Angeles, California Workgroup Leaders Lynn Dorman, Ph.D., J.D. Brattleboro, Vermont David Duncan, Dr.P.H., C.A.S. Associate Professor Center for Alcohol and Addiction Studies Brown University Providence, Rhode Island Jerry P. Flanzer, D.S.W., L.C.S.W., C.A.C. Director Recovery and Family Treatment, Inc. Alexandria, Virginia Marie Littlejohn, M.S.W., C.S.W. Director of Social Work Maternity Infant Care Medical and Health Research Association New York, New York Joan E. Massaquoi, M.S.W., L.C.S.W., B.C.D. Chicago, Illinois Thomas J. McMahon, Ph.D. Assistant Professor of Psychology Substance Abuse Center Yale School of Medicine New Haven, Connecticut Panelists Sarah A. Addlesberger Program Coordinator Castle Medical Center Ocean View, Hawaii Christian A. Akiwowo, Ph.D. President/Chief Executive Officer Alajobi Rehabilitative Services Olympia Fields, Illinois http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.63145 (7 of 9)08/01/2006 7:32:55 AM Darlene Allen, M.S. Director Child Welfare Services Children's Friend and Services Providence, Rhode Island Michael D. De Bellis, M.D. Assistant Professor of Psychiatry Developmental Traumatology Laboratory University of Pittsburgh Medical Center Pittsburgh, Pennsylvania Pamela L. Donaldson, A.R.N.P-C., C.A.R.N, Ph.D. Post-Doctoral Fellow New York State Psychiatric Institute Columbia University Hackensack, New Jersey James Herrera, M.A., L.P.C.C. Center on Alcoholism, Substance Abuse and Addictions University of New Mexico Albuquerque, New Mexico Margo H. Juarez, L.A.D.A.C., R.I.M.H.C. Albuquerque Metropolitan Central Intake Albuquerque, New Mexico Lewis Jay Lester, M.S.W., L.C.S.W. Briceland, California Herschel Swinger, Ph.D. Children's Institute International Los Angeles, California Foreword The Treatment Improvement Protocol (TIP) series fulfills SAMHSA/CSAT's mission to improve treatment of substance abuse by providing best practices guidance to clinicians, program administrators, and payors. TIPs are the result of careful consideration of all relevant clinical and health services research findings, demonstration experience, and implementation requirements. A panel of non-Federal clinical researchers, clinicians, program administrators, and client advocates debates and discusses their particular area of expertise until they reach a consensus on best practices. This panel's work is then reviewed and critiqued by field reviewers. The talent, dedication, and hard work that TIPs panelists and reviewers bring to this highly participatory process have bridged the gap between the promise of research and the needs of practicing clinicians and administrators. We are grateful to all who have joined with us to contribute to advances in the http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.63145 (8 of 9)08/01/2006 7:32:55 AM substance abuse treatment field. Nelba Chavez, Ph.D. Administrator Substance Abuse and Mental Health Services Administration H. Westley Clark, M.D., J.D., M.P.H, CAS, FASAM Director Center for Substance Abuse Treatment Substance Abuse and Mental Health Services Administration Copyright and Disclaimer Short Contents | Full Contents Other books @ NCBI Search (: on) Checked This book (text) (: on) Unchecked All books (: on) Unchecked PubMed Navigation About this book SAMHSA/CSAT Treatment Improvement Protocols 36. TIP 36: Substance Abuse Treatment for Persons with Child Abuse and Neglect Issues Executive Summary and Recommendations Chapter 1 Working With Child Abuse and Neglect Issues Chapter 2 Screening and Assessing Adults For Childhood Abuse and Neglect AHCPR Archived reports, Put Prevention Into Practice and Minnesota Health Technology Advisory Committee SAMHSA/CSAT Treatment Improvement Protocols 36. TIP 36: Substance Abuse Treatment for Persons with Child Abuse and Neglect Issues Executive Summary and Recommendations Child abuse and neglect pose an increasingly recognized and serious threat to the nation's children. The reported cases of abused and neglected children have more than doubled from 1.4 million in 1986 to more than 3 million in 1997. Research suggests that adults with histories of child abuse and neglect are at high risk for developing substance abuse disorders. Moreover, these childhood abuse and neglect issues may negatively affect clients' chances for recovery from substance abuse. Compounded with these problems is the increased likelihood of substance-abusing parents abusing their own children. By most accounts, substance abuse contributes to almost three fourths of the incidents of child abuse or neglect for children in foster care. Two major reports released in 1999 highlight the need to address this intergenerational cycle of substance abuse and child abuse if effective progress is to be made on either problem. These studies are Blending Perspectives and Building Common Ground: A Report to Congress on Substance Abuse and Child Protection by the U.S. Department of Health and Human Services (DHHS) and No Safe Haven: Children of Substance-Abusing Parents by the National Center on Addiction and Substance Abuse (CASA) at Columbia University. Both reports emphasize that the rise in substance abuse as a factor in child abuse and neglect cases has severely complicated efforts by child welfare systems to protect children and rehabilitate families. In response to these issues, this Treatment Improvement Protocol (TIP) presents information to assist alcohol and drug counselors and other treatment providers to work more effectively with adults who have histories of childhood abuse or neglect and adults who abuse or who are at risk for abusing their own children. The effects of childhood abuse and neglect perpetrated by family members and the intergenerational transmission of the cycle of substance abuse and child Chapter 3 Comprehensive Treatment for Adult Survivors of Child Abuse and Neglect Chapter 4 Therapeutic Issues for Counselors Chapter 5 Breaking the Cycle: The Substance- Dependent Client as Parent/Caregiver Chapter 6 Legal Responsibilities and Recourse Chapter 7 Emerging and Continuing Issues Appendix B -Protecting Clients' Privacy Appendix C -Implications of Recent Federal Legislation for Clients in Treatment Appendix D Obtaining Screening and Assessment Tools Appendix E -Resources Related to Childhood Trauma Among Adults abuse and neglect are the focus of this TIP. However, not all clients in treatment have a history of childhood abuse, not all children who are maltreated become substance abusers or child abusers, and not all child abusers have a history of childhood abuse or current substance abuse. Although these are common factors that often arise in substance abuse treatment, they are not present in every case. This TIP does not address the treatment needs of children who are currently being abused, as that area of concern is extensively addressed in multidisciplinary literature. This TIP also does not address children who are abusing substances, many of whom may have experienced abuse and neglect. The issues involved in treating children and adolescents for substance abuse differ greatly from those encountered with an adult client population. Guidelines for screening, assessing, and treating adolescents with substance abuse disorders are offered in TIP 31, Screening and Assessment of Adolescents for Substance Use Disorders (CSAT, 1999a), and TIP 32, Treatment of Adolescents With Substance Use Disorders (CSAT, 1999b). A third group not addressed here is pedophiles. The Consensus Panel considers pedophilia to be a separate category of child sexual abuse beyond the scope of this document. The most pervasive form of child maltreatment is neglect (60 percent); however, because most research has focused on childhood physical and sexual abuse, this TIP will primarily address these two forms. Definitions of the types of behaviors and specific acts that constitute physical, emotional, and sexual abuse and neglect are provided in Chapter 1 so that counselors can better understand the range of potential experiences of their clients. In Chapter 2, the TIP discusses common signs and behaviors that suggest a history of childhood emotional, physical, and sexual abuse and neglect, as well as indicators that clients might be abusing their own children. Chapter 3 addresses the distinct treatment issues that counselors may encounter in working with adults who have been abused or neglected in childhood. Among the factors that can complicate treatment for this population are comorbid mental disorders and trauma-related symptoms. Because of the abhorrent nature of child abuse and the emotional difficulty of working with traumatized individuals and with individuals who harm children, personal issues for counselors are discussed throughout this TIP and are the focus of Chapter 4. Substance-abusing parents who may be abusing or neglecting their children are the subject of Chapter 5. In working with child abusers, many of whom are ordered into treatment by the courts, treatment counselors must understand the structure of the child protective services (CPS) system and the family and criminal courts in order to help clients negotiate these systems. The TIP provides some guidelines for communicating with Appendix F -Resource Panelists Appendix G Field Reviewers Figures Appendix A -Bibliography these systems; however, treatment providers must learn the particulars of how these services are structured in their State and local jurisdictions. Chapter 6 discusses the relevant laws on reporting current child abuse and maintaining client confidentiality; recent legislation on family preservation, fast-track adoption, and reunification laws are reviewed in Chapter 7. Throughout this TIP, the term "substance abuse" has been used in a general sense to cover both substance abuse disorders and substance dependence disorders (as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition [DSM-IV] American Psychiatric Association, 1994). Because the term "substance abuse" is commonly used by substance abuse treatment professionals to describe any excessive use of addictive substances, in this TIP it will be used to denote both substance dependence and substance abuse disorders. The term relates to the use of alcohol as well as other substances of abuse. Readers should attend to the context in which the term occurs in order to determine what possible range of meanings it covers; in most cases, however, the term will refer to all varieties of substance use disorders as described by DSM-IV. To avoid both sexism and awkward sentence construction, the TIP alternates between the pronouns "he" and "she" in generic examples. Recommendations The Consensus Panel's recommendations, summarized below, are based on both research and clinical experience. Those supported by scientific evidence are followed by (1); clinically based recommendations are marked (2). Citations to the former are referenced in the body of this document, where the guidelines are presented in detail. The Consensus Panel recommends that, when working with clients with substance abuse problems and histories of childhood abuse and neglect, counselors adopt a broad approach that considers the meaning of the experience to the client, not just legal definitions of child abuse and neglect. (1) Counselors must, therefore, understand how clients interpret their experiences. Not all abuse meets the legal or commonly held criteria for abuse, nor do all clients perceive as abusive behavior that which might be legally defined as "abuse." Screening and Assessment Without proper screening and assessment, treatment providers may wrongly attribute symptoms of childhood trauma-related disorders to consequences of current substance abuse. Comprehensive screening for root causes of clients' presenting symptoms may greatly increase the effectiveness of treatment. However, counselors face many challenges when screening for and assessing childhood abuse or neglect. Many abuse survivors are ashamed of having been victims of childhood physical, emotional, or sexual abuse and may believe that the abuse was self-induced. Screening and assessment, therefore, should be designed to reduce the threat of humiliation and blame and should be done in a safe, nonthreatening environment. (2) While conducting screenings and assessments, counselors should be mindful that adult survivors of childhood trauma commonly suppress memories of certain traumatic events or minimize their symptoms, either intentionally or unintentionally. Moreover, issues of confidentiality, mandated reporting, and trust may influence the responses to interviews and questionnaires by making some clients less inclined to reveal personal histories of abuse or neglect. Given the variable reliability of clients' responses, counselors should neither overemphasize nor overvalue the role of standardized instruments. Counselor issues Counselors who will be screening for and assessing histories of child abuse or neglect should receive specific training in these areas. (2) Although there are no rigid rules regarding who should conduct screenings, having certain skills will increase the likelihood that the screening process is conducted appropriately. Staff members should have an understanding of the types of psychiatric disorders and symptoms that are commonly associated with histories of childhood abuse and neglect. Counselors who conduct screenings will be prompting clients to recall painful and traumatic events. The reemergence of painful memories may cause intense reactions from clients. Treatment staff should be sensitive to this and prepare for the interview in the following ways: . Inform clients that talking about such issues might create discomfort; clients should be given a choice to disclose such information, being aware of the possible aftermath. (2) . Have proper supervision and support mechanisms in place for clients in case a crisis occurs following disclosure (e.g., accessibility to mental health practitioners or medical personnel). (2) . Assess the sources of social and emotional support available to clients when they return home. (2) There are many potential barriers to successful screenings and assessments of