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Sexual Victimization and Substance Abuse in Psychiatrically Hospitalized Adolescents.

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Title: Sexual Victimization and Substance Abuse in Psychiatrically Hospitalized Adolescents.
Language: English
Authors: Singer, Mark I.
Source: Social Work Research. Jun 1994 18(2):97-103.
Peer Reviewed: Y
Page Count: 7
Publication Date: 1994
Document Type: Reports - Research
Journal Articles
Descriptors: Adolescents, Child Abuse, Hospitalized Children, Psychiatric Hospitals, Sexual Abuse, Substance Abuse, Victims of Crime
ISSN: 1070-5309
Abstract: Investigated relationship between substance abuse and sexual abuse in population of 260 psychiatrically hospitalized adolescents. Resulting model suggests that, within clinical populations, sexually abused adolescents should be screened for substance abuse, and attention should be given to parental alcohol abuse as well as degree to which adolescents perceive benefits from their alcohol or drug use. (Author/NB)
Journal Code: CIJOCT1994
Entry Date: 1994
Accession Number: EJ484693
Database: ERIC
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  Value: <anid>AN9608010415;SWK01JUN.94;1996Dec13.08:44;v2.3</anid> <title id="AN9608010415-1">SEXUAL VICTIMIZATION AND SUBSTANCE ABUSE IN PSYCHIATRICALLY HOSPITALIZED ADOLESCENTS </title> <p>This article investigates the relationship between substance abuse and sexual abuse in a population of 260 psychiatrically hospitalized adolescents. Seven hypotheses are set forth to test a model that uses parental alcohol abuse, sexual abuse status, and gender as exogenous variables, perceived benefit of alcohol or drugs as an endogenous mediating variable, and substance abuse as the dependent variable. Using these variables, a path model was constructed and revised based on empirical testing. The revised model achieved an adjusted R[sup2] of .38, thus explaining 38 percent of the variance in this sample's abuse of alcohol or drugs. The model suggests that within clinical populations, sexually abused adolescents should be screened for substance abuse, and attention should be given to parental alcohol abuse as well as the degree to which adolescents perceive benefits from their alcohol or drug use. </p> <p>Key words: adolescents; path analysis; psychiatric admissions; sexual abuse; substance abuse </p> <p>Sexual victimization of children has received considerable attention from researchers and clinicians. Although a growing volume of research has focused on the various emotional, psychological, and behavioral sequelae found in children and in adult survivors of sexual abuse, far less empirical attention has been given to finding the determinant factors that heighten or increase the victim's risk of vulnerability to such sequelae; even less attention has been given specifically to sexually abused adolescents. </p> <p>The horror and trauma of sexual victimization can lead to feelings of dehumanization, to feelings of powerlessness, and to a deflated sense of self. Such trauma may also elicit an extensive number of distress symptoms in children including insomnia, nightmares, bed wetting, social withdrawal, fearfulness, and somatic complaints such as lower abdominal or pelvic pain (Herman, 1988). For adolescents, the symptoms of victimization may escalate to such acting-out behaviors as runaway attempts, suicide attempts, prostitution, promiscuity, and drug and alcohol use (Faller, 1981; Herman, 1988). </p> <p>Although numerous sequelae of childhood sexual abuse have been reported in the clinical and research literature, few reports have documented the relationship between sexual abuse and substance abuse in adolescent populations. Preliminary support for this relationship in adult populations has been reported in two extensive reviews of the literature, both of which suggest a conspicuous absence of studies focusing on adolescents (Alter-Reid, Gibbs, Lachenmeyer, Sigal, & Massoth, 1986; Browne & Finkelhor, 1986). </p> <p>Rohsenow, Corbett, and Devine (1988) investigated the prevalence of childhood sexual victimization among adolescent substance abusers and the extent to which the problem was minimized or underestimated. They observed the rate of disclosure over time and compared a sample of inpatient substance abusers who were systematically asked about a history of sexual abuse to rates of disclosure in a sample before the question was routinely asked. They found that with routine inquiry, approximately 42 percent of the adolescent boys reported sexual abuse, and 71 percent to 90 percent of adolescent girls disclosed such histories. Their study, however, did