ARCHIVED: Chapter 1: Coping with Becoming a Teen: When You Have Been Maltreated as a Child

Substance Use in Adolescence

Substance use during adolescence can have multiple negative effects. Alcohol is the most frequently used substance among adolescents, and its use is associated with significant risks including impaired driving, physical and psychological concerns, school failure and dropout (Battin-Pearson et al., 2000). Research suggests that initiating drinking at a younger age is associated with an increased risk of developing alcohol abuse or alcohol dependence (Grant & Dawson, 1997). In addition, alcohol use is significantly associated with four of the leading causes of death among adolescents: motor vehicle accidents, other unintentional injuries, homicides, and suicides (Tucker, Ellickson, & Klein, 2003).

Alcohol's effects on neurodevelopment may mediate all of these consequences. Recent research on brain development during adolescence argues that "excessive use" is the introduction of any "toxin" during a critical growth period (Mayes & Bornstein, 1996; Annenberg Commission on Adolescent Substance Abuse, 2005).

Although alcohol use by those younger than 19 years is illegal in Ontario, a distinction between licit and illicit substances persists in the literature. Specifically, legal substances typically refer to alcohol and cigarettes, and account for the majority of substance-related costs in Canada (Canadian Centre on Substance Abuse, 2007). Illicit drugs typically refer to those classified as "controlled" under the Controlled Drugs and Substances Act , including cannabis, cocaine, hallucinogens, and ecstasy. For the purposes of this report, all substance activity discussed is illegal, given the focus on under-age alcohol consumption and use of illicit drugs.

Regarding substances other than alcohol, cannabis (marijuana) is the most widely used drug among adolescents and is associated with risks similar to those of alcohol use. For example, early adolescent marijuana use is associated with increased risk of academic problems, unsafe sexual practices, and further alcohol and marijuana use (Brook, Balka, & Whiteman, 1999). In addition, marijuana use in adolescence has been implicated as a causal factor in the development of schizophrenia in those at risk of developing the disease, with higher levels of use associated with a greater risk (Arsenault et al., 2004). Early drug use (i.e., use by age 13) has also been found to predict later drug addiction, even when controlling for well-established risk factors such as parental alcoholism and criminal justice involvement (King & Chassin, 2007).

These findings highlight the potential negative and long-term consequences associated with excessive substance use in adolescence-underscoring the need for additional research and knowledge dissemination concerning risk and protective factors, youth prevention and treatment programming, and health policy strategies for reducing the negative impact of adolescent substance use and abuse.

Prevalence of Substance Use in Adolescence

Despite the negative consequences, substance use is common among adolescents (Adlaf & Paglia-Boak, 2007; Johnston et al., 2007), as is involvement in other risk behaviours including aggression and unsafe sexual practices (Centers for Disease Control and Prevention, 2006). Motivations for risky behaviours can include acceptance by peers, thrill-seeking, assertion of independence, and testing of limits. Findings from a recent national survey of American adolescents indicate that more than one-quarter tried substances before entering high school, with just under 50% remaining abstinent throughout high school (Johnston et al., 2007). For teens, alcohol remains the substance of choice; almost half of the students in grade 12 (45.3%) reported alcohol use in the past 30 days, and 30% reported being drunk (Johnston et al., 2007).

According to the most recent Ontario Student Drug Use and Health Survey (OSDUHS: Adlaf & Paglia-Boak, 2007), alcohol, cannabis, and other drug use seems to have stabilized or decreased in Ontario. There is, though, increased use of non-medical prescription opioids (e.g., pain relievers including Oxycontin, Percocet, Percodan, Tylenol #3, Demerol and Codeine). Overall, 12% of Ontario adolescents reported past-year substance use other than marijuana and alcohol, with solvents (5.8%), stimulants (5.7%), hallucinogens (5.5%), ecstasy (3.5%), and cocaine (3.4%) being the most commonly used substances.

Consistent with findings from an American survey (Johnston et al., 2007), alcohol remains the most frequently used substance among Ontario youth. Approximately 61% of Ontario students in grades 7 to 12 reported alcohol use in the past year, and one-quarter reported engaging in binge drinking (i.e., drinking five or more drinks per drinking occasion). In addition, 19% of Ontario youth were classified as hazardous drinkers, meaning they met the cut-off for problem drinking as assessed by the Alcohol Use Disorders Identification Test (AUDIT, in Saunders et al., 1993), a screening measure for assessing alcohol-related problem levels within the OSDUHS.