childhood trauma. To reduce some of these barriers, the Consensus Panel http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.section.63294 (4 of 14)08/01/2006 7:33:42 AM recommends the following: . Be sensitive to cultural concerns. (1) . Recognize potential language differences. (2) . Become aware of gender issues. (2) . Be nonjudgmental and sensitive. (1) If counselors experience intense discomfort and anxiety when conducting screenings and assessments, the Consensus Panel recommends that they receive guidance and support from a clinical supervisor and consider whether they could benefit from therapeutic assistance to explore the reasons for their discomfort. (2) A variety of instruments for screening and assessment are discussed in Chapter 2. Screening The Consensus Panel suggests screening for child abuse and neglect histories early in the assessment process to identify individuals who exhibit signs and symptoms associated with child abuse and neglect (such as posttraumatic stress disorder [PTSD], major depression, or mood disorders) and to identify those who may benefit from a comprehensive clinical assessment. (2) Screenings should also be conducted at different times throughout the treatment process. Repeated screenings help elicit information about these traumatic experiences--especially after trust has been established in the therapeutic relationship. (2) To conduct a screening effectively, treatment staff should . Learn and understand ways in which childhood abuse and neglect can affect adult feelings and behaviors. (2) . Identify those individuals who appear to exhibit these symptoms. (2) . Identify the trauma-related treatment needs of these clients. (2) . Provide or coordinate appropriate treatment services that will help meet clients' treatment needs. (2) Screening for childhood abuse or neglect can set in motion a proactive plan with the following benefits: . Stopping the cycle. Although not all adults who were abused or neglected during childhood abuse their own children, they are at greater risk for doing so. (1) . Decreasing the probability of relapse. Many substance abusers consume substances to self-medicate posttraumatic stress symptoms related to past physical or sexual abuse or trauma. (1) http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.section.63294 (5 of 14)08/01/2006 7:33:42 AM . Improving a client's overall psychological and interpersonal functioning. Childhood sexual abuse and neglect may affect the individual's self-concept, sense of self-esteem, and ability to self- actualize. (2) . Improving program outcome. Screening for a history of child abuse or neglect will help a program to determine the needs of its clients, thus improving treatment outcomes. (2) Assessments The primary purpose of an assessment is to confirm or discount a positive screening for childhood abuse or neglect, as well as to identify clients' needs so that treatment can be tailored to meet them. The more clinical information a program has about clients' particular treatment needs, the better the program can accommodate them. All clients who screen positive for a history of childhood abuse or neglect should be offered a comprehensive mental health assessment. (2) There is no standard trauma-oriented assessment tool, and no single tool can be considered truly comprehensive. Rather, wisely selected, each of these tools can be a valuable component of a comprehensive assessment process. When deciding whether to conduct assessments for a history of child abuse or neglect, the treatment team should evaluate clients' . Current substance use or quality and length of abstinence . Commitment to the treatment and recovery process . Risk of relapse The Consensus Panel believes that treatment decisions and activities are best conducted within the context of a multidisciplinary treatment team, with members having special knowledge in such areas as mental health, child abuse and neglect, and family counseling. (2) Each member of the treatment team should help decide if and when to conduct assessments for childhood trauma, and clients should be asked to evaluate their own readiness to confront child abuse or neglect issues. Trauma-related assessments are important because they can help the treatment staff understand the types of childhood traumatic events experienced by clients, their subjective response and perceptions of these events, and common current symptoms that may result from childhood trauma. Decisions regarding the types of instruments to use should be influenced by the purpose of the assessment, the setting of the assessment, the population being treated, and the http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.section.63294 (6 of 14)08/01/2006 7:33:42 AM individual client and the severity of his problems. (2) Assessing histories of childhood trauma can provoke or exacerbate a psychological emergency that must be addressed; therefore the Consensus Panel recommends that the treatment team include a licensed mental health professional to handle medical issues that may arise and to conduct more formal assessments that may be required. Subjective experience of the events How clients remember traumatic events can shape their psychological response more than the actual circumstances can; counselors, therefore, need to obtain subjective information about these events. Such information is necessary in order to plan appropriate treatment. Information that should be obtained includes: . What the client thought about during the abuse . What the client felt during the abuse . How the client understood, as a child, what was happening to her and what she thinks about it now . How the client thinks and feels about how the abuse has affected his adulthood and substance abuse, and how he deals with the aftereffects of the abuse now . The feelings most closely associated with the abuse experience . The client's memories of the abuse . The unique aspects of the client's perceptions about the abuse . The client's coping strategies, and their effectiveness for the client Childhood symptoms and family characteristics The assessment should inquire about childhood symptoms and family characteristics that are consistent with and suggest a history of childhood abuse or neglect. (2) Symptoms to look for include . Depression (including thoughts of death, passive suicidal ideation, and feelings of hopelessness) . Dissociative responses during childhood . Aggressive behavior or other "acting out," including . Early sexual activity or sexualized behavior . Physically abusing or harming pets or other animals . Other destructive behaviors http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.section.63294 (7 of 14)08/01/2006 7:33:42 AM . Poor relationships with one or both parents . Attachment disorder, difficulty trusting others . Excessive passivity . Passive/aggressive behavior . Inappropriate age/sexuality formation . Blacked-out timeframes during childhood . Excessive nightmares, extreme fear of the dark, or requested locks on doors Family-of-origin characteristics to consider include . Parental substance abuse . Battering within the family . Involvement with CPS agencies or foster care . Placement with foster parents or relatives . Severe discipline during childhood . Traumatic separations and losses Treatment Planning A very important factor in predicting treatment success is the number of services clients receive (e.g., case management, parenting education, counseling for PTSD and childhood abuse). (1) Clients receiving more specialized services, often concurrently with substance abuse treatment, are more likely to stay in recovery. (1) Treatment planning for clients with childhood abuse histories should be a dynamic process that can change as new information is uncovered, taking into account where a client is in the treatment process (e.g., confronting abuse issues too early in treatment can lead to relapse). (2) However, it is also important for counselors to remember that until some degree of sobriety is achieved, a client's sense of reality is likely to be distorted and her judgment poor. When disclosures of past abuse take place before a client has achieved sobriety, information on childhood abuse and neglect should be heeded, but full exploration of the issue should be postponed until later. (2) Listed below are general recommendations and guidelines counselors should be aware of when planning a client's treatment. . Counselors should exhibit unconditional positive regard, a nonjudgmental attitude, and sincerity--therapist characteristics that are essential for effective treatment, regardless of therapeutic modality. (1) http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.section.63294 (8 of 14)08/01/2006 7:33:43 AM . Providers must be sensitive to their clients' cultural issues and how they interact with clients' child abuse or neglect history. The Consensus Panel strongly urges alcohol and drug counselors to be aware of how clients' backgrounds may affect treatment. (2) . Sympathetic listening can be an important first step in helping a formerly abused client begin the healing process. (2) . In the initial crisis that often follows a disclosure, the counselor's most important task may be affect management, such as keeping the client calmer by using relaxation techniques. (2) . Clients who suffered severe childhood abuse may need to be reassured that they are in a safe environment and will not be abused in the present. They may also have to be taught techniques to stay focused in the present. (2) . Some clients may require medical supervision in inpatient or intensive outpatient programs (at least during the early stages of abstinence) in order to deal with their feelings of rage, anxiety, depression, or suicidality. (2) . Clients with past trauma should be reassured in treatment that they have the capacity to deal with traumatic memories or related destructive behaviors stemming from childhood abuse. (2) . Counselors must carefully pace the client's treatment by monitoring anxiety and depression levels and by taking other cues directly from the client. (2) . Counselors need to isolate the symptoms of substance abuse disorders caused by trauma due to childhood abuse. (2) . Counselors should search for and apply any available leverage to help clients endure the short-term pain--until some treatment benefits can be realized. Clients must be engaged in a way that will give them hope and increase their beliefs in their own power to create a new life. (2) . For clients entering substance abuse treatment, the mere act of completing a questionnaire acknowledging a history of abuse can be tremendously healing and can lead to change, even without the intervention of a counselor. For other clients, however, actively confronting the fact of childhood abuse may be highly disturbing, and counselors must be prepared to respond supportively. (2) . In acknowledging the client's history of childhood abuse and neglect, the counselor must validate the client's experience by recognizing the issue, refocusing the treatment, and addressing the issue. (2) . The counselor can help the client develop interpersonal skills through modeling behavior, by empathizing and respecting the client, and by setting boundaries. (2) . For victims of abuse, the process of reattaching--or attaching for the first time--to other individuals, to a community, or to a spiritual power has tremendous therapeutic value. (2) . Linkages between substance abuse treatment and mental health agencies are important if the two programs are to understand each other's activities. In the interest of the client, a case summary should be developed that includes the key issues that should be addressed in the next program. (2) . When symptoms indicate mental health problems that are beyond the scope of the counselor's ability to treat, a referral is clearly warranted. Suicidal thoughts, attempts at self-mutilation, extreme dissociative reactions, and major depression should be treated by a mental health professional, although that treatment may be concurrent with substance abuse treatment. (2) . Counselors should prepare clients for mental health treatment by helping them realize . That their history of childhood abuse or neglect has contributed to some of their errors in thinking, behavior, and decisionmaking . That they self-medicated with substances in order to avoid dealing with emotions . That they are not alone and that there are resources to help (2) . Working with at-risk clients in today's litigious climate requires counselors to adhere closely to the accepted standards and ethics of practice as well as the legal requirements of their position. Creating a multidisciplinary team and using proper supervision will help ensure that the counselor maintains such standards. (2) . Substance abuse counselors always must evaluate the appropriateness of including childhood abuse and neglect survivors in group therapy for other clients in substance abuse treatment. Abuse survivors may not be able to handle the group process until they are able to deal effectively with their attachment issues. (2) . It is a delicate matter to discuss past abuse in the presence of family members who participated in or were present during it. When such a decision is made, the counselor must bear in mind that he does not, and should not, have the role of confronting the perpetrator or perpetrators. (2) Therapeutic Issues for Counselors It is inevitable that the counselor will react to the client in ways that are not completely objective. Working with this population may evoke powerful feelings in the counselor. It is important that counselors be aware of and manage their own countertransference reactions and seek supervision as necessary. The Consensus Panel offers the following suggestions to help counselors deal with personal issues when working with clients with childhood http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.section.63294 (10 of 14)08/01/2006 7:33:43 AM abuse and neglect histories. . In order to teach and model appropriate and healthy interactions, counselors should establish and maintain clear and consistent boundaries