Parental substance use disorder and child abuse: risk factors for child maltreatment?

Introduction

Substance use disorders (SUDs) are a widespread and harmful condition. The prevalence of 12-month and lifetime drug use disorder, as diagnosed with the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) (American Psychiatric Association, Citation2013), is estimated at 3.9% and 9.9%, respectively (Grant et al., Citation2016). Crucially, children growing up with parents with SUDs suffer serious consequences from such circumstances (Brown, Cohen, Johnson, & Salzinger, Citation1998). Besides other negative effects, parental SUDs are consistently identified as a serious risk factor for child physical abuse (Dubowitz et al., Citation2011; Laslett, Room, Dietze, & Ferris, Citation2012). Children of parents with SUDs, therefore, are at risk for abuse, which could manifest in serious physical, emotional and psychological trauma (e.g. Raitasalo & Holmila, Citation2016; Schury & Kolassa, Citation2012). In the Netherlands, an estimated 3% of all youth in the country are subjected to child abuse each year (Alink et al., Citation2018), and an estimated 3 to 10% of children under the age of 18 have experienced or been threatened with physical abuse (ten Boom & Wittebrood, Citation2019). A large portion of this population – around 23,000 children in the Netherlands – live with parents who suffer from SUDs (Goossens & van der Zanden, Citation2012).

Due to the danger that parents with SUDs may pose to their children, it is essential to be able to adequately identify those parents who are at risk of committing child abuse. There is a large body of literature on the risk factors for child abuse and more generally domestic violence, including intimate partner violence. Even though intimate partner violence is not the same as child abuse, there is an overlap; in 40% of the families in which intimate partner violence occurs, the child or children also suffer abuse (Herrenkohl, Sousa, Tajima, Herrenkohl, & Moylan, Citation2008). Drug use has been consistently related to all forms of aggression and violence, including intimate partner violence (Cafferky, Mendez, Anderson, & Stith, Citation2018; Foran & O’Leary, Citation2008) and child abuse (Stith et al., Citation2009). In a review of 285 studies analysing the relationship between substance use and intimate partner violence, Cafferky et al. (Citation2018) found alcohol and different types of drugs to be equally strongly related to intimate partner violence, whilst an earlier meta-analysis of 96 studies reported similar findings, with an especially strong relationship for cocaine (Moore et al., Citation2008). With regard to child abuse, Stith et al. (Citation2009) conducted a meta-analysis of 155 studies that had empirically examined the relationship between an identified risk factor and either child physical abuse or neglect, in order to generate composite effect sizes for 39 risk factors of child physical abuse. They found that alcohol abuse is more significantly related to child physical abuse than is drug abuse. As such, a potential factor for discerning violent parents with SUDs from non-violent parents is the type of substance being abused.

In Stith et al.’s (Citation2009) meta-analysis, medium to large effect sizes were also found between child physical abuse and several parental characteristics, such as depression and psychopathology (conceptualized as any measure of mental illness besides depression or anxiety, such as schizophrenia, bipolar disorder, etc.). This suggests that comorbid disorders may play a role in the relationship between SUDs and child abuse. Especially relevant is the comorbidity of Cluster B personality disorders, which are consistently linked with intimate partner violence as well as SUDs (e.g. Kelley & Braitman, Citation2016) and aggression in general (e.g. Goldstein et al., Citation2006). Furthermore, Stith et al. found large effect sizes for anger and hyper-reactivity and moderate effect sizes for parental coping and problem-solving skills, suggesting that it may be important to address personality disorders when studying the relationship between SUDs and child abuse.