not provide for equivalence of the two sample groups. </p> <p>Cavaiola and Schiff (1988), in describing behavioral sequelae of physical and sexual abuse in adolescents, surveyed 500 admissions to a short-term residential chemical dependency treatment center. Four subgroups of abuse were assigned based on definitions and criteria for abuse as described by Kempe and Kempe (1984): (<reflink idref="bib1" id="ref1">1</reflink>) physical abuse, (<reflink idref="bib2" id="ref2">2</reflink>) sexual abuse, (<reflink idref="bib3" id="ref3">3</reflink>) incest and physical abuse, and (<reflink idref="bib4" id="ref4">4</reflink>) incest. Cavaiola and Schiff found that 150 adolescents (30 percent) were identified as physical abuse victims, 24 subjects (4.8 percent) were identified as victims of incest and physical abuse, 29 (5.8 percent) were identified as sexual abuse victims, and 21 (4.2 percent) were identified as incest victims. Although their study gathered data on the abuse status of the perpetrators (73.8 percent of the perpetrators also had substance abuse histories), it did not provide data on parental abuse of substances unless the parent was the perpetrator. </p> <p>A study by Harrison, Hoffman, and Edwall (1989) on sexual abuse correlates drew from a sample of 1,824 adolescents in inpatient treatment for substance abuse and found that 35.2 percent of the girls and 6.6 percent of the boys disclosed histories of sexual victimization. Their study also reported significant differences between victim and nonvictim participants in self-reported motivations for drug or alcohol use; victims were more likely to report using drugs or alcohol to reduce tension, to get to sleep, to relieve pain or discomfort, and to escape family problems. The authors concluded that more sexual abuse victims than nonvictims used drugs to medicate distress and escape from family problems; they also provided a concise review of the theoretical research explaining such distancing techniques and motivations. </p> <p>Dembo et al. (1987) offered a structural model of the influence of child physical and sexual abuse on illicit drug use with self-derogation as a mediating variable. They also provided a concise summary of the literature to support the model in which the psychological trauma suffered by a child victim of physical or sexual abuse leads to low self-esteem, poor self-image, and self-hatred that, in turn, places the child at high risk for drug use. The data were drawn from a sample of 145 detainees (52 percent male and 48 percent female) housed in a juvenile detention center, 46 percent of whom were found to have histories of sexual victimization. Whereas sexual abuse was found to have a substantial direct effect on drug use, self-derogation was found to mediate the effect of physical abuse (but not sexual abuse) on lifetime substance abuse. Their research highlights the need for further investigation and empirical studies that consider the influence of physical and sexual abuse on illicit drug use separately and the need to determine other mediating variables that might increase a sexually abused teenager's risk for subsequent substance abuse. </p> <p>Studies of psychiatric populations have focused almost exclusively on adults. Herman (19813 investigated distress symptoms in female psychotherapy outpatients comparing incest victims to a matched sample of women whose fathers were merely seductive and found that significantly more female incest victims had abused drugs or alcohol (35 percent) than did the comparison group women (5 percent). Most of the women described their drug or alcohol abuse behavior as unsuccessful efforts to handle feelings of loneliness and depression. </p> <p>In a later study, Herman, Russell, and Trocki (1986) compared a nonclinical sample and an outpatient sample of adult women with histories of incest and found long-term sequelae to include generalized feelings of anxiety and distrust as well as problems in forming and preserving intimate relationships. They noted early on that incest patients commonly sought relief from such long-term effects by abusing alcohol or drugs. Their findings were limited, however, because women who were actively drinking or drug dependent were screened out of the patient sample. Another study of adults used a matched sample of 105 female state hospital patients and found that significantly more female sexual abuse victims were chemically dependent (69 percent) than women in the control group (31 percent) (Craine, Henson, Colliver, & MacLean, 1988). </p> <p>A study by Singer, Petchers, and Hussey (1989) focused on the relationship between sexual abuse and substance abuse among