with their clients. Adult survivors of child abuse or neglect often need a great deal of affection and approval, and counselors must make clear to the client that they are not responsible for directly meeting all those needs. (2) . Counselors should focus on empowering the client, recognizing that getting overinvolved will rob clients of the opportunity to draw on their own inner resources. (2) . Clients' previous experiences may cause them to be mistrustful and suspicious of others, including the counselor. To facilitate the development of a trusting relationship, the counselor should not personalize negative responses but be open, consistent, and nonjudgmental whenever interacting with the client. (2) . The level of violence and cruelty in disclosures about childhood victimization and exploitation may be very disturbing to counselors. When counselors find themselves manifesting symptoms of anxiety or depression, they should seek direction and support through supervision or peer support. (2) . Counselors must recognize their personal and professional limitations and not attempt to work with abused clients if they lack the clinical expertise or are not able to manage their own countertransference reactions. (2) . Burnout, or secondary trauma responses, affects many counselors and can shorten their effective professional life. If counselors meet with a large number of clients (many with trauma histories), do not get adequate support or supervision, do not closely monitor their reactions to clients, and do not maintain healthy personal lifestyles, counseling work of this sort may put them at personal risk. To minimize the likelihood of burnout, counselors should not work in isolation and should seek to treat a caseload of individuals with a variety of problems, not only those who have experienced childhood trauma. (1) . Alcohol and drug counselors are often subject to great stress. They can be expected to function well and provide effective treatment only if their agency gives them the appropriate support. The agency's leadership should strive to impart a sense of vision to staff members that communicates how important their work is as part of the larger effort to break the cycle of abuse and neglect and its impact on society. (2) Breaking the Cycle While many adults with substance abuse disorders do not abuse their own children, they are at increased risk of doing so. When children who are victims of maltreatment become adults, they often lack mature characteristics: the ability to trust, to make healthy partner choices, to manage stress constructively, and to nurture themselves and others. Adults with child abuse histories are then more likely than the general population to develop substance abuse disorders. This intergenerational cycle of substance abuse and child abuse and neglect reflects both the direct and indirect relationship between parental substance abuse and family dynamics, child and adult maltreatment, and second-generation substance abuse. Unless effective intervention occurs, there is an increased likelihood that these patterns will be repeated in future generations. The following list offers recommendations to address this cycle. . Interventions aimed at breaking the cycle of substance abuse, child neglect, and maltreatment are more successful when they are family centered. (1) . Counselors can elicit information on a client's childhood experience, which can be useful in predicting the nature of current family relationships. (2) . Just as counselors can expect that substance-abusing parents often will deny their drug use, they can also expect parents to deny neglecting or abusing their children. Counselors should help parents understand that their parenting behaviors may not be appropriate and that these behaviors can negatively influence their children's future development, especially their ability to trust others and to develop self-esteem and pride. (1) . Counselors should remember to articulate the positive aspects of clients' lives. (1) Focusing only on the negative or risk factors results in shame and a sense of futility and is counterproductive. Increasing clients' self- esteem and self-efficacy (their effectiveness and ability to take responsibility) is a primary step to acceptance of the child-rearing role. In addition, it is critical that counselors be able to distinguish between actual cases of child abuse and neglect and situations that arise due to cultural differences, poverty, and lack of education. Providers who work with clients from different cultures should try to develop an understanding of that culture's norms concerning child rearing and discipline. Legal Issues Because many parents who abuse substances also neglect or abuse their children, it is common for clients in substance abuse treatment to have some http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.section.63294 (12 of 14)08/01/2006 7:33:43 AM involvement with the CPS system. Some substance-abusing parents will be drawn into the CPS system during treatment; others will be compelled into substance abuse treatment by a CPS agency. In either case, it is critical that treatment providers become familiar with the laws governing the CPS system, including . How child abuse and neglect are defined in their State . Whether, when, and how a counselor must report a parent or other primary caretaker--or a parent who was maltreated in childhood--to a CPS agency or police . What happens after a report is made . How State-mandated family preservation services operate Although inappropriate child-rearing practices should be addressed in treatment, they may not, in and of themselves, constitute grounds for an abuse or neglect report. However, if counselors have a reasonable suspicion or firm belief that abuse or neglect has occurred, they are required to make a report. (2) It is important for counselors to bear in mind that a parent who abuses substances is not able to adequately supervise a child and, unless other adults are known to be caring for the child, the counselor should alert the CPS agency regarding potential neglect. It will then be the CPS agency's responsibility to decide whether or not to investigate the matter. (2) Clients should be informed about the mandatory reporting laws at the time of admission and provided with written documentation regarding both the Federal regulations regarding confidentiality and the counselors' duty to report suspected abuse or neglect. The Consensus Panel recommends that the client be required to acknowledge receipt of such notice in writing. (1) Counselors are usually not under any obligation to report childhood abuse experienced by an adult client many years ago. However, if the known perpetrator now has custody of--or access to--other children, the program should seek advice about its responsibility to report potential abuse or neglect. (2) Programs should ask staff members who are mandated reporters to consult a supervisor or team leader before calling a CPS agency to report suspected child abuse or neglect, unless the emergency nature of the situation requires immediate action. Clinical supervisors can help determine whether the staff members are dealing with countertransference issues or inappropriate attachment. Staff members should be guided primarily by a trained understanding of the Federal requirements and the written procedures established by the treatment program. Other staff members can offer support, http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.section.63294 (13 of 14)08/01/2006 7:33:43 AM especially when the decision to report is difficult. (2) Treatment organizations and agencies should provide orientation for all new staff members to inform them about reporting policies and procedures. It is recommended that these policies include provisions requiring staff members to notify their supervisor or appropriate program personnel whenever they make a report. (2) It is the decision of the client and his lawyer, not the counselor, to determine whether communication or cooperation with a CPS agency will benefit the client. Therefore, it is essential that the counselor communicate with the client's attorney before taking it upon herself to communicate with a CPS agency, except when there is a legal mandate to report. (2) If a lawyer calls with questions about a client's treatment history or current treatment, the counselor must avoid giving any information (even that the client is indeed in treatment), unless the client has consented in writing to the counselor's communicating with the lawyer. (2) Copyright and Disclaimer Short Contents | Full Contents Other books @ NCBI Search (: on) Checked This book (text) (: on) Unchecked All books (: on) Unchecked PubMed Navigation About this book SAMHSA/CSAT Treatment Improvement Protocols 36. TIP 36: Substance Abuse Treatment for Persons with Child Abuse and Neglect Issues Executive Summary and Recommendations Chapter 1 Working With Child Abuse and Neglect Issues Chapter 2 Screening and Assessing Adults For Childhood Abuse and Neglect AHCPR Archived reports, Put Prevention Into Practice and Minnesota Health Technology Advisory Committee SAMHSA/CSAT Treatment Improvement Protocols 36. TIP 36: Substance Abuse Treatment for Persons with Child Abuse and Neglect Issues Chapter 1 Working With Child Abuse and Neglect Issues Child abuse and neglect pose an increasingly recognized and serious threat to the nation's children. In the last 10 years the reported cases of abused and neglected children more than doubled, from 1.4 million in 1986 to more than 3 million in 1997; substance abuse was involved in more than 70 percent of the cases. A recent survey of State child welfare administrators found that parental substance abuse was a factor in at least 50 percent of substantiated cases of child abuse and neglect. Moreover, 80 percent reported that substance abuse and poverty were the two primary factors contributing to abuse and neglect (U. S. Department of Health and Human Services [DHHS], 1999). Children whose parents abuse substances are almost three times more likely to be abused and four times more likely to be neglected than other children (National Center on Addiction and Substance Abuse at Columbia University [CASA], 1999). Substance abuse is a contributing factor to the abuse of at least one third of the children in the child welfare system (DHHS, 1999). It is estimated that each day five children die as a result of child abuse or neglect- up from three a day reported in 1994 (CASA, 1999; McCurdy and Daro, 1994). In reported cases, the most pervasive form of child maltreatment is neglect (60 percent), followed by physical abuse (25 percent), sexual abuse (13 percent), and emotional maltreatment (5 percent). More than 50 percent of the victims were 7 years old or younger; slightly more than half of victims were girls (Sedlak and Broadhurst, 1996). Statistics will vary because of differences in criteria and methodology and because many cases of child maltreatment involve overlapping forms of abuse or neglect. (More details regarding the prevalence of child abuse and neglect Chapter 3 Comprehensive Treatment for Adult Survivors of Child Abuse and Neglect Chapter 4 Therapeutic Issues for Counselors Chapter 5 Breaking the Cycle: The Substance- Dependent Client as Parent/Caregiver Chapter 6 Legal Responsibilities and Recourse Chapter 7 Emerging and Continuing Issues Appendix B -Protecting Clients' Privacy Appendix C -Implications of Recent Federal Legislation for Clients in Treatment Appendix D Obtaining Screening and Assessment Tools Appendix E -Resources Related to Childhood Trauma Among Adults are provided later in this chapter, along with specific definitions of what is meant by the terms "child abuse" and "neglect.") For the same reasons, it is difficult to determine if the incidence of child maltreatment is actually continuing to rise or not. However, researchers, counselors, and program administrators agree that the rise in substance abuse disorders as a factor in child abuse and neglect cases has severely complicated efforts by child welfare systems to protect children and rehabilitate families (CASA, 1999; DHHS, 1999). Parents with substance abuse problems are less educated and less likely to be employed full time; they are much less likely than other parents to be married and much more likely to be involved in the welfare system (DHHS, 1999). However, these statistics may result from a population's reliance on public welfare systems; parents in higher socioeconomic classes can afford private systems where reporting is not mandated. Many clients in substance abuse treatment have histories of child abuse or neglect that might affect their chances for recovery. There is accumulating research and clinical evidence that physical, sexual, and emotional abuse and neglect during childhood increase a person's risk of developing substance abuse disorders (DHHS, 1999). In addition, relapse and treatment complications may be more likely if issues related to maltreatment are not identified and treated (Brown, 1991; Rose, 1991; Young, 1995). The counselor might have more difficulty engaging clients with abuse histories, and these clients may have a variety of disabling comorbid conditions, such as posttraumatic stress disorder (PTSD) and dissociative disorders. Given the presence of substance abuse in the majority of child abuse or neglect cases, alcohol and drug counselors may also have reason to suspect, or may discover, that clients are abusing or neglecting their own children. The children of substance-abusing parents will also face an increased risk of developing a substance abuse disorder themselves. A recent study confirms what has long been suspected, that children of alcoholics (whether or not they have been abused) have an altered brain chemistry that may make them more likely to become alcoholics themselves (Wand et al., 1998). If the cycle of intergenerational substance abuse and child abuse and neglect is to be broken, counselors must address these issues. This is discussed in Chapter 5. Counselors will sometimes find it challenging to maintain the therapeutic alliance with clients that is central to successful treatment while meeting their legal obligations to report suspected or known maltreatment (see Chapter 6). Appendix F -Resource Panelists Appendix G Field Reviewers Figures Appendix A -Bibliography Substance Abuse and Child Abuse and Neglect Treatment providers have observed that a large proportion of their clients report being physically, emotionally, or sexually abused as children. This clinical knowledge is increasingly supported by research findings. Most of this research has focused on one of two questions: 1. Are people with substance abuse disorders more likely to have been abused or neglected as children than are people without substance abuse disorders? 