Cigarette use is less common than drinking, with 12% of youth reporting use in the past year, and 5% reporting daily cigarette smoking. Cannabis is the most commonly used drug among Ontario students; 26% reported using cannabis at least once in the past year, 14% used cannabis six or more times in the past year, and 3% reported using it daily.

The OSDUHS also includes a screening tool that measures drug use situations experienced by adolescents called the CRAFFT, where the acronym refers to alcohol use in certain contexts (i.e., C= in car; R=to relax; A=while alone; F=forget use; F=family/friends tell you to cut down; T=use lead to trouble) (Knight et al., 1999). The CRAFFT measure asks about activity over the last 12 months. A score of two or more identifies adolescents who exhibit problematic drug use. About 25% of OSDUHS drug-using youth reported problematic drug use.

Overall, these statistics confirm what is already known: drug and alcohol use is common among adolescents, with alcohol, cannabis, and cigarettes being the most commonly and frequently used substances.

Adolescent Addiction: Abuse, Dependence, and Co-morbidity

Adolescent addiction has reached a consensus definition in the literature (Annenberg Commission on Adolescent Substance Abuse, 2005) with key features that include:

1. preoccupied thoughts or cravings of drugs or drug-related experiences;
2. repetitive, compulsive drug behaviours that interfere with normal activities; and
3. neuroadaptation to drug exposure, such that pharmacological tolerance and withdrawal behaviours are observed with abrupt cessation of use.

According to the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV; American Psychiatric Association, 1994), substance use disorders involve impairments in functioning across a range of contexts, including school, work, with friends, partners and family. Often, recurrent use results in negative consequences accompanying abuse, such as failure to fulfill expected obligations. Next, substances are used in situations that may cause physical harm. Then, substance-related legal problems emerge. Finally, serious impairment in functioning accompanies dependence , including tolerance and/or withdrawal. Although not included in the DSM-IV diagnostic criteria, dependence is frequently associated with neglect of basic functions such as eating, sleeping, and hygiene. Withdrawal effects are typically opposite those for intoxication (e.g., if intoxication leads to elation, withdrawal reflects low mood), and vary widely across drugs.

It is clear that a substance use disorder diagnosis is associated with a host of negative consequences, and that adolescent substance use disorders frequently co- occur with other psychological diagnoses. Among community samples, adolescents with a substance use disorder diagnosis are up to six times more likely to be diagnosed with a mood disorder, two times more likely to be diagnosed with an anxiety disorder, and 14 times more likely to be diagnosed with a conduct/ oppositional disorder (Roberts, Roberts, & Xing, 2007). Within alcohol and drug treatment settings, approximately 60% of clients were diagnosed with some type of mental health disorder within the last year including attention deficit hyperactivity disorder, conduct disorder, oppositional defiant disorder, and anxiety and mood disorders (Garland et al., 2001). These findings suggest that among adolescents with substance use disorders, concurrent psychiatric diagnoses are the norm.

Several reasons could explain the overlap between substance use and other diagnoses. For example, teens who experience anxiety symptoms may seek relief with alcohol and drugs, such as marijuana, for their sedating properties-so-called self-medication (e.g., Stewart, 1996). Furthermore, substance use is often seen as part of a larger "problem behaviour syndrome" (e.g., Donovan & Jessor, 1985), with higher levels of substance use co-occurring with other adolescent problem behaviours, including aggression and disruptive behaviours, rule violations, and difficulties with attention and impulsivity.

Although the order in which substance use and psychiatric diagnoses occurs is not yet established, youth who are already at risk for mental health concerns are also at an increased risk for substance use. In particular, youth who have experienced maltreatment and are already at risk for psychological concerns may be particularly susceptible to substance use. As discussed below, several other factors heighten the risk of substance use among youth who have experienced maltreatment.

Substance Use among Youth Who Have Experienced Maltreatment: Multiple Sources of Risk

Within normative development, the testing of limits that often accompanies adolescent substance use may help to establish parameters for future acceptable conduct. Ongoing monitoring by parents, consistent correction, school consequences and, in some cases, legal sanctions, often serve the purpose of righting the youth's behaviour toward pro-social norms and responsible autonomy. But teenagers who have histories of neglect and/or abuse may lack supervision and emotional support from parents and, given frequent school changes, from involved school officials - all of which may disrupt this natural corrective process for excessive youth substance use (e.g., see Clark, Thatcher & Maisto, 2004). In addition, risk factors for substance use, such as poverty, social skills deficits, parental substance abuse, and academic problems, are more likely among youth with histories of maltreatment, compared with those without such histories (Cash & Wilke, 2003; Crozier & Barth, 2005).