Lastly, environmental and other psychosocial factors have been identified as risk factors for child abuse. For instance, strong and very strong correlations have been found between neighbourhood poverty and child physical abuse and neglect, respectively (Drake & Pandey, Citation1996). Similarly, an overview of 18 ecological studies of child maltreatment found that areas with higher levels of poverty have higher rates of child maltreatment. In addition, relationships have been found between drug and alcohol availability in neighbourhoods and child maltreatment (Freisthler, Merritt, & LaScala, Citation2006) and between unemployment and child physical abuse (Stith et al., Citation2009). Furthermore, weak family bonds (CASAColumbia, Citation2012; Stith et al., Citation2009) and parenting stress (Rodriguez & Green, Citation1997; Stith et al., Citation2009) – meaning the amount of stress experienced by individuals in their role as a parent – have been found to exhibit correlations with child abuse.

In a longitudinal study of risk factors for child maltreatment, it was found that the risk of child maltreatment increases with the number of risk factors present, but especially when more than four risk factors are present (Brown et al., Citation1998). The effects of accumulating risk factors have also been shown to be predictive of child maltreatment in other studies (Ridings, Beasley, & Silovsky, Citation2017; Solomon, Åsberg, Peer, & Prince, Citation2016). This underlines that an interplay of factors may be responsible for child abuse.

Many of the risk factors for child abuse and maltreatment discussed above are highly prevalent among patients with SUDs. As such, it may not be possible to use some of these risk factors to distinguish between parents with SUDs who abuse their children and those who do not. Evidently, not all parents who suffer from SUDs commit violence against their children. This raises the question of whether or not there are differentiating factors that could be used to discern non-abusive parents with SUDs from abusive ones. This article aims to identify such factors by comparing two groups of parents with SUDs who were enrolled in a SUD treatment programme, either with or without documented instances of abuse.

It was hypothesized that parents who abuse their children are more likely to have psychological comorbidity, particularly Cluster B personality traits (Kelley & Braitman, Citation2016). It was also hypothesized that abusive parents with SUDs are more likely to use alcohol or cocaine than non-abusive ones (see also Moore et al., Citation2008; Stith et al., Citation2009). Lastly, based on the idea that there may be cumulative dose-response effects of multiple risk factors (see Brown et al., Citation1998; Ridings et al., Citation2017; Solomon et al., Citation2016), it was expected that child abuse would be found to be associated with a higher amount of psychosocial and environmental problems.

Method

Results

Discussion

The results of the current study show hardly any differences between parents with SUDs who do not have a known history of committing child abuse and those who do. Specifically, a marginally significant difference was observed between the two groups in terms of the severity of the addiction. However, no statistically significant differences emerged in the severity and type of the problematic substance, the amount and type of psychiatric comorbidities, the number of problems across the socio-environmental life domains and the reported quality of life. This was unexpected, as it was the results of previous studies which led to the hypotheses that the abuser group would have more psychological comorbidities (cf. Stith et al., Citation2009) particularly regarding personality disorders (cf. Kelley & Braitman, Citation2016), would be more likely to have a SUD involving alcohol or cocaine (cf. Moore et al., Citation2008; Stith et al., Citation2009) and would have a higher number of problems across the life domains (Brown et al., Citation1998; Ridings et al., Citation2017; Solomon et al., Citation2016) when contrasted with the comparison group. The lack of differences between the groups may be explained by several factors, of which the most recognizable is the small sample size, which significantly reduces the strength of the results in terms of statistical power; with only 19 cases per group, the statistical power is undermined. When looking at the data, the difference in addiction severity was found to be statistically insignificant but on face value appears interesting enough to warrant further attention. As such, further research with larger groups is needed to address this potential difference.

An important explanation for the lack of differences could also lie in the clinical nature of the current sample. All participants in both groups were being treated, rendering them by definition two clinical samples – but the abuser group was referred for treatment by an external institute (i.e. the Control Centre). In general, only a minority of individuals suffering from SUDs receive healthcare. For instance, in a study of American individuals, only 11% of those who needed specialized treatment actually received it (Substance Abuse and Mental Health Services Administration, Citation2014), and in the Netherlands only one out of every ten individuals with SUDs eventually reach a healthcare institution (Wisselink et al., Citation2016), resulting in the biggest treatment gap across all psychiatric disorders (Kohn, Saxena, Levav, & Saraceno, Citation2004). Herewith, it seems that the few patients with SUDs who seek treatment may possess characteristics that distinguish them from non-clinical patients (Grant et al., Citation2016; Moos & Moos, Citation2006; Raimo, Daeppen, Smith, Danko, & Schuckit, Citation1999). For instance, one study has shown that individuals with alcohol dependency who recover without professional care have fewer socio-environmental difficulties and lower and less severe rates of psychological and substance-related comorbidities than those who have been enrolled in healthcare institutes (Raimo et al., Citation1999). As such, although they are clinical samples, the abuser and comparison groups may not be similar enough in their clinical nature due to the former being referred for treatment and the latter seeking it voluntarily. Therefore, the differences between parents with SUDs who abuse their children and those who do not could potentially be more visible in two samples that are either fully community based or truly clinical.

Regarding the lack of differences between the two groups, it is also important to realize that a large proportion of child abuse cases remain unknown to authorities. It was found that, in high-income, Western countries including the Netherlands, only 10% of all children facing physical abuse are reported to and identified by the relevant authorities (Alink et al., Citation2018; Gilbert et al., Citation2009). Due to such observations, it is possible that some of the parents in the comparison group had committed child physical abuse that had not been identified. In addition, the between-group differences in the ages of the parents – and consequently most likely also in the ages of the children – may have affected the findings, because it is known that younger parents are at higher risk for committing child abuse than older parents (Sidebotham & Golding, Citation2001). Because it was not possible to match the two groups in terms of age, this variable could not be controlled for.

While retrieving the data and analysing the results, two other observations were made that are worth mentioning. Most striking is the patients who were referred for SUD treatment based on a warning from child protection services but for unknown reasons never received this treatment after their intake meeting. It is remarkable that these individuals did not receive the support that they need, especially considering the unsafe family circumstances which pose a serious hazard to their children’s development; child abuse is a significant risk factor for depressive disorders, drug use, suicide attempts and risky sexual behaviour later in life (Norman et al., Citation2012; Steenrod & Mirick, Citation2016). Unfortunately, this problem seems to be widespread – other studies suggest a similar trend wherein only a small percentage of parents complete treatment programmes, despite being required to do so (Oliveros & Kaufman, Citation2011). Secondly, the involvement of children in their parents’ treatment and recovery phases is often overlooked. Professionals in mental health institutions for addicts are able to indicate the family situation of the patient during intake – and the institutions strongly recommend that they do so. However, when retrieving the Control Centre clients from the VNN database, some clients were registered as childless, even though they were referred to healthcare based on warnings regarding child abuse. Clearly, the children are often not involved in the treatment process, even though they are one of the primary reasons for enrolment in the first place. This suggests that mental health systems and procedures in general may not be adequately equipped to provide appropriate care for the families of patients, especially the children of parents with SUDs, who ought to be part of the treatment plan since they are a particularly vulnerable group.

To conclude, this study is important in addressing matters of child support and protection in a group that is at high risk for committing child abuse. The strength of this study comes from the comparison of two different groups, with attention to diagnostic features that are usually assessed at intake. This provides a practical and naturalistic overview of variables that can easily be retrieved from electronic data files or intake procedures and assessed by healthcare professionals. Future studies addressing this topic may benefit from the present research set-up, but should employ a larger sample size and maybe also the inclusion of community samples or unselected clinical samples. Distinguishing features and improved procedures could result in better prediction, prevention and rehabilitation of perpetrators of child abuse. Moreover, mental health institutions may become better facilitated to incorporate the well-being of abused children into their protocols and systems for parent treatment and recovery.

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.

Declaration of conflicts of interest

Anna Goldberg has declared no conflicts of interest.

Eric Blaauw has declared no conflicts of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.