2. Are those who report a history of childhood abuse or neglect more likely than their peers to have a substance abuse disorder? Specific answers to these questions depend to some extent on gender, and therefore the literature for men and women should be examined separately. Because most of the available information in this area focuses on childhood sexual and physical abuse, this TIP primarily addresses these two forms of maltreatment. As noted above, however, neglect is the most prevalent type of child maltreatment, and witnessing domestic violence is also a common (and potentially damaging) form of childhood trauma. (See TIP 25, Substance Abuse Treatment and Domestic Violence [CSAT, 1997b] for more information on how to deal with this significant problem.) Rates Among Adolescent Girls and Women A review of several studies found that women who abuse alcohol reported higher rates of childhood sexual and physical abuse than their peers without such disorders (Langeland and Hartgers, 1998). The likelihood of substance abuse disorders was directly related to the severity of childhood abuse as well. A more exhaustive literature review found that women with substance abuse disorders were nearly two times more likely than women in the general population to report childhood sexual abuse. These women were also more likely to have experienced physical abuse (Simpson and Miller, in press). Miller and her colleagues found that 70 percent of women in treatment for alcohol use disorders reported some form of childhood sexual abuse, while only 35 percent of the women in the general population did the same (Miller et al., 1993). Twelve percent of the women with alcohol use disorders did not suffer any form of sexual or physical abuse, compared with 41 percent of the control sample. The study concluded that parental alcoholism and child abuse were both independent risk factors for problematic drinking among adults, suggesting that childhood abuse itself contributes uniquely to the genesis of substance abuse disorders. A 1995 literature review reveals a link between childhood sexual abuse and substance abuse (Polusny and Follette, 1995). In community samples, the authors found that the lifetime diagnosis rate of substance abuse disorders was 14 to 31 percent among women who had been sexually abused and 3 to 12 percent among women who had not been abused. In clinical samples, the rate of lifetime substance abuse diagnoses among sexual abuse survivors ranged from 21 to 57 percent, compared with a range of 2 to 27 percent for women without such histories. Another representative study of young adults found that 43.5 percent of the women who had been sexually abused as children met diagnostic criteria for an alcohol abuse disorder, while the criteria were met by only 8 percent of those who had not been sexually abused (Silverman et al., 1996). The available research does indicate that women with substance abuse disorders are more likely than other women to report childhood abuse and women with childhood abuse histories are more likely than other women to have substance abuse disorders. Despite these findings, it is unclear to what extent the relationship between childhood abuse and the development of substance abuse is causal. Genetics, for example, might account for the association--child abuse might simply be incidental to the process in which the genetic propensity for drinking is passed from parent to child. Childhood stress from sources other than abuse and neglect might also contribute to substance abuse among adults (Malinosky-Rummell and Hansen, 1993). However, even when parental history of alcohol problems and measures of childhood stress are statistically controlled, childhood sexual and physical abuse still seem to contribute significantly to the alcohol-related problems of women (Bennett and Kemper, 1994; Miller et al., 1993). Rates Among Adolescent Boys and Men There are fewer studies of child abuse among boys and men with substance abuse disorders, and findings are less consistent than those generated for girls and women. One group of researchers believes that data are insufficient to determine (1) whether men with alcohol abuse disorders are more likely than their peers to have suffered childhood abuse, or (2) whether men with childhood abuse histories are more likely than other men to have alcohol abuse disorders (Langeland and Hartgers, 1998). Simpson and Miller found 27 studies that addressed the issue of childhood abuse and neglect among men with substance abuse disorders (Simpson and Miller, in press). Only 10 of these studies found childhood sexual abuse rates http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.section.63389 (4 of 19)08/01/2006 7:34:03 AM higher than the national average of 16 percent (Finkelhor et al., 1990), and only six of these studies found rates above 10 percent. Most studies reveal that men with substance abuse disorders actually suffered less sexual abuse than their peers; however, these men did report unusually high rates of childhood physical abuse. The few prospective studies of childhood abuse among men suggest that abuse does increase the risk of alcohol abuse (Simpson and Miller, in press). Men who report childhood abuse also may be more likely to have a substance abuse disorder, but this conclusion is not certain. Societal expectations of self- reliance and fear of homosexual stigmatization may prevent these men from disclosing childhood sexual abuse (Briere et al., 1988). Current trends, however, suggest that men are becoming more willing to disclose histories of sexual abuse. Although the incidence of abuse has remained stable for women, far more men are reporting sexual abuse than have done so in the past (Simpson and Miller, in press). Men with substance abuse disorders are also reporting more childhood physical abuse. Current study techniques simply may be more sensitive for sexual abuse among men, but further study is needed. Most studies that have examined the rates of substance abuse among men with child abuse histories have found elevated rates of substance abuse disorders (Simpson and Miller, in press). One important exception to this pattern is a study that examined the rates of arrest for alcohol- and drug-related offenses among young adults with and without documented histories of childhood abuse or neglect (Ireland and Widom, 1994). This study found no relationship between a history of childhood abuse and neglect and substance abuse problems among men. It should be mentioned, however, that Ireland and Widom did not assess whether the study participants experienced child abuse or neglect that was not officially reported. Some of those who were classified as not having been abused or neglected may have experienced such maltreatment, and the results of this study are therefore difficult to interpret. Most of the available literature indicates that men with childhood abuse histories are more likely to have substance abuse disorders than men without childhood abuse histories (Simpson and Miller, in press). The rates of childhood physical abuse appear to be higher among men with substance abuse disorders than among men from the general population. However, men with substance abuse disorders do not report more childhood sexual abuse than other men. Holmes and his colleagues uncovered several factors that contribute to the reluctance of men to report sexual abuse (Holmes et al., 1997). The shame, homosexual stigmatization, and perceptions of weakness associated with disclosure are perceived by many men to be more burdensome than the secret of abuse. Also, men are prone to minimize the negative effects that childhood sexual abuse may have, though men who were sexually abused as children are at greater risk than their nonabused peers for later psychological and emotional difficulties. Holmes and colleagues found that when men disclose a history of child abuse to their mental health counselors, its importance is often dismissed. The researchers concluded that the childhood sexual abuse of males is viewed with far less gravity then the childhood abuse of girls and women (Holmes and Slap, 1998;Holmes et al., 1997). Implications for Treatment of Clients With Child Abuse Histories Mental Health Issues Adults with histories of child abuse and neglect may differ from other clients in a number of ways. Although the research base is still limited, clients with childhood abuse histories have been found to have more severe substance abuse disorders, to have started using at younger ages, and to use substances for reasons that differ from other clients. They are also more likely to have attempted suicide, to have PTSD, and to have personality or relationship problems that make them hesitant to accept help (Felitti et al., 1998), which also makes them more vulnerable to relapse. Clients who have been sexually or physically abused as children often attribute at least part of their substance abuse to their childhood victimization. Hayek found that more than two thirds of women with incest histories believed that the abuse contributed to their alcoholism (Hayek, 1980). Another study revealed that 25 percent of incest victims in alcohol treatment programs believed their drinking problems were caused by their incest experiences (Janikowski and Glover, 1994). Individuals with alcohol abuse disorders and histories of sexual or physical abuse believe that their trauma was a considerable factor in causing their drinking problems and that it was a moderate factor in precipitating their most recent relapses (Brown et al., 1993). Researchers who have focused on women and girls have found that those with histories of childhood abuse are likely to have developed their substance abuse problems at a younger age ( Edwall and Hoffman, 1987; Jarvis et al., 1998; Paone et al., 1992) and that adolescent girls in this group are more likely than their nonabused peers to use cocaine, amphetamines, sedatives, and tranquilizers (Harrison et al., 1989a). Women in substance abuse treatment programs who were sexually abused as children use alcohol to facilitate sexual encounters more often than do other women ( Hayek, 1980; Hurley, 1990; Lammers et al., 1995). They are also more likely than their nonabused peers to use substances to alleviate pain (Jarvis et al., 1998), escape family turmoil, and calm tremors (Harrison et al., 1989a). Women might also use substances to escape memories of sexual abuse (Miller and Downs, 1995; Young, 1995). Alcohol abuse disorders are more severe among men who were sexually abused as children (Simpson, in press; Simpson et al., 1994) and may include overdoses and substance-related seizures ( Krinsley et al., 1994). They are also more likely to have gone on "suicidal drinking" binges (Kroll et al., 1985). Suicide is a major problem among clients who were abused as children. These clients are more likely than their nonabused peers to attempt suicide, according to most studies ( Harrison et al., 1989b; Jarvis et al., 1998; Krinsley et al., 1994; Wallen and Berman, 1992; Windle et al., 1995). Moreover, the first attempt increases the risk of others ( Linehan, 1993a), so that these clients are more likely to attempt suicide again. Research is inconclusive about whether clients with childhood abuse histories are more depressed than their peers. Some findings suggest they are ( Benward and Densen-Gerber, 1975; Boyd et al., 1997; Deykin et al., 1992), although others suggest they are not ( Krinsley et al., 1992; Neisen and Sandall, 1990; Windle et al., 1995). PTSD is relatively common among people who were abused physically or sexually as children (Polusny and Follette, 1995; Rowan and Foy, 1993). Among people with substance abuse problems, those with histories of childhood abuse are more likely to meet diagnostic criteria for PTSD (Brady et al., 1994; Hien and Levin, 1994; Krinsley et al., 1992), and PTSD is associated with less successful treatment outcomes (Brady et al., 1994; Brown et al., 1995; Stewart, 1996). People abused as children are also prone to dissociative disorders (Polusny and Follette, 1995), but it is unclear whether people who have substance abuse disorders and childhood abuse histories engage in more dissociative behaviors than those without childhood abuse histories. Research on male clients in substance abuse treatment has found that those with childhood abuse histories do not report more dissociation than their nonabused peers (Dunn et al., 1993, 1995), but research on female clients in substance abuse treatment suggests that those who were abused as children use a wider variety of dissociative behaviors than other women in treatment (Jarvis et al., 1998). Ostendorf, however, found that female incest victims with alcohol problems scored lower on an index of dissociation than those without alcohol problems (Ostendorf, 1995). Alcohol, the author suggested, may serve the same functions for some as dissociation does for others. More research is needed in this area to clarify the importance of dissociative disorders among clients with childhood abuse histories. Clients abused as children also seem to be at higher risk than their peers for other mental health and social problems. These include antisocial personality disorder (Windle et al., 1995), legal problems (Brabant et al., 1997; Krinsley et al., 1994; Kroll et al., 1985; Paone et al., 1992), and paranoia (Jarvis et al., 1998; Krinsley et al., 1992; Kroll et al., 