According to social learning theory, youth who have experienced maltreatment are at risk of substance use that goes beyond experimentation or time-limited episodes because they have poor role models, their caregiver reinforces drug-taking behaviours directly, or they make decisions based on what they perceive to be limited options. Youth who have experienced maltreatment may escalate from experimentation to problem use or dependence because they are already vulnerable and living in a risk-promoting environment (Annenberg Commission on Adolescent Substance Abuse, 2005). Further, as some caregivers who maltreat their children abuse substances themselves, risk is present even if environmental risks are minimized, as with the presence of a competent, non-substance abusing co-caregiver. In addition, children of alcoholics have a greater likelihood of developing an addiction, even when separated from their birth parents and raised by non-alcoholic parents (Schuckit, 2000). Thus, a history of alcoholism from either biological parent increases the risk for the child, regardless of home placement status.

Findings from an Ontario sample of youth and adults (ages 15 and older) indicate that parental substance abuse increases the likelihood of childhood maltreatment (adult retrospective reporting on physical and sexual abuse; Walsh, MacMillan, & Jamieson, 2003). Other researchers have found that parental substance use is more likely among youth with maltreatment histories (e.g., Kilpatrick et al., 2003). Secondary analyses of the first wave of the Canadian Incidence Study of Reported Child Abuse and Neglect (Wekerle, Wall, Leung, & Trocmé, 2007) found that caregiver drug or alcohol use was a predictor of substantiated maltreatment. In 15% of cases where maltreatment was substantiated, the caseworker confirmed drug or alcohol use by the caregiver during the previous six months by either witnessing intoxication, or through evidence of caregiver treatment for substance abuse. Taking into account a range of caregiver vulnerability factors (e.g., social isolation, mental health), caregiver substance use was the strongest single predictor of substantiation of maltreatment versus non-substantiation, particularly in terms of physical abuse and neglect case decisions.

Thus, caregiver substance abuse may be an issue for understanding the outcomes for youth who are maltreated. Youths with histories of maltreatment whose caregivers have problem substance use are not only exposed to adult models that engage in violence and illegal activity, but they also have access to substances at home-and may lack sanctions or even be encouraged to use. Finally, the protective factors noted in the alcohol literature (e.g., strong commitment to prosocial activities like sports, religion/church, and high self-esteem; Liepman et al., 2002; Luster & Small, 1997) may be absent in families where maltreatment occurs.

Deterrents to avoid excessive use or modeling of healthy coping strategies may be absent in the home of children who have experienced maltreatment. Such homes, which are frequently socio-economically disadvantaged, chaotic, and unsafe, may bolster access to substances because of lack of adult supervision, more time spent on the street, and the presence of greater illegal drug trade activity in the neighbourhood (Wekerle & Wall, 2002).

Direct peer pressure does not seem to be a strong factor in teen alcohol use. According to the OSDUHS, 21% of youth reported that they had been offered, sold, or given a drug at school in the past year (Adlaf & Paglia-Boak, 2007). Youth tend, however, to select similarly oriented peers that are either supportive or non- supportive of drug use (e.g., Schulenberg & Maggs, 2002).

Also of particular concern in youth who have experienced maltreatment is functional impairment. Alcohol and drug use can cause deficits in learning and memory, difficulties concentrating, and long-term neurological damage (National Institute on Drug Abuse, 2008). Substance use among youth with histories of maltreatment may lead to cognitive difficulties that result in school frustration and disengagement, heightening the already established risk of school dropout. Indeed, research has shown that dropping out of school is significantly associated with alcohol and drug use (Townsend, Flisher, & King, 2007). Staying in school, however, may have a protective effect for youth with histories of maltreatment. Research shows that remaining in school is linked with lower rates of psychopathology for Canadians reporting physical and/or sexual abuse in childhood (Williams, MacMillan, & Jamieson, 2006). Specifically, those who completed high school, whether they were high or low achievers, were less likely to show externalizing disorders, which are also commonly associated with substance use disorders. Overall, staying in school affects social and psychological functioning, with benefits such as greater interpersonal competence and a sense of personal mastery. A healthy school environment may compensate for the lack of discipline, responsiveness, predictability, and structure at home, possibly playing a key role in promoting mental health.