psychiatrically hospitalized adolescents. They found significantly more substance abuse among sexually victimized patients than among members of the nonvictimized matched control group. Sexually abused adolescents reported more occasions of being drunk or high on drugs than their nonabused counterparts. Cocaine and stimulant use was reliably different, with 23 percent of the abused group" compared with 6 percent of the control group reporting regular use of cocaine, and 29 percent of the abuse group compared with 13 percent of the control group reporting regular use of stimulants. </p> <p>Although preliminary studies suggest a relationship between sexual abuse and substance abuse among adolescents, further investigations are needed to document the nature and extent of this relationship. To this end, the study discussed in this article was undertaken to explain alcohol and drug use among psychiatrically hospitalized adolescents. The model variables include sexual abuse status, parental alcohol abuse, adolescents' perceived benefits of alcohol or drug use, and gender (Figure 1). The proposed model promulgates the following hypothesis: </p> <olist> <item> Adolescents who have been sexually abused will perceive greater benefits of drug and alcohol use than adolescents who have not been abused. </item> <item> Sexually abused adolescents will have greater drug and alcohol abuse levels than non-sexually abused youths. </item> <item> Parental alcohol abuse will be positively associated with adolescents' perceived benefits of drug and alcohol use. </item> <item> Parental alcohol abuse will be positively associated with adolescents' abuse of drugs and alcohol. </item> <item> Males will perceive more benefits of drug and alcohol use than females. </item> <item> Males will get drunk or high on drugs more frequently than females. </item> <item> Greater perceived benefits of substance use will be associated with more severe drug and alcohol abuse patterns. </item> </olist> <hd id="AN9608010415-2">METHODS</hd> <hd1 id="AN9608010415-3"> Sample </hd1> <p>The sample frame consisted of all patients admitted to a 24-bed adolescent psychiatric unit at St. Vincent Charity Hospital and Health Center in Cleveland over a two-year period (N= 260). The data collected from the patients were part of the usual clinical evaluation that uses several self-administered questionnaires. The final sample included all potential subjects, because none refused to participate. </p> <p>The sample was predominantly white (86 percent). Fifty-eight percent of the subjects were male ( n = 150) and 42 percent female (n = 110). The mean age was 16.7 years (SD = 1.3), and the median age was 16.0 years (range was 12 to 18 years). Most of the patients were considered middle-and upper-middle-class, based on location of residence, parents' employment, and type of third-party insurance. As can be seen in Table 1, the most frequent category of admitting diagnosis was adjustment disorders (55.9 percent), followed by conduct disorders (16.4 percent) and mood disorders (11.7 percent). </p> <hd1 id="AN9608010415-4"> Instruments and Variables </hd1> <p>Two questions were asked to measure alcohol and drug abuse: (<reflink idref="bib1" id="ref5">1</reflink>) How many times were you drunk in the past two months? and (<reflink idref="bib2" id="ref6">2</reflink>) How many times were you high on drugs in the past two months? Answers were rated on an eight-point scale (0 = none to = 7 seven times or more). A composite of these two-time scores was generated as the measure of the endogenous dependent variable substance abuse. </p> <p>Three exogenous independent variables were included in the study: gender, parental alcohol abuse, and sexual abuse of the adolescent. Parental alcohol abuse was measured through use of the Children of Alcoholics Screening Test (CAST). The CAST is composed of 30 items with 1 = yes and 0 = no response categories. These items tap children's reports of their concerns regarding parents' drinking behaviors and consequences. The CAST has demonstrated good validity and reliability, achieving a Spearman-Brown split-half reliability coefficient of .98 and a successful classification rate (100 percent) for self-reported children of alcoholics (Pilaf & Jones, 1985). </p> <p>Sexual abuse was determined through official records, reports of family members, and self-disclosures. Self-disclosures were facilitated by the use of a screening protocol that included completion of a sexual abuse questionnaire followed by a clinical interview (Hussey & Singer, 1989). </p> <p>Two brief scales were used for assessing adolescents' perceived benefits of using alcohol or drugs: the