1985). Women with substance abuse disorders and childhood abuse histories are more likely than other women in treatment to report sexual problems and abnormal sexual behaviors (Edwall et al., 1989; Hayek, 1980; Jarvis et al., 1998; Swift et al., 1996; Wallen and Berman, 1992). Clients who were abused as children are also more likely than others in treatment to be assaulted as adults, both physically ( Edwall and Hoffman, 1987; Edwall et al., 1989; Haver, 1987; Lammers et al., 1995) and sexually (Wallen and Berman, 1992), and they are more likely to develop PTSD following the attack (Brady et al., 1994). Risk for Relapse Relapse is common during the treatment of substance abuse, and few clients achieve permanent abstinence on their first attempt. Although clinicians have applied a variety of promising pharmacotherapeutic and psychosocial strategies to prevent relapse ( Carroll, 1997), relapse rates remain high ( Miller et al., 1995a). Many in the field believe that recovery from substance abuse is even more difficult for people who were abused as children (Brown, 1991;Rose, 1991; Young, 1995). There is fairly strong evidence that men who were abused as children enter treatment more often than other men ( Krinsley et al., 1994; Simpson et al., 1994). This suggests that these men may be at greater risk for posttreatment relapse. Studies that combined males and females have also found poorer treatment compliance and outcomes for those who were victimized as children (Carran et al., 1996; Glover et al., 1996; Palmer et al., 1995). Gutierres and colleagues, however, did not find a connection between childhood abuse and treatment completion among males and females (Gutierres et al., 1994). Childhood abuse does not seem to affect treatment outcomes among women. Women who were sexually assaulted as children do not relapse any more frequently than other women in the year following treatment (Stephenson, 1990). Childhood sexual abuse is not associated with either the likelihood of a woman attending her first referral appointment following detoxification (Hien and Scheier, 1996) or the likelihood that she will complete subsequent treatment (Wallen and Berman, 1992). Childhood abuse is also unrelated to the number of times a woman enters treatment (Brabant et al., 1997; Simpson et al., 1994). Incest victims, moreover, do not report having tried more treatment modalities or having had more relapses than other women (Jarvis et al., 1998; Kovach, 1983). However, Haver reported poorer treatment outcomes among women who were physically abused by their mothers (Haver, 1987). In a study of aftercare compliance following childbirth, 67 percent of noncompliant women reported some form of childhood abuse while only 25 percent of compliant mothers did the same (Killeen et al., 1995). Implications for Treatment Providers The Consensus Panel recommends that alcohol and drug counselors be aware of childhood abuse and the issues involved in its treatment for the following five reasons: 1. People who were abused as children are more likely than others to attempt and reattempt suicide, as noted earlier. Alcohol and drug counselors, therefore, must watch for signs of suicidal ideation. Counselors should work to help clients ease the emotional burdens of past abuse in order to diminish the likelihood of suicide. 2. Counselors may need to address childhood sexual and physical abuse in order to reduce clients' risk of abusing their own children. Most abuse survivors do not abuse their own children (Kaufman and Zigler, 1987), although people with substance abuse disorders are at greater risk of doing so. As reported above, substance abuse contributes to almost three fourths of the incidences of child abuse and neglect (CASA, 1999; Famularo et al., 1992; Finkelhor et al., 1983; McCurdy and Daro, 1994). At least 675,000 children are abused or neglected each year by parents or caretakers with substance abuse disorders, and more than 8 million children (11 percent) in the United States are being raised by substance-abusing parents (Kropenske and Howard, 1994). Although it is not known how many of these parents are struggling with their own abuse histories, counselors should be able to address their clients' abuse issues in order to break the cycle of addiction and violence. 3. Clients often suspect that childhood abuse contributed to their substance abuse disorders and relapses. Although they are not likely to identify precise clinical syndromes, clients may seek help in http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.section.63389 (9 of 19)08/01/2006 7:34:03 AM overcoming the emotional pain of childhood abuse. Counselors should be able to help these clients so that they do not turn to substances for relief. 4. By addressing child abuse issues, the risk of relapse among clients who were abused as children might actually drop below that of their nonabused peers. Preliminary evidence suggests that people with childhood abuse histories use substances as a means of "chemical dissociation." Once trauma issues are resolved, substance use may clear substantially (Roesler and Dafler, 1993). 5. People who were severely sexually or physically abused as children often develop PTSD (Rowan et al., 1994; Wolfe et al., 1994), and this disorder increases their risk of relapse because it engenders intrusive memories and attempts to avoid those memories through self- medication (Kuyken and Brewin, 1994). Therefore, clients suffering from abuse-related PTSD are likely to have endured the most severe forms of abuse. Counselors should be aware of this and know how to help such clients. Cultural Considerations Few researchers have studied the influence of ethnic and racial factors on childhood abuse and substance abuse disorders, but specific populations have been the object of several recent studies. For example, Carol Boyd and her colleagues researched crack cocaine addiction among African-American women (Boyd et al., 1997). Boyd's findings for this group are consistent with the larger body of research described earlier. The limited evidence in community-based samples suggests that there are not significant ethnic or racial differences in the base rate of childhood sexual abuse between African- Americans and Whites and between Hispanics and Whites ( Arroyo et al., 1997). Another study reveals similar rates of emotional, physical, and sexual abuse among Native Americans, Mexican-Americans, and European-Americans in treatment for substance abuse (Gutierres and Todd, 1997). However, Native American women reported substantially more physical abuse than other women, and European-American men reported more sexual abuse than other men. This research, along with Boyd's work, points to the possibility of problems specific to groups, as well as the likelihood of differences in group reporting. Treatment providers must be sensitive to the ways in which cultural factors http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.section.63389 (10 of 19)08/01/2006 7:34:03 AM interact with a client's child abuse or neglect history. In a review on the relationship between racism and mental health, racism was found to be a major contributor to psychopathology among ethnic minorities (Carter, 1994; Landrine and Klonoff, 1996; Thompson, 1996). Sensitivity to such cultural phenomena helps facilitate effective interventions for ethnic minorities who have experienced childhood abuse ( Manson, 1997). The Consensus Panel urges alcohol and drug counselors to be aware of how clients' backgrounds may affect treatment. Some of the challenges faced by culturally diverse populations seeking treatment are disparities in access and availability of services, and language and literacy differences. It is also important for counselors to be aware that sensitivity to cultural issues includes avoiding a double standard--being overly tolerant or flexible because of uncertainty about unfamiliar social norms. Cultural differences should not be allowed to excuse abusive or neglectful behavior by parents. Incidence of Child Abuse and Neglect Child protective services (CPS) agencies received reports of over 3 million suspected cases of child abuse and neglect in 1996. CPS staff investigated 75 percent of these reports and substantiated more than 970,000 cases of child maltreatment in that year alone ( DHHS, 1999; Sedlak and Broadhurst, 1996). The reported incidence of child abuse and neglect climbed from 41 children per 1,000 in 1990 to 44 children per 1,000 in 1996. Even more disturbing, researchers agree that most incidents--as many as 70 percent--of child abuse and neglect still go unreported ( Briere, 1992a; DHHS, 1999). It is estimated that 42 of every 1,000 children in the United States (under age 18) have been either abused or neglected. The number of sexually abused girls is three times the number of boys, but boys are more likely than girls to be seriously injured by abuse (Holmes and Slap, 1998). Boys are also more likely to be emotionally neglected. As noted above, there seem to be no significant differences among racial and ethnic groups in the incidence of maltreatment or maltreatment-related injuries (Sedlak and Broadhurst, 1996). Child maltreatment may not necessarily be on the rise; society may be more informed about reporting procedures, and victims may be more educated on resources, safety in disclosure, and ability to seek help in comparison to the past. Some researchers suspect that the tremendous rise in child abuse rates may be largely due to heightened awareness of the issue by society in general (Van Dam et al., 1985). Some of the increase in reported cases may also stem from greater sensitivity among researchers to the subtle cues of abuse and neglect. However, the rate of serious injuries due to child abuse has risen dramatically (Sedlak and Broadhurst, 1996), and (as noted above) the incidence of abuse and neglect might be underestimated as a result of underreporting. Indeed, in one review of children's death certificates, 85 percent of abuse- and neglect-related deaths had been attributed to other causes (McClain et al., 1993). Incidence of Child Abuse and Neglect Histories Among Adults Given the high incidence of documented abuse and neglect among children, it is reasonable to assume that a sizable proportion of adults experienced similar childhood trauma. However, the true incidence of childhood abuse and neglect among adults is unknown. Research definitions have not been consistent, and this makes estimations difficult (Wyatt and Peters, 1986a). Inclusive definitions yield substantially higher estimates of abuse and neglect, while narrow definitions yield lower ones. Variations in research methods (e.g., questionnaires versus interviews) and populations studied also affect estimates (Wyatt and Peters, 1986b). A large national study of randomly identified adults in the United States estimates that 27 percent of women and 16 percent of men were sexually abused as children (Finkelhor et al., 1990). Additional estimates of childhood sexual abuse among women range from approximately 7 percent (Burnam et al., 1988) to 54 percent (Russell, 1983). The actual incidence of childhood sexual abuse is unknown ( Trickett and Putnam, 1993). The true incidence among adults of other forms of childhood abuse and neglect is also unclear. Physical maltreatment has been studied less than childhood sexual abuse, and inconsistent methods and definitions have made the results uncertain. The incidence of emotional abuse and neglect among adults has not been significantly studied. Long-Term Consequences of Child Abuse and Neglect Although a causal relationship has been difficult to establish, investigators report that childhood abuse and neglect are associated with later problems. Sexual abuse, for instance, has been linked to depression, anxiety, and sexual dysfunction as well as eating, personality, dissociative, and substance abuse disorders (Beitchman et al., 1992; Browne and Finkelhor, 1986; Cahill et al., 1991; Polusny and Follette, 1995). People sexually abused as children are more likely than others to have social difficulties, and their risk of physical and sexual assault is greater (Polusny and Follette, 1995). One review of the physical abuse literature found that physically abused boys are more likely to become substance abusers, though the reviewers did not include any studies of the risk of substance abuse among physically abused girls (Malinosky- Rummell and Hansen, 1993). Low self-esteem (Briere and Runtz, 1990b) and depression (Braver et al., 1992) are relatively common among college students who were emotionally abused. In fact, they are more common among those who were emotionally abused than they are among those who were physically abused ( Gross and Keller, 1992; Ney et al., 1993). Defining Abuse and Neglect Alcohol and drug counselors must understand the definitions of abuse and neglect in order to adequately screen and assess clients who were exposed to them as children. Counselors must also know the definitions because they, like all clinicians, are required by law to report suspected or known child abuse (see Chapter 6). Clinicians who understand the definitions of child abuse and neglect can also help clients who might not recognize that they were abused or neglected as children. According to researchers, some adults tend to deny, minimize, or forget experiences of abuse (Brown et al., 1999; Della Femina et al., 1990; Kufeldt and Nimmo, 1987). For example, Williams interviewed a sample of women in the early 1990s who had documented histories of sexual abuse occurring between 1973 and 1975 (Williams, 1994). Forty percent of the women failed to report the documented abuse during their assessments. Many of the women in this subgroup, however, did report other instances of childhood sexual abuse, leading the author to suggest that these women may in fact have traumatically forgotten the documented abuse. General Definition Both Federal and State legislation define child abuse and neglect. The Federal legislation provides a foundation for States by identifying a minimum set of acts or behaviors that constitute maltreatment. The