In short, substance use may be one of several elements defining a negative trajectory for youth who have experienced maltreatment. For child welfare youth, this risk for negative outcomes may be further increased when support by the foster family and child protective services terminates when the youth enters the upper age-limit for care-typically 16-21 years of age. A youth's successful adaptation may be jeopardized if, after care ends, the youth returns to caregivers whose parental rights had been terminated (in the case of Crown wards), turns to the streets, or relies more heavily on unhealthy ways of coping, such as substance use. Thus, for children involved in child welfare, substance use is both an immediate concern and a long-term quality- of-life issue.

Child Maltreatment, Trauma, and Substance Use among Youth

Maltreatment may occur as a single episode or as a chronic pattern of interactions within the family. It can manifest as a failure to protect or as actual perpetration of maltreatment. The differing clinical features of a single-event versus chronic maltreatment are well documented (e.g., De Bellis, 2002b; Koob, 1999). Maltreatment of high intensity that is witnessed, perceived, or actual may be deemed traumatic if it was experienced as a severe threat to the person's life, safety, or integrity. This includes direct assaults of physical and sexual abuse; indirect assaults, such as witnessing domestic violence; and the higher likelihood of injury and assault, as with neglect. Further, we know that child welfare youth often experience more than one form of maltreatment (see Wekerle, MacMillan, Leung, & Jamieson, 2007) and that the cumulative effects of various types of maltreatment are often more severe than effects from a single type (for a review, see Higgins & McCabe, 2001). These traumatic reactions fall into the category of post-traumatic stress disorder (PTSD), as defined by psychiatric diagnostic criteria (American Psychiatric Association, 1994).

The initial response to single-event trauma by a child or youth may be hyper-arousal-notably, hyperactivity, disorganization, and disrupted routines. However, as trauma is repeated, the adaptation response can become more complicated by dissociation, affective disturbance, and prolonged gaps in historical memory. With a single- event trauma, there is an emphasis on pathological fear and erroneous associations of people and objects with danger (Tolin & Foa, 2002). Separation anxiety may follow and extend over time in the form of not wanting to be alone, believing that the world and people are dangerous, and that bad things happen unpredictably.

From ages 8 to 10, post-traumatic reactions are more in line with adult diagnostic criteria, with females more likely to show PTSD-like responses and males to show aggression responses (Dyregrov & Yule, 2006). A PTSD response includes three categories of symptoms: re- experiencing the trauma (flashbacks, nightmares, intrusive images, recurring dreams); avoiding trauma- related cues (cognitive and "escape" behaviours, numbness, feelings of detachment); and increased arousal (exaggerated startle response, hyper-vigilance, irritability, sleep problems).

A diagnosis of PTSD is often associated with other psychological concerns, including major depression; anxiety disorders such as panic disorder, social anxiety disorder, and generalized anxiety disorder; and behavioural problems such as aggression. Substance use is also associated with PTSD and trauma in general: teens with a substance use disorder are five times more likely to have PTSD and a history of trauma (Deykin & Buka, 1997).

Researchers have typically focused on the PTSD diagnosis, although sub-clinical symptoms are important as they have been linked to significant functional impairment in youth (Carrion et al., 2002; Putnam, 1998). Particularly with youth, symptoms in all three categories may not be present or, if present in all categories, fewer symptoms per category are present as per diagnostic criteria. From a developmental traumatology theoretical perspective (e.g., De Bellis, 2002a), sub-clinical PTSD symptoms can act as a bridging mechanism from maltreatment to subsequent maladjustment in its chronic-albeit low level-affective disturbance. In brief, sub-clinical symptoms point to impairment of the body's stress response system in that brain structure and functioning has adapted to the maltreatment environment (e.g., vigilance to threat). However, in the non-maltreatment environment, the body's over-taxed stress response system does not "reset" to normal functioning. Thus, youth who have experienced maltreatment and suffer from PTSD may have difficulty recovering from prolonged stress periods.

