ARCHIVED: Chapter 4: Coping with Becoming a Teen: When You Have Been Maltreated as a Child

This is the first attempt to capture substance use levels among a randomly selected group of child welfare youth and compare the results with the general high school population. Furthermore, since youth from the general population were queried on lifetime child welfare involvement, it is likely that comparisons between the child welfare involved sample and the general population sample reflect true differences between youth whose maltreatment was officially detected (i.e., MAP youth who are identified based on child protective involvement and whose maltreatment histories are self-reported and verified by caseworker report) and non-system involved youth (i.e., OSDUS youth who self-report no child protective involvement).

It should be noted that a history of maltreatment was not assessed for the OSDUS sample. As a result, some of the non-system involved youth may have also experienced maltreatment. National epidemiological surveys with high school youth do not typically query maltreatment, and there is currently no available data on differences in substance use between youth who have experienced maltreatment and are involved with the child welfare system and those from high school samples. Further refinement of the present findings would include establishing groups based on maltreatment status (i.e., present or absent) within the high school group. This strategy is expected to occur in the 2009 OSDUHS cycle.

Several important findings emerged from the present analyses. First, youth who are involved in the child welfare system are more likely to report lifetime and past-year cannabis use, and are more likely to report lifetime and frequent other drug use (i.e., more than six times in the past year). Youth from the general high school population, however, were more likely to report lifetime and past-year use of alcohol. These findings may reflect greater access to alcohol among general populations. In the case of youth involved in child welfare, alcohol use and caseworker monitoring may deter them from using alcohol, however, other substances (e.g., cannabis, cocaine, nonprescription opioids, Ritalin) may be perceived as more benign or less easily detected by caseworkers.

Within the MAP sample, a history of severe physical abuse, witnessing domestic violence, and believing that one had been neglected or emotionally abused were all associated with an increased likelihood of substances use. Only witnessing domestic violence was associated with an increased likelihood of other drug use. When workers' reports of abuse were examined, a history of sexual abuse was associated with a greater likelihood of more frequent past-year alcohol and cannabis use.

When gender differences were examined, female youth in the MAP study emerged as the group at greatest risk for substance use, a trend that is the reverse of what is typically observed in the general high school population . Females also emerged higher among samples of youth with histories of maltreatment, substance use, and other health consequences (i.e., violence victimization). Taken together, these findings suggest that females may be more susceptible to the effects of adverse childhood experiences on substance use than males, and that the specific mechanisms and strategies involved in preventing and intervening with child welfare involved youth should be gender-specific.

For females, it appears that sexual abuse histories as well as emotional/physical abuse are dominant predictors of frequency of cannabis and other drug use. Consistent with other analyses, sexual abuse is common in teenage youth, considering lifetime exposure (about 25% of MAP youth report some form of sexual abuse)-and it is predictive of drug use. Emotional/physical abuse is not considered in the substance literature as much as sexual abuse, and other drugs not considered as much as alcohol.

As suggested by developmental traumatology theory, PTSD symptomatology emerges as a significant mediator of drug use (cannabis, other drugs), which is in keeping with other prior research on teens (Wekerle et al., 2001). This finding points to the potential value of addressing PTSD symptoms in adolescence, even though the maltreatment experience may have terminated in childhood. Other factors, such as exposure to dangerous places and persons, potentially in connection with the drug-procuring and drug-using activities, may contribute to an ongoing activation of PTSD symptoms. Ongoing traumatic events in the lives of child welfare youth, especially females, seem to warrant further investigation.

Overall, these analyses highlight the need for thoroughly assessing youth at the earliest possible age, with the possibility of averting the initiation of substance use. In addition, given the greater engagement with drugs among MAP youth, assessment of substance use involvement should be broadened. There is clearly a need to promote drug abuse prevention among youth involved in child welfare. These youth emerge as a subpopulation of particular interest to drug educators and treatment providers, and represent an at-risk, priority group for the prevention and treatment of substance use disorders. Specific recommendations for public health policy and practice are presented below.

RECOMMENDATION 1

Promote the early detection and screening of substance use for youth with a history of maltreatment.