Child Abuse Prevention and Treatment Act (42 U.S.C., 5106g), enacted in 1974 and reauthorized in 1996, defines child abuse and neglect as, at minimum, any recent act or failure to act that results in "imminent risk of serious harm, death, serious physical or emotional harm, sexual abuse or exploitation" (Courtney, 1998) to a child under the age of 18, or, except in the case of sexual abuse, under the age specified by the child protection law of the State, by a parent or caretaker (including any employee of a residential facility or any staff person providing out-of-home care) who is responsible for the child's welfare. The act defines sexual abuse as . Employment, use, persuasion, inducement, enticement, or coercion of any child to engage in, or to assist any other person to engage in, any sexually explicit conduct or any simulation of such conduct for the purpose of producing any visual depiction of such conduct . Rape, prostitution, and in cases of caretaker or interfamilial relationships, statutory rape, molestation, or other form of sexual exploitation of children . Incest with children (although legal definitions may vary from State to State, incest can be broadly defined as the imposition of sexually inappropriate acts, or acts with sexual overtones, by one or more persons who derive authority through ongoing emotional bonding with that child--or any use of a minor child to meet the sexual or emotional needs of such persons) Each State is responsible for providing definitions of child abuse and neglect within this civil and criminal context. Laws vary widely from State to State, and treatment providers must be familiar with the definitions outlined in their own State's laws. In particular, they must understand reporting laws, which describe the circumstances and conditions under which they are obligated to report known or suspected abuse or neglect. These laws also list the conditions under which counselors are allowed to report known or suspected cases described to them by a third party. Counselors should also be familiar with juvenile/family court acts that dictate when a court is allowed to take custody of a child alleged to have been abused or neglected. The definitions in these acts are often the same as those in the reporting law. Finally, treatment providers should know the criminal law in their State that defines criminally punishable forms of abuse and neglect--such as sexual abuse, severe physical abuse, and child endangerment--and the reporting requirements (see Chapter 6 for further information). Types of Abuse and Neglect There are four major types of child maltreatment: neglect, physical abuse, sexual abuse, and emotional or psychological abuse. Neglect Neglect is the failure to provide for a child's basic needs. Neglect can be physical, educational, medical, or emotional. Physical neglect is the most common type of neglect, and it includes the failure to meet a child's basic needs for food, shelter, and clothing that is not due to a lack of financial resources. Physical neglect also encompasses inadequate supervision and http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.section.63389 (14 of 19)08/01/2006 7:34:03 AM abandonment of a child, expulsion from home, and rejection of a runaway who wishes to return home. Educational neglect is the second most frequent type of neglect and includes failing to enroll a child in school, allowing chronic truancy, and not attending to a child's special educational needs. Medical neglect involves the refusal of, noncompliance with, or avoidable delay in seeking health care. Emotional neglect, which, like emotional abuse, is difficult to document, includes marked inattention to a child's needs for affection, refusal of or failure to provide needed psychological care, or chronic or extreme spousal abuse in the child's presence. The assessment of child neglect requires consideration of cultural values and standards of care, as well as recognition of the role of poverty in failure to provide the necessities of life. In substance-abusing families, neglect is a much more common reason than physical abuse for a parent to be reported to CPS agencies. In one study of children in foster care who had substance-abusing parents, neglect or abandonment accounted for 70 percent of placements, whereas physical abuse accounted for only 15 percent. For children placed in foster care from families in which substance abuse was not a factor, neglect or abandonment accounted for 37 percent of the cases and physical abuse accounted for 33 percent (Walker et al., 1994). Physical abuse Physical abuse can range from minor bruising to killing a child and may involve a single act or repeated occurrences. It is characterized by physical injury inflicted by punching, beating, kicking, biting, burning, or other actions. Such injuries are not accidental, although caretakers may not believe that they intended to harm the child. Physical abuse includes punishment that is not appropriate to a child's age, size, or physical, mental, or emotional condition. Normal disciplinary measures do not require medical treatment, nor do they leave physical marks, such as welts and bruises. Any punishment that involves hitting with a closed fist or with an instrument, as well as kicking, burning, or throwing the child is considered abuse regardless of the severity of the injury. Sexual abuse Sexual abuse or incest involves a range of behaviors--including all forms of oral-genital, genital, or anal contact with the child (such as fondling a child's genitals), or nontouching abuse (e.g., exhibitionism, voyeurism), as well as sexual penetration (e.g., intercourse, rape, sodomy), and commercial exploitation of the child via prostitution or the production of pornography. It involves not only acts committed by the perpetrator but inappropriate actions the child is forced or encouraged to perform on the adult. Child sexual abuse http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.section.63389 (15 of 19)08/01/2006 7:34:03 AM means engaging a child in sexual activities that the child cannot comprehend, for which the child is developmentally unprepared, and for which he cannot give informed consent. Most State laws distinguish between sexual abuse and sexual assault: An act of abuse is perpetrated by a person who has some responsibility for the child's care, whereas an assault is committed by someone other than a caregiver. However, researchers and survivors of childhood abuse perceive that caregivers or relatives who engage a child in sexual activity by use of force, life threats, and beatings are by definition committing sexual assault. For more information on consequences of sexual abuse and assault, see Funk, 1980; Gomes-Schwartz et al., 1985; Paradise et al., 1994; and Sullivan et al., 1979. Emotional or psychological abuse Emotional or psychological abuse includes acts of commission or omission by parents or caregivers that have caused, or could cause, serious behavioral, cognitive, emotional, or mental disorders. Examples include the verbal or emotional assault of a child as well as the child's extreme confinement by ropes or other means. Emotional abuse often coexists with other forms of abuse, and it is the most difficult to identify. Many of its potential consequences, such as learning and speech problems and delays in physical development, can also occur in children who are not being emotionally abused. In addition, the effects of such abuse may not be evident until later in life. In some States, a CPS agency can intervene in cases of emotional or psychological abuse without evidence of harm to the child's behavior or condition. Only proof of an extreme form of psychological punishment, such as confining the child to a closet, is required. CPS agencies in these States will not, however, intervene in cases of excessive rejection, blame, or belittlement without proof of harm. Factors Affecting Research and Screening Variations in the definitions of child abuse and neglect have made it difficult to assess the extent of the problem and its prevalence in the histories of adults. Although definitions have not yet been standardized ( Briere, 1996; Whipple and Richey, 1997), researchers recognize consistency in definitions as an important goal. At present, researchers debate whether to define child abuse and neglect by their impact on the child's development (Garbarino, 1977; Garbarino et al., 1986) or by community standards for appropriate behavior toward children. These distinctions have been central in trying to define emotional abuse, but they have also helped frame discussions about other forms of abuse and neglect. However, in an effort to discourage overly zealous interventions, policymakers tend to advocate narrow definitions of emotional abuse that require proof that the child was harmed (see McGee and Wolfe, 1991, for a discussion of the issues). Some researchers, however, argue for definitions of emotional abuse that are independent of the apparent effects of the abuse (Barnett et al., 1991; Shaver et al., 1991). Emotional abuse and neglect are often ranked on a continuum, and participants are not typically categorized by the mere occurrence or absence of maltreatment. This continuum approach is becoming more common in the study of child abuse (Bernstein et al., 1994). Child sexual abuse is often defined broadly by researchers as any unwanted sexual experience occurring before the age of 18, including genital exposure and verbal propositions (Wyatt and Peters, 1986b). More restricted definitions typically specify that the experience must have involved physical contact with someone at least 5 years older than the victim if the victim is under a certain age, usually 15 through 18 years old ( Krinsley et al., 1992; Rohsenow et al., 1988). The broader conceptualization of sexual abuse yields substantially higher rates of reporting than do more narrow definitions. Acts of physical violence aimed by a parent or caretaker toward a child are considered by most to be abuse, though many studies also specify that the child must have been physically injured ( Straus and Gelles, 1990; Whipple and Richey, 1997). Simply asking clients if they were abused or neglected as children is no longer considered an adequate evaluation of maltreatment (Briere, 1992b; Miller and Downs, 1995; Wyatt and Peters, 1986b). Instead, clients are provided clear behavioral descriptions of experiences to which participants respond "yes" or "no." For example, MacMillan and colleagues used the following questions to assess physical abuse: "During childhood, did an adult often or sometimes push, grab, or shove you? Throw something at you? Hit you with something? Did an adult often, sometimes, or never kick, bite, or punch you? Choke, burn, or scald you? Physically attack you in any other way?" (MacMillan et al., 1997). The number of and manner in which such questions are asked influence the way they are answered. Also, spurious links between child abuse and other symptoms can sometimes be made. Patients with psychiatric disorders, for example, frequently search their past lives for some explanation of their distress (Pope and Hudson, 1992). Underreporting of sexual abuse appears to be much more likely than overreporting. A therapeutic alliance may have to exist before a patient will disclose an incest history (Pribor and Dinwiddie, 1992). It may be necessary to pose questions at an intake history and then again later in the therapeutic process. For the same reasons of client reticence, Miller and Downs recommend a self-report questionnaire combined with an interview (Miller and Downs, 1995). Each method has been shown to identify cases of abuse missed by the other. See Chapter 2 for more on this issue. One of the critical new areas of research on people with substance abuse disorders is the study of "resilience factors" that permit some sexually abused individuals to avoid addiction, while others become addicted. Research demonstrates, for example, that victimized women who become alcoholics experienced prolonged, severe sexual abuse in isolation ( Beckman and Ackerman, 1995). The courts' tendency to intervene minimally can perpetuate isolation and make the development of resilient behavior less likely. Another study notes a variety of specific factors that affect resilience against addiction in individuals sexually abused in childhood, including level of self-esteem, quality of adolescent peer group, and extent to which PTSD symptoms are experienced (Miller and Downs, 1995). A client's ability to dissociate may actually promote resilience against addiction. It will be very difficult to do any type of resilience studies if "sexual abuse" is not defined as such unless there has been some measurable negative outcome for the victim. Personal Meanings of Abuse Counselors must recognize when it is appropriate or necessary to report incidents of clients' maltreatment of their children to government agencies, and for this they must know legal definitions of abuse and neglect. However, a broader approach, especially one that considers the meaning of the experience to the client, may be more useful in treatment. Finkelhor, for example, notes how sexual abuse may alter a child's perception of the world (Finkelhor, 1987). It is this altered perception, he argues, that leads to the devastating consequences of abuse. The sexually abused child might well feel betrayed and, as a result, no longer trust others (Springer, 1997). Stigmatization and shame may compromise the child's self-esteem, as well. People who were traumatized might even question their very right to exist ( Greening, 1997). Clinicians must, therefore, understand how clients interpret their experiences. Not all abuse meets the legal or commonly held criteria for abuse; nor will all clients perceive as abusive those experiences which fit the legal definition. For example, a client might report being spanked every day as a small child and might feel that he deserved the spankings because he disobeyed his mother. He might also explain that his mother loved him and that the spankings occurred within a context of caring. Such a client would deny that he had been abused as a child and would not be well served by therapists who insisted otherwise. In contrast, another client may have accepted chronic belittling and criticism http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.section.63389 (18 of 19)08/01/2006 7:34:03 AM while growing up and may not understand its relationship to career failures and repeated relapses. The Difficulty of Distinguishing Poverty From Neglect Almost every theoretical model of child abuse and neglect recognizes the contribution of stress to poor outcomes, and poverty is a major source of family stress. Substandard and overcrowded housing in unsafe neighborhoods strains families, as do unemployment and discrimination. In some cases, impoverished families should not be subjected to accusations of intentional child neglect (Besharov and Laumann, 1997). CPS agencies can help counselors understand which cases truly merit investigation and which should be referred to other agencies. Counselors can contact CPS agencies and discuss confusing cases without identifying individuals and families. Counselors can also refer clients to various agencies to help them secure child care, food stamps, and free family health care as needed. (See "Role of Child Protective Service Agencies" in Chapter 5 for more information on working with the child welfare system.) Child neglect and the conditions of poverty often overlap. Even when there is no intent, physical and emotional injury can still occur. Disenfranchisement may lead to deviance, such as criminal activity, that may have an unintended impact on children, as when a parent is arrested or incarcerated. It is the responsibility of the counselor to report instances of reasonable suspicion of abuse or neglect; however, counselors should use caution when distinguishing cases of class and cultural differences from child abuse and neglect. A comprehensive assessment should be conducted before any conclusions are reached. Many CPS agencies provide training for counselors on mandated reporting requirements, and some CPS agencies have the resources for assisting families. See Chapter 6 for more information on requirements and guidelines for reporting. Copyright and Disclaimer Short Contents | Full Contents Other books @ NCBI Search (: on) Checked This book (text) (: on) Unchecked All books (: on) Unchecked PubMed Navigation About this book SAMHSA/CSAT Treatment Improvement Protocols 36. TIP 36: Substance Abuse Treatment for Persons with Child Abuse and Neglect Issues Executive Summary and Recommendations Chapter 1 Working With Child Abuse and Neglect Issues Chapter 2 Screening and Assessing Adults For Childhood Abuse and Neglect AHCPR Archived reports, Put Prevention Into Practice and Minnesota Health Technology Advisory Committee SAMHSA/CSAT Treatment Improvement Protocols 36. TIP 36: Substance Abuse Treatment for Persons with Child Abuse and Neglect Issues Chapter 2 Screening and Assessing Adults For Childhood Abuse and Neglect Substance abuse is a chronic and relapsing condition. It is often associated with problems in physical, psychological, emotional, spiritual, and social functioning (Brown, 1998; Landry, 1994). These problems are not likely to be the result of one specific cause but rather the result of an accumulation of factors that clients have faced in their lives (Luthar and Walsh, 1995). Risk factors associated with substance abuse disorders include histories of childhood abuse and neglect ( Carlson, 1997). In fact, a recent study found that adults with histories of child abuse have an increased likelihood of heart disease, cancer, and chronic lung disease, as well as greater risk for alcoholism, drug abuse, depression, and attempted suicide (Felitti et al., 1998). These findings emphasize the importance of comprehensive screening and assessment for individuals with substance abuse disorders and client access to adequate health care. Although childhood abuse and neglect disproportionately affect adult substance abusers and their families, clients' substance abuse disorders are not often examined within the context of past abuse or neglect experiences. The reasons for not considering or eliciting this kind of historical information vary. Treatment providers may not have comprehensive screening and assessment measures available. Often, counselors simply fail to ask, or the intake organization does not instruct them to ask, about childhood abuse. Yet in some instances disclosure rates have risen dramatically when substance abuse treatment clients were asked directly about their experience of child abuse. Clients may be unable to address traumatic childhood events because of memory problems that, in the past, have helped them cope with the trauma Chapter 3 Comprehensive Treatment for Adult Survivors of Child Abuse and Neglect Chapter 4 Therapeutic Issues for Counselors Chapter 5 Breaking the Cycle: The Substance- Dependent Client as Parent/Caregiver Chapter 6 Legal Responsibilities and Recourse Chapter 7 Emerging and Continuing Issues Appendix B -Protecting Clients' Privacy Appendix C -Implications of Recent Federal Legislation for Clients in Treatment Appendix D Obtaining Screening and Assessment Tools Appendix E -Resources Related to Childhood Trauma Among Adults (Brown et al., 1999). Clients' family members may not be available or appropriate as family historians, and it is not the counselor's role to independently investigate family histories. Sometimes the immediacy of other problems causes assessments of child abuse and neglect to be delayed. Yet without proper screening and assessment, treatment providers may wrongly attribute symptoms of childhood trauma-related disorders to consequences of current substance abuse. Mental health issues often precede, rather than follow from, substance dependence. Therefore, comprehensive screening for root causes of clients' presenting symptoms may greatly increase the effectiveness of treatment. Challenges to Accurate Screening and Assessment Counselors face great challenges when screening for and assessing childhood abuse or neglect. Few adults are comfortable with a history of violation and neglect. Many abuse survivors are ashamed of having been victims of childhood physical, emotional, or sexual abuse and may feel that the abuse was self-induced. Screening and assessment, therefore, should be designed to reduce the threat of humiliation and blame and should be done in a safe, nonthreatening environment. Although family members can be an important part of a comprehensive assessment (with the client's consent), treatment providers should be aware of what impact their involvement may have on the client's safety (or the safety of the client's children) and which family members the client considers nonthreatening. The following sections illustrate the challenges that treatment staff should anticipate and prepare for when screening for a history of childhood abuse or neglect and when assessing its impact on clients with substance abuse disorders. Underreporting Trauma History or Symptoms When screening for and assessing a history of childhood trauma, the counselor should ask clients to recall and indirectly reexperience abuse-related events ( Briere, 1997). This process can trigger defense mechanisms--such as denial, minimization, repression, amnesia, and dissociation (Bernstein et al., 1994; Briere, 1992a; Cornell and Olio, 1991)--that diminish the distress associated with these events and memories (Fink et al., 1995). These mechanisms may cause a client to withhold or ignore information that is important for the assessment. Adult survivors of childhood trauma commonly suppress memories of certain traumatic events or minimize, either consciously or unconsciously, their symptoms (Brown et al., 1999; Whitfield, 1997a). Frequently, such defense mechanisms relate to the shame and stigma of the Appendix F -Resource Panelists Appendix G Field Reviewers Figures Appendix A -Bibliography events. Clients may fear retribution from perpetrators or family members or loss of contact with people on whom they are emotionally dependent. Minimizing has often served to protect family members from having to deal with the criminal justice system (including the possible arrest of the perpetrator). Also, clients may fear that treatment staff will assume that they are abusive to their own children and report them to the police or child protective services (CPS) agencies. Still others may have never perceived their experiences as abusive or harmful but rather as normal and deserved. Certain sociocultural factors may encourage denial and minimization. For example, there is a social imperative among males to be strong and silent and unaffected by abuse. Physical abuse is difficult to evaluate because most males see their abuse as normal punishment for their behaviors (Langeland and Hartgers, 1998). Men may self-report child abuse and neglect less than women because their occurrence implies weakness and an inability to protect themselves ( Evans and Sullivan, 1995; Holmes et al., 1997). Recent studies have concluded that sexual abuse of boys is underreported and undertreated (Holmes and Slap, 1998). Issues of confidentiality, mandated reporting, and trust may influence responses to interviews and questionnaires by making some clients less inclined to reveal personal histories of abuse or neglect. Reporting requirements may vary from State to State (see Chapter 6 for more information on reporting child abuse and neglect). Maryland law, for example, requires that treatment providers report incidents of childhood abuse disclosed by adults in substance abuse treatment programs. Repressed Memories An important limitation of most of the research on childhood abuse is that it relies on retrospective recall of personal events that usually are not independently corroborated. This is a standard problem in many areas of research, but particular concerns have been raised about the retrospective recall of childhood sexual abuse. The primary concerns have revolved around the "false memory syndrome" and child sexual abuse that has been forgotten and later remembered in the context of counseling (Loftus, 1996). Laboratory research on memory indicates that people may be led to remember events that did not actually happen to them (Loftus, 1993). These findings have raised the concern that suggestible clients may be led by therapists to believe that they were sexually abused as children when they were not. Other research indicates, however, that people can only be led to believe that nontraumatic events happened to them and that they are much more impervious to suggestions that false traumatic events occurred (Bowman, 1996). See Farrants, 1998, for a review of the research on this subject. Overreporting Trauma History or Symptoms Recently, research has suggested that some individuals may overreport or misrepresent abuse histories or abuse-related symptomatology, although this does not normally happen ( Briere, 1997). In such cases, the client's conscious or unconscious should be viewed as having significant pathology that may contaminate the screening and assessment processes. For example, some clients may report inaccurate abuse histories or symptoms so that they may receive treatment rather than be incarcerated, may receive inpatient instead of outpatient treatment, or may qualify for disability-related entitlements, such as Supplemental Security Income (LaCoursiere, 1993). Others may overreport their history of trauma or current trauma-related symptoms in an effort, consciously or unconsciously, to deny or minimize their substance abuse disorder. Although overreporting is probably a less frequent phenomenon than underreporting, staff should be aware of the possibility that clients may receive secondary gains from overreporting symptoms or the severity of past abuse. Just as many clients with substance abuse disorders tell "war stories," some, with a great deal of experience in treatment settings, have become experts at giving psychiatric labels to all their problems. Coexisting Psychiatric Disorders A number of studies have found that childhood maltreatment and trauma are significant risk factors for later psychiatric problems (Beitchman et al., 1992; Neumann et al., 1996; Polusny and Follette, 1995; Trickett and McBride- Chang, 1995). Indeed, individuals with a history of childhood trauma--such as being sexually abused, being physically assaulted, or repeatedly witnessing violence--often develop psychopathology during adulthood (Beitchman et al., 1992; Bryer et al., 1987; Malinosky-Rummell and Hansen, 1993; Pollock et al., 1990; Roesler and Dafler, 1993). Thus, many adults receiving treatment for substance abuse who have a history of childhood abuse and neglect will have a coexisting psychiatric disorder (seeFigure 2-1). As mentioned in Chapter 1, abuse and neglect during childhood are particularly associated with major depression, suicidal thoughts, posttraumatic stress disorder (PTSD), and dissociative symptoms (Briere and Runtz, 1990a; Craine et al., 1988; Felitti et al., 1998; Rowan and Foy, 1993; Rowan et al., 1994). In treatment programs for veterans, where PTSD symptoms are often assumed to be occupation related, a history of childhood abuse can be particularly difficult to identify. Childhood abuse also has been associated with borderline personality disorders (Herman et al., 1989), as well as dissociative amnesia and dissociative identity disorder (Brown et al., 1999; Briere, 1997; Briere and Conte, 1993; Ross et al., 1990). Given the potential for coexisting psychiatric disorders in this population, treatment providers should not rely only on self-assessment tools and patient feedback. Neuropsychological Consequences Of Childhood Abuse Clients will benefit from understanding how severe and chronic physical, emotional, and sexual abuse in childhood can affect their memory and emotions long after the abuse has ceased. The long-term consequences of physical battering, for example, might include minimal or severe brain damage (from learning disabilities to mental retardation), aggressive behavior and lack of impulse