Although not conducted with a random sample of child welfare youth, prior research indicates that PTSD symptoms (self-reported by youth) may partially explain the relationship between maltreatment and adolescent dating violence (Wekerle et al., 2001; Wolfe et al., 2004). No study to date has considered the associations among maltreatment history, PTSD, and substance use in a child welfare sample. Research is needed to examine the mechanisms involved in the relationship between a history of child maltreatment and substance use-including the possible involvement of PTSD symptomatology as a mediating factor.

Substance Use among Youth with Maltreatment Histories: Gender Differences

Adolescents exhibit clear gender differences in drug and alcohol use. Male youth typically demonstrate higher levels of use than female youth. For example, according to the 2007 OSDUHS, male drinkers binge drink and use marijuana more frequently than do female drinkers. Motivations for use also differ by gender, with females rating most favourably the tension-reducing properties of alcohol, and males rating most favourably its euphoric, relaxing, and sexual disinhibition effects (Annenberg Commission on Adolescent Substance Abuse, 2005).

Some evidence suggests that the relationship between substance use and childhood maltreatment also differs between genders. For example, in follow-up interviews with adults who had reported maltreatment as children, Widom, Ireland, and Glynn (1995) found that women with a history of maltreatment had higher levels of alcohol use as adults than those who had not been maltreated, even when considering factors such as parental alcohol use and socio-economic disadvantages. Studies examining male youth who exhibit delinquent behaviours show a relationship between maltreatment and substance use, including greater use of marijuana/hashish (Dembo et al., 1992). In determining the effects of maltreatment between genders, other considerations are gender differences in maltreatment rates, notably the consistently higher rate of sexual abuse of females (e.g., Wekerle & Wall, 2002).

Further, the link between substance use and psychopathology may vary by gender. For females, high school alcohol use was linked with earlier onset of anxiety problems (Rohde, Lewinsohn, & Seeley, 1996, as cited in the Annenberg Commission on Adolescent Substance Abuse, 2005). Although anxiety disorders- particularly social phobia and PTSD-are associated with problem alcohol use, such usage typically exacerbates the anxiety issues (e.g., Stewart, 1996; Stewart & Israeli, 2002). In studies of adolescents who have experienced maltreatment, the PTSD-problem alcohol link has been found to be stronger in females (e.g., Clark et al., 1997).

Although the literature is inconsistent in this area, gender remains an important factor related to maltreatment and substance use: analyses of large samples should consider males and females separately.

The Prevalence of Substance Use among Youth with Maltreatment Histories: Current Findings

Although almost 30% of adolescents in Ontario reported past year drug use (e.g., used one of the following: cannabis, LSD, PCP, other hallucinogens, methamphetamine, cocaine, crack, heroin, stimulants, and/or tranquilizers), and 19% reported hazardous drinking (in OSDUHS, Adlaf & Paglia-Boak, 2007), it remains unclear at the population level how many youth in this high-risk minority are involved with child welfare.

The National Survey of Child and Adolescent Well-Being is a national longitudinal study of 11- to 15-year-olds in the U.S. child welfare system that were reported and investigated as victims of maltreatment. It found that 20% reported low levels of substance use in the past 30 days (i.e., infrequent use and/or use of cigarettes, alcohol, inhalants and non-prescribed medications), and 9% reported moderate-to-high levels of use (i.e., more frequent use of substances and/or use of alcohol or illicit substances). Higher levels of use were reported among youth with conduct problems and among those who reported poor relationships with their caregivers (Wall & Kohl, 2007).

In a sample of older adolescents (i.e., students in grades 10 through 12) in Oregon (Moran, Vuchinich, & Hall, 2004), youth with a history of physical maltreatment were over two times more likely to report high levels of tobacco and alcohol use, and almost three times more likely to report high levels of illicit drug use, compared with those with no physical maltreatment. In addition, youth with a history of sexual maltreatment were approximately three times more likely to report high levels of tobacco and alcohol use, and almost four times more likely to report high levels of illicit drug use, compared with those without a history of sexual maltreatment (Moran et al., 2004).

What is missing from the literature on child maltreatment in general, and in Canadian samples in particular, is an examination of the rates of substance use among youth with histories of maltreatment compared with those without such histories. The present report represents an analysis of Year-1 data from the Maltreatment and Adolescent Pathways (MAP) Longitudinal Study, which includes a random selection of teens, aged 14-17 years, from the active caseload of urban child welfare (Children's Aid Society) agencies.