Perceived Benefit of Alcohol (PBA) Scale and the Perceived Benefit of Drugs (PBD) Scale. The endogenous mediating variable perceived benefits was measured by summating these two scores. The PBA and PBD scales each have five items measured by 0 = false and 1 = true responses. The five perceived benefit items for each scale include the use of alcohol or drugs as a means of (<reflink idref="bib1" id="ref7">1</reflink>) relaxing, (<reflink idref="bib2" id="ref8">2</reflink>) feeling good about yourself; (<reflink idref="bib3" id="ref9">3</reflink>) forgetting about problems, (<reflink idref="bib4" id="ref10">4</reflink>) making friends with other substance users, and (<reflink idref="bib5" id="ref11">5</reflink>) being friendlier. The items in the PBD Scale have very good internal consistency (Cronbach's alpha = .82). The reliability of the PBA Scale is lower (r = .69); however, it is acceptable for a five-item scale. The validity of the PBA and PBD scales has been demonstrated through the significant relationships between each of them and the frequencies and consequences of substance use or abuse (Petchers & Singer, 1987; Petchers, Singer, Angellotta, & Chow, 1988). </p> <hd1 id="AN9608010415-5"> Analyses </hd1> <p>Multiple regression analyses were conducted first using substance abuse as the dependent variable. The three exogenous variables and the perceived benefits score were entered into the regression model simultaneously, thereby allowing the effect of each independent variable to be examined while taking into account the rest of the variables in the model. The standardized regression coefficients were used as the path coefficients for the model. The same procedure was performed using the perceived benefits score as the dependent variable in a multiple regression analysis to test the effect of each exogenous variable on the intervening variable perceived benefits of alcohol and drugs. </p> <hd id="AN9608010415-6">RESULTS</hd> <p>The results of multiple regression indicated acceptance of all hypotheses except hypotheses 4 and 5, the path from parental alcohol abuse to adolescents' substance abuse and the path from gender to perceived benefit. The proposed model explained 38 percent of the variance in substance abuse. The model was trimmed (as displayed in Figure 2) by dropping the insignificant paths. The revised model achieved a multiple R of .62, accounting for 37.8 percent (adjusted R[sup2]) of the variance in the dependent variable. A comparison between the initial model and the revised model applying the formula devised by Specht and Warren (1975) (Dillon & Goldstein, 1984) revealed no significant differences between the two models, suggesting that the revised model with fewer variables is more parsimonious. In addition, the relationships among the exogenous variables--sexual abuse, parental alcohol abuse, and gender--were examined for the possible problem of multicolinearity. As shown in Figure 2, the relationships among them ranged from weak to moderate, indicating that significant multicolinearity was not present in this model. </p> <p>As depicted in Table 2, whether an adolescent had been sexually abused had a significant direct effect on substance abuse and an indirect effect on substance abuse through perceived benefits. Patients who had been sexually abused tended to abuse alcohol or drugs more than those who were not abused. In addition, sexually abused adolescents reported greater perceived benefits of using alcohol or drugs, which in turn resulted in increased levels of drunkenness and drug abuse. </p> <p>Perceived benefits had a positive direct effect on substance abuse; the more benefits adolescents perceived from using alcohol or drugs, the more they got drunk or high on drugs. Males tended to abuse substances more than females; however, there was no indirect effect of gender on substance abuse through perceived benefit of using alcohol or drugs. Parental alcohol abuse had a weak indirect effect on substance abuse through perceived benefits. Perceived benefits had the most powerful contribution (total effect = .565) to adolescents' substance abuse, followed by sexual abuse (.270) and gender (.187). </p> <hd id="AN9608010415-7">DISCUSSION</hd> <p>In the proposed model, five of the seven hypotheses were accepted. Although parental alcohol abuse did not have a direct effect on adolescent chemical abuse (hypothesis 4), the indirect effect of parental abuse was significant. Thus, in this sample, parental alcohol use influenced the degree to which adolescents perceived benefits from alcohol or drug use, which in turn influenced adolescents' alcohol or drug abuse patterns. </p> <p>The hypothesis specifying