control, and physical limitations. Childhood abuse or neglect also may hinder the development of a mature personality, because it becomes difficult for the abused person to develop a healthy sense of self. These effects have the potential to seriously complicate substance abuse treatment. New neuroimaging techniques--such as positron emission tomography (PET) scans or functional magnetic resonance imaging (MRI)--have revealed that chronic abuse may actually affect pathways in the brain and alter thinking processes. Some studies show reductions in the volume of the hippocampus, the seat of long-term memory, in both combat veterans with PTSD and women with PTSD who experienced severe sexual abuse during childhood (Bremner et al., 1995; Gurvitz et al., 1995; Stein et al., 1997). In another study (Rauch et al., 1996), individuals reliving abusive episodes had marked decreases in blood flow to the left brain--most notably to Broca's area, which governs language capacity--and increased blood flow to the amygdala and limbic system, believed to be the site of emotion and long-term memory. These findings suggest that remembering trauma can produce intense emotional states while at the same time it inhibits individuals' capacity to verbalize their experiences ( van der Kolk, 1996). Counselors should be aware that clients may not be able to verbalize feelings when experiencing intense emotional states. Behavioral treatments such as exposure and desensitization in a safe therapeutic environment should help clients progressively manage these states without losing the ability to communicate. In this way, clients will be able to verbalize feelings instead of experiencing upsetting symptoms in response to traumatic triggers. Dissociation Many researchers and counselors now believe that dissociation is a common and readily available defense against childhood trauma, since children http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.section.63421 (5 of 36)08/01/2006 7:34:23 AM dissociate more easily than adults ( Turkus, 1998). To defend against abuse, the child psychologically flees (dissociates) from full awareness. Under severe trauma, especially if inflicted at a young age, parts of the self may split off, in some cases creating a compartmentalized way of experiencing the world, with strong or painful emotions and memories shut off from consciousness. These emotions may surface as intense fear or anger when the client is under stress or is in situations that trigger memories of the abuse. In extreme cases, parts of the self may assume separate identities. Dissociation serves many purposes. It provides a way out of an intolerable situation, it numbs pain, and it can erect barriers (i.e., amnesia) to keep traumatic events and memories out of awareness. The child may begin by using the dissociative mechanism spontaneously and sporadically ( Courtois, 1988). With repeated victimization, it may become a chronic defensive pattern that persists into adulthood, resulting in a dissociative disorder. Arising as a survival mechanism to protect the child, over time dissociation changes into a pattern of behavior that interferes with the individual's daily functioning and ability to interact with others. Sometimes these dissociative periods can last hours and require emergency psychiatric treatment. The counselor may see symptoms of dissociation but be unaware of the cause. For example, the client may "space out" when talking to the counselor, appearing disoriented or forgetful in order to avoid an intimate (and seemingly threatening) situation. The client may be temporarily unresponsive to conversation or questions, although he may reengage if the counselor persists in seeking his attention ( Briere, 1989). These periods of disengagement usually last only a few seconds or minutes. However, they may cause the client to miss important insights or opportunities for self-examination. The client may also report or exhibit intense moods that are out of proportion to the present situation. Rage, terror, overwhelming sadness, or self-destructive impulses may take hold of the client as a result of what may appear to be minor issues, and the client may seem unable to respond to the counselor's attempts to reason with the client. Because there can be many causes of such extreme emotional reactions, it is important to isolate the symptoms of dependency or withdrawal from those caused by trauma resulting from childhood abuse. Dissociative symptoms can mimic the effects of drugs or of withdrawal from drugs, making it difficult to determine the type of problem being presented. In victims of trauma, substance abuse itself can be seen as a method of dissociating for those who cannot do it successfully through other means. For http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.section.63421 (6 of 36)08/01/2006 7:34:23 AM this reason, it is common for survivors of child abuse to self-medicate with substances, thus beginning a process that often leads to substance abuse and dependence. Counselor Issues Any counselor or treatment provider who might be screening for and assessing histories of child abuse or neglect must receive specific training in these issues. The screening process and followup sessions will invariably involve listening to traumatic stories. Not all treatment providers will be comfortable hearing about their clients' experiences of abuse. Some may experience vicarious trauma or feel overwhelmed by these painful personal accounts. This may be especially true among counselors whose own traumatic childhood experiences were not addressed therapeutically. The counselor's biases from these experiences, regardless of their similarity to a client's, could have a harmful impact. If counselors experience intense discomfort and anxiety when conducting screenings and assessments, the Consensus Panel recommends that they receive guidance and support from a clinical supervisor and consider whether they could benefit from therapeutic assistance to explore the reasons for their discomfort. (For a more detailed discussion on counselor issues, see Chapter 4.) Prior training on handling abuse issues can help counselors "screen" themselves to recognize if they are unprepared to work with clients who have experienced childhood abuse or neglect. It is better to find out ahead of time than for the counselor to risk damaging the therapeutic process by having to confront personal issues in the middle of it--possibly even ending the session prematurely, leaving the client confused, feeling abandoned, or wondering "What's wrong with me?" Many counselors avoid issues of childhood abuse simply from lack of experience. They need assurance that the proverbial can of worms that has been opened can be closed in a reasonable length of time. Proper training can help counselors better deal with trauma and with secondary PTSD, sometimes known as "compassion fatigue." Screening for a History of Child Abuse or Neglect Because adults who were abused or neglected during childhood can experience significant trauma-related consequences that require clinical intervention, the Consensus Panel suggests using child abuse and neglect screening (1) to identify individuals who exhibit certain signs and symptoms associated with child abuse and neglect (such as PTSD, major depression, or mood disorders) and (2) to identify who may benefit from a comprehensive clinical assessment. Consequently, treatment staff should http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.section.63421 (7 of 36)08/01/2006 7:34:23 AM . Learn and understand ways in which childhood abuse and neglect can affect adult feelings and behaviors . Identify those individuals who appear to exhibit these symptoms . Identify the trauma-related treatment needs of these clients . Provide or coordinate appropriate treatment services that will help to meet clients' treatment needs The Need for Screening Adults who were abused as children are more likely to use drugs or alcohol (Dembo et al., 1989; Singer et al., 1989; Zierler et al., 1991); therefore, they are more likely to be in treatment for substance abuse. The consequences of childhood abuse and neglect can dramatically affect a client's treatment needs. For instance, as noted in Chapter 1, a history of childhood trauma can increase the number and intensity of treatment services required, lengthen the time needed for treatment, and increase the number of sessions, particularly for male clients ( Downs and Miller, 1996; Felitti, 1991; Felitti et al., 1998; Steinglass, 1987; Young, 1995). The consequences of childhood abuse and neglect can also affect the psychosocial supports that such clients may need following treatment ( Steinglass, 1987). Screening for childhood abuse or neglect can set in motion a proactive plan with the following benefits: . Stopping the cycle. Although not all adults who were abused or neglected during childhood abuse their own children, they are at greater risk of doing so (Kaufman and Zigler, 1987). Thus, screening for abuse and neglect can be an important step in stopping the cycle of abuse in many families. . Decreasing the probability of relapse. Many substance abusers use alcohol and illicit drugs to self-medicate posttraumatic stress symptoms related to past physical or sexual abuse or trauma ( Price et al., 1998); clients may abuse substances to deal with hyperarousal or stress (Clark et al., 1997; De Bellis, 1997). Since these are important causes of continued substance-abusing behavior, addressing them may facilitate treatment and reduce relapse. . Improving a client's overall psychological and interpersonal functioning. Childhood sexual abuse and neglect may affect the individual's self-concept, sense of self-esteem, and ability to self- actualize. They also affect a person's ability to trust, be intimate, and set limits with others. Identifying a history of abuse or neglect enables the client to address these issues as they relate to overall functioning as http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.section.63421 (8 of 36)08/01/2006 7:34:23 AM well as to recovery. The ability to trust is especially important; difficulties with trust can impede the client's ability to utilize treatment to its fullest. . Improving program outcome. Screening for a history of child abuse or neglect helps to determine the percentage of abused and neglected individuals who are in a substance abuse treatment program. Furthermore, screening, combined with assessment, helps to determine the trauma-related treatment needs of clients. With this information, programs can make informed decisions about providing the treatment services that can best meet their clients' needs. When Should Screenings Be Conducted? Clients' treatment needs change over time. For this reason, counselors must conduct ongoing assessments of their clients' problems, including substance abuse, health concerns, psychological problems, family-related stressors, parenting stressors, interpersonal stressors, social support, and vocational problems. Having up-to-date information allows counselors to deliver individualized treatment to each client that meets specific needs and is of the appropriate length and intensity. As with psychosocial evaluations, screenings for child abuse and neglect should be conducted early in a comprehensive assessment process. However, because denial and minimization are prominent defense mechanisms associated with childhood trauma and trauma survivors may feel shame and discomfort answering abuse-related questions, screenings should also be conducted at different times throughout the treatment process. Repeated screenings help elicit information about these traumatic experiences-especially after trust has been established in the therapeutic relationship. Treatment providers should be aware, however, that repeated screenings may give the impression that the therapist does not believe the client. For clients who typically were disbelieved as children, this can be an important therapeutic issue. Furthermore, cognitive and memory impairment caused by substance abuse decreases with length of sobriety; that is, over time, a client may physiologically be more capable of recalling past experiences if she maintains sobriety (Leber et al., 1981; Reed et al., 1992). Who Should Conduct Screenings? The Consensus Panel believes that treatment decisions and activities are best conducted within the context of a multidisciplinary treatment team, with members having special knowledge in such areas as mental health, child abuse http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.section.63421 (9 of 36)08/01/2006 7:34:23 AM and neglect, and family counseling. Team members should possess varied levels of training and experience. At the same time, there are different types of treatment settings, including drop-in centers, residential treatment programs, and intensive and less intensive outpatient and hospital-based programs. These varied treatment settings and the composition of the treatment team will affect screening decisions, including who is available to conduct them. Although there are no rigid rules regarding who should conduct screenings, having certain skills will increase the likelihood that the screening process is conducted appropriately. Irrespective of the level of academic credentials, training, supervision, or specific role within the treatment team, treatment staff members should all have an understanding of the types of psychiatric disorders and symptoms that are commonly associated with a history of childhood abuse and neglect (see Figure 2-1). They should understand the role of screening and assessment for a history of trauma, and they should know the types of questions that constitute a screening for child abuse and neglect. Moreover, they should have developed a sensitivity to the issues of child abuse and neglect. Training and supervision No one should screen for childhood trauma without specific training and supervision. The Consensus Panel strongly recommends that counselors administering the screening understand the reasons for conducting the screening, be knowledgeable about the best