Early initiation of substance use and abuse is a potential concern for adolescents with a history of childhood maltreatment. Screening for substance use in early adolescence with youth who have been maltreated should be conducted by skilled health professionals to facilitate early identification, family safety and adolescent well-being. For males and females, early intervention may support better adaptation to adversity, and may help set the stage for a healthier lifestyle in adulthood.

RECOMMENDATION 2

Develop tailored and targeted substance use prevention programs for youth who have a history of maltreatment.

The current findings highlight the need to allocated resources toward the development of targeted prevention programs for youth with a history of maltreatment who are at-risk of engaging in substance use. Unfortunately, current universal prevention programs that target all youth (e.g., school-based prevention programs) may not be sufficient to address the needs of those youth who have been maltreated and most at risk.

It is important to recognize that youth with a history of maltreatment may require multifaceted treatment approaches that are sensitive to their trauma backgrounds. The sequences of the trauma-based and substance abuse therapeutic targets is a clinical issue and may require case-by-case evaluation, and may be complicated further by other co-occurring factors, such as teen dating violence and other mental health issues (Wekele &Wall, 2002). However, some authors have posited that, as long as underlying maltreatment issues are unresolved, it is unlikely that substance abuse and other problem behaviors can be prevented or treated (Watts & Ellis, 1993).

RECOMMENDATION 3

Continue to monitor and identify risk and protective factors of substance use patterns among youth who have been maltreated.

This study represents only a preliminary investigation of substance use differences between youth involved in child welfare and high school adolescents. The present findings highlight the need for continued monitoring of substance use patterns and trajectories among samples of Ontario youth who have experienced maltreatment. Further research is needed to determine the extent to which adolescent predictors of substance use among child welfare youth (e.g., gender, maltreatment status) also predict long-term substance use, requiring the use of longer-term repeated measures data. It would be important to consider similar prospective longitudinal data in sub-populations within child welfare, such as Aboriginal youth, youth with other mental health issues (e.g., mood and anxiety disorders), and youth in care.

In addition, a more in-depth analysis of risk and protective factors is needed among youth who have experienced maltreatment. Although rates of substance use are higher among youth with histories of maltreatment compared with the general population, not all youth with such histories will develop a substance use disorder. Identifying protective factors that differentiate between youth whose trajectories include substance use/abuse versus those who maintain normative levels of licit drug use into adulthood would provide important information concerning targets for health promotion and prevention programming.

RECOMMENDATION 4

Provide additional training for child welfare workers and health practitioners.

Additional training and education that focuses on youth with a history of child maltreatment and substance use is needed within child welfare agencies and pre-service professional school programming (e.g., social work). It is critical that caseworkers within child welfare and addiction specialists who work with youth who have experienced maltreatment understand the cluster of issues associated with maltreatment and how they are linked with substance use and related outcomes over time. For example, training should extend beyond identifying existing substance use disorders for those with a history of maltreatment, and start with services aimed at prevention (e.g., delivering age-appropriate messages). It should also extend beyond substances most commonly used by the general population of youth (i.e., alcohol) to substances most likely to be used by child welfare involved youth in Ontario (e.g., cannabis and other drugs). Training and education should also be made available to group home staff, foster parents, and other professionals with whom youth spend most of their time and who have access to a greater sampling of youths' behaviour.

Training should also include ongoing continuing education on both maltreatment and substance use/abuse. As well, cross-training in both areas is important since treating maltreatment and substance use has been shown to be most effective when treated simultaneously within an integrated treatment program (Kofed, Friedman & Peck, 1993).

RECOMMENDATION 5

Improve collaboration and communication among systems.

To effectively address the complex and multiple factors associated with maltreatment and substance use integrated, collaborative and multi-sectoral approaches are needed to ensure continuity of care. Given the range of issues these youth could potentially face it is important that there is improved collaboration and communication among systems (i.e. health, justice, mental health). Strengthening the relationship among these systems will necessitate a high level of coordination and collaboration. As well, intensive levels of care and gender specific treatment programming need to be further developed and evaluated for effectiveness.