a relationship between gender and perceived benefits (hypothesis 5) also was not accepted. There were no reliable differences in perceived benefits of alcohol or drug use between males and females, suggesting that both genders' perceptions of benefits were roughly equivalent. There was, however, a direct relationship between gender and substance abuse, with males getting drunk or high on drugs more frequently than females (hypothesis 6). </p> <p>As hypothesized, sexual abuse had both direct and indirect effects on alcohol or drug abuse. Sexually abused adolescents were significantly more likely to abuse mood-altering substances than non-sexually abused adolescents. Furthermore, sexually abused adolescents, more than their nonabused counterparts, reported greater perceived benefits of alcohol or drug use. Indeed, the total effects of sexual abuse on the dependent variable substance abuse were second in magnitude only to the effects of perceived benefits (.27 and .57, respectively) and were the most powerful of the exogenous predictor variables. </p> <p>The results of this study highlight the abusive patterns of substance use by sexually victimized adolescents. Furthermore, the results demonstrate that one reason for the use of mood-altering substances by sexually abused adolescents was the perception that they would derive benefits from such use. Sexually abused adolescents, more than their non-sexually abused counterparts, believed that alcohol or drug use helped them to relax, to forget their problems, to be friendlier or to make friends, and to feel better about themselves. These convictions served to intensify their patterns of substance abuse. Sexually victimized adolescents used mood-altering substances as coping mechanisms and as means of modifying tension, addressing problems, and fraternizing. Feeling less pain or feeling better about oneself is a powerful inducement to use alcohol or drugs. </p> <p>Interestingly, sexually abused youths more than nonabused youths used alcohol and drugs as a means of making friends. It is possible that sexually abused youths were attracted to the type of comradeship and affiliation found in the drug culture. It is not unusual for sexually victimized individuals to have difficulty forming intimate relationships or difficulty trusting others. Their experiences have taught them that intimacy can be quite destructive. In friendships based on drug use, intimacy, and interpersonal closeness are not stressed; access to and use of mood-altering substances is the central theme of relationships. Therefore, an individual can be seemingly surrounded by friends but have only minimal intimate involvement. Such built-in limitations on intimacy may be quite attractive to many sexually victimized adolescents. </p> <p>Programmatically, the data suggest that sexually victimized adolescents in clinical settings should be screened for coexisting substance abuse problems. Such screening should give special attention both to parental use patterns and to the benefits derived from alcohol or drug use. To facilitate substance abuse screening, helping professionals working with sexually victimized adolescents need to understand issues related to alcohol and drug use. Specifically, these individuals should be trained in recognizing substance abuse through use of a specific screening protocol. The use of such a protocol would help ensure uniformity of screening and create a minimum level of compefence among treatment staff. </p> <p>The results of this study do not necessarily apply to nonclinical populations of sexually abused adolescents. The subjects in this study were psychiatrically hospitalized adolescents and therefore represented individuals whose mental health and behaviors were extremely compromised. </p> <ct id="AN9608010415-8"> TABLE 1--Psychiatric Diagnosis of Adolescents at Admission Category n[a] % Adjustment disorder 143 55.9 Conduct disorder 42 16.4 Mood disorder 30 11.7 Eating disorder 12 4.7 Neurotic disorder 10 3.9 Thought disorder 8 3.1 Identity disorder 7 2.7 Other disorder 4 1.6 Total 256 100.0 [a] Four cases were missing diagnoses. TABLE 2--Direct and Indirect Effects of Variables on Alcohol or Drug Abuse Effect Variable Intervening Variable Direct Indirect Total Perceived benefit .565 None .565 Sexual abuse Perceived benefit .133 .137 .270 Children of Alcoholics Perceived benefit None .104 .104 Screening Test Gender .187 None .187 </ct> <p>ILLUSTRATION FIGURE 1--Proposed Model of the Relationship between Substance Abuse and Sexual Abuse </p> <p>ILLUSTRATION FIGURE 2--Revised Model of the Relationship between Substance Abuse and Sexual Abuse </p> <p>REFERENCES </p> <p>Alter-Reid, K., Gibbs, M. S., Lachenmeyer, J. R., Sigal, J., & Massoth, N. A. (1986). Sexual abuse of children. A review of the empirical findings. Clinical Psychology Review, 6, 249-266. Browne, A. G., & Finkelhor, D. (1986). Impact of child sexual abuse: A review of the research. Psychological Bulletin, 99, 66-77. </p> <p>Cavaiola, A. A., & Schiff, M. (1988). Behavioral sequelae of physical and/or sexual abuse in adolescents. Child Abuse & Neglect, 12, 181-188. </p> <p>Craine, L. S., Henson, C. E., Colliver, J. A., & MacLean, D. G. (]988). Prevalence of a history of sexual abuse among female psychiatric patients in a state hospital system. Hospital and Community Psychiatry, 39, 300-304. </p> <p>Dembo, R., Dertke, M., LaVoie, L., Borders, S., Washburn, M., & Schmeidler, J. (1987). Physical abuse, sexual victimization and illicit drug use: A structural analysis among high-risk adolescents. Journal of Adolescence, 10, 13-34. </p> <p>Dillon, W., & Goldstein, M. (1984). Multivariate analyses: Methods and applications. New York: John Wiley & Sons. </p> <p>Faller, K. C. (1981). Sexual abuse. In K. C. Faller (Ed.), Social work with abused and neglected children: A manual of interdisciplinary practice (pp. 143-161). New York: Free Press. </p> <p>Harrison, P.A., Hoffman, N. G., & Edwall, G. E. (1989). Sexual abuse correlates: Similarities between male and female adolescents in chemical dependency treatment. Journal of Adolescent Research, 4, 385-399. </p> <p>Herman, J. L. (1981). Father daughter incest. Cambridge, MA: Harvard University Press. </p> <p>Herman, J. L. (1988). Father-daughter incest. In F. M. Ochberg (Ed.), Post-traumatic therapy and victims of violence (pp. 175-195). New York: Brunner/Mazel. </p> <p>Herman, J., Russell, D., & Trocki, K. (1986). Long-term effects of incestuous abuse in childhood. American Journal of Psychiatry, 143, 1293-1296. </p> <p>Hussey, D., & Singer, M. (1989). Innovations in the assessment and treatment of sexually abused adolescents: An inpatient mode]. In S. Sgroi (Ed.), Vulnerable populations (Vol. 2, pp. 43 64). Lexington, MA: Lexington Books. </p> <p>Kempe, R. S., & Kempe, C. H. (1984). The common secret: Sexual abuse of children and adolescents. New York: W. H. Freeman. </p> <p>Petchers, M. K., & Singer, M. I. (1987). Perceived-Benefit-of-Drinking Scale: An approach to screening for adolescent alcohol abuse. Journal of Pediatrics, 110, 977-981. </p> <p>Petchers, M. K., Singer, M. I., Angellotta, J. W., & Chow, J. (1988). Revalidation and expansion of adolescent substance abuse screening instrument. Journal of Developmental and Behavioral Pediatrics, 9, 25-29. </p> <p>Pilat, J. M., & Jones, J. W. (1985). Identification of children of alcoholics: Two empirical studies. Alcohol Health and Research World, 8, 27-33. </p> <p>Robsenow, D. J., Corbett, R., & Devine, D. (1988). Molested as children: A hidden contribution to substance abuse? Journal of Substance Abuse Treatment, 5, 13-18. </p> <p>Singer, M. I., Petchers, M. K., & Hussey, D. (1989). The relationship between sexual abuse and substance abuse among psychiatrically hospitalized adolescents. Child Abuse & Neglect, 13, 319-325. </p> <p>Specht, D. A., & Warren, R. D. (1975). Comparing causal models. In D. Heise (Ed.), Sociological methodology (pp. 123-149). San Francisco: Jossey-Bass. </p> <p>Original manuscript received February 7, 1992 Accepted July 31, 1992 </p> <aug> <p>By Mark I. Singer, Li-Yu Song, and Billie Ochberg </p> <p></p> <p>Mark I. Singer, PhD, ACSW, is associate professor, Mandel School of Applied Social Sciences, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106. Li-Yu Song, PhD, is research program manager, and Billie Ochberg, MSSA, is a research assistant, Center for Practice Innovations, Mandel School of Applied Social Sciences, Case Western Reserve University, Cleveland. This research was supported by a grant from the Woodruff Foundation. An earlier version of this article was presented at the 1990 meeting of the Society for Research on Adolescents and was supported by an NTAAA/NIDA/OSAP Faculty Development Program Grant. </p> </aug> <nolink nlid="nl1" bibid="bib1" firstref="ref1"></nolink> <nolink nlid="nl2" bibid="bib2" firstref="ref2"></nolink> <nolink nlid="nl3" bibid="bib3" firstref="ref3"></nolink> <nolink nlid="nl4" bibid="bib4" firstref="ref4"></nolink> <nolink nlid="nl5" bibid="bib5" firstref="ref11"></nolink>
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  Data: Investigated relationship between substance abuse and sexual abuse in population of 260 psychiatrically hospitalized adolescents. Resulting model suggests that, within clinical populations, sexually abused adolescents should be screened for