As many as two-thirds of all people in treatment for drug abuse report that they were physically, sexually, or emotionally abused during childhood, research shows. However, the role of child abuse - physical trauma, rape and sexual abuse, neglect, emotional abuse, and witnessing or being threatened with violence or other abuse - in the pathway to drug abuse needs closer examination. Although studies probing the effects of child abuse have increased in recent years, researchers still are confronted with broad gaps in information.

"The sheer weight of the many reports over the years certainly implicates child abuse as a possible factor in drug abuse for many people," says Dr. Cora Lee Wetherington, NIDA's Women's Health Coordinator. "But we lack hard data that clearly establish and describe the role of child abuse in the subsequent development of drug abuse. Is child abuse indeed a cause of drug abuse, or is child abuse a marker for other unidentified factors?"

Many critical questions remain unanswered, NIDA researchers agree. How can child abuse victims be identified and studied to track the variables that may contribute to subsequent drug abuse? What factors lessen or strengthen the risk that child abuse will progress to drug abuse? What, in fact, constitutes child abuse?

Answers to questions such as these will help develop creative new drug abuse therapies and prevention strategies. With new knowledge, special interventions could target victims of child abuse to prevent progression to drug abuse. A better understanding of the consequences of child abuse would enable researchers to develop ways to tailor drug abuse treatment to adults who are victims of child abuse. Awareness of this potential has prompted interest among NIDA researchers in further studies into the relationship between child abuse and progression to drug abuse.

However, important obstacles hamper these investigations, which involve not only the researchers and the victims and their families, but also doctors, hospitals, psychologists, child welfare agents, police, and the justice system. The involvement of so many professional disciplines and divergent interests makes identifying victims of child abuse and gathering information from them and their families extremely difficult. Some critical information is not publicly available due to both the need for confidentiality laws designed to protect minors and the secrecy spawned by feelings of guilt or shame by victims, abusers, and family members.

The involvement of so many professional disciplines and divergent interests makes identifying victims of child abuse and gathering information from them and their families extremely difficult.

These barriers severely limit data gathering during the period when child abuse is occurring. Most data are gathered years later, in what are called retrospective assessments, from victims' memories and self-reports. Thus, much assessment occurs only after victims have grown up or at least reached adolescence, entered treatment programs for drug abuse, and often are also experiencing other psychological disorders.

Nevertheless, researchers are making inroads.

Most information about the role of child abuse has come indirectly - from studies of drug abuse that bring to light information about childhood trauma. Some of these studies trace stress-related disorders in adult drug abusers back to childhood traumas. One example is a NIDA-funded review by Dr. Lisa M. Najavits and her colleagues at Harvard Medical School in Boston that examined 49 studies involving drug-abusing women with posttraumatic stress disorder (PTSD). Victims of PTSD re-experience trauma and terror through unexpected flashbacks or nightmares. Child abuse is one trauma that is frequently reported by PTSD patients who are drug abusers.

While drug abusers overall show high rates of coexisting PTSD diagnoses, female drug abusers show much higher rates of this dual diagnosis than do males who abuse drugs. Various studies reviewed by Dr. Najavits report that from 30 percent to 59 percent of women in drug abuse treatment also have PTSD - two to three times higher than the rate among men in treatment, according to Dr. Najavits' review.

A history of trauma independent of PTSD is even more common among women in drug abuse treatment. The reviewed studies show that from 55 percent to 99 percent of these women reported a history of physical or sexual trauma. Most of the trauma occurred before age 18 and was commonly related to repetitive childhood physical or sexual assault. When the women are victims of both types of abuse, they are twice as likely to abuse drugs as are those who experienced only one type of abuse.

A better understanding of the consequences of child abuse would enable researchers to develop ways to tailor drug abuse treatment to the needs of drug abusers who say that they are victims of child abuse.

In another study, Dr. Najavits and her colleagues reviewed data from NIDA's Collaborative Cocaine Treatment Study, which collected treatment and outcome data from patients at five drug abuse treatment sites in eastern cities. Dr. Najavits examined lifetime traumatic events and current PTSD symptoms of 122 adult cocaine-dependent men and women outpatients. She found a high rate of life-time exposure to traumatic events - an average of 5.7 - and a 20.5 percent rate of currently diagnosed PTSD. The patients with PTSD showed significantly more impairments and different circumstances related to their trauma. For example, they reported that their first trauma occurred at an average age of 8.4 years, significantly younger than patients without a current PTSD diagnosis, whose first reported trauma was at the average age of 13.1.

Another NIDA-funded study, which documents that women rape victims are dramatically more likely to abuse drugs than are women who are not victims, also directly implicates child abuse. Dr. Dean G. Kilpatrick at the Medical University of South Carolina found that more than 61 percent of rapes of the 4,008 women in his study occurred by age 17. About half of those occurred by age 11; these obviously were cases of child abuse. The rape victims, compared to others who were not raped, were:

more than three times as likely to have used marijuana;

six times more likely to have used cocaine; and

more than 10 times as likely to have used drugs other than cocaine, including heroin and amphetamines.

One recent study illustrates both progress in studying the relationship of child abuse to subsequent drug abuse and the difficulty in gathering data that specifically address that relationship. The 1997 NIDA-funded study examined data from previous ethnographic studies of drug-abusing adults in New York City. The study found a significant statistical association between inhalant abuse and the abusers' reports that they were abused as children. However, the data do not demonstrate a causal relationship between the two, says Dr. Michael Fendrich of the University of Illinois at Chicago, the study's principal author. Evidence of a causal role for child abuse would require more data to substantiate that the onset of child abuse occurred before the onset of inhalant abuse, he points out.

The fact that most data marking a trail from child abuse to drug abuse are collected retrospectively poses a variety of problems for researchers. Investigators recognize that memory is subjective. Also, drug abusers may choose consciously to emphasize the role of parents or others in their retrospective accounts of events leading to their drug abuse. Thus, researchers, may seek additional data from other sources, such as juvenile court records of child abuse cases.

But NIDA-funded researchers are seeking innovative approaches to address these information-gathering problems to understand the connections between child abuse and later drug abuse. Dr. Cathy Spatz Widom of the State University of New York at Albany is comparing rates of drug abuse between a group of adults who had court-substantiated cases of child abuse and neglect and a control group of their childhood peers who did not have such records. Her initial findings show little difference in rates of drug abuse between the two groups. She recognizes that other factors are, of course, involved. For example, since many cases of child abuse never wind up in court, some in the control group with no court records may have been abused as well. Also, court-ordered interventions and therapies may have reduced the prevalence of drug abuse among court-documented child abuse victims. Even so, the preliminary results cause Dr. Widom to express concerns. "Child abuse is a factor in subsequent drug abuse, but it may be much less a factor than we now believe," she says. "Child abuse may be an important factor primarily for certain subgroups - some groups of women, for example - more than for the population in general." Other factors, such as poverty or family substance abuse problems, play a role, too, she says.

Difficulties such as these have hindered development of drug abuse treatment and prevention approaches that specifically address the needs of child abuse victims. However, some progress has been made in enhancing treatment for specific groups, such as drug-abusing women with PTSD, that include high percentages of child abuse victims (see "Innovative Treatment Helps Traumatized Drug-Abusing Women").

Recognizing the need for broad new research agendas, NIDA continues to encourage studies into child abuse and its relationship to drug abuse during adolescence and young adulthood. Examining the role of child abuse is a major goal of the Interagency Consortium on Violence Against Women and Violence Within the Family that NIDA has joined with a number of other Federal agencies. Also under discussion is a NIDA-sponsored scientific meeting in 1998 on drug abuse and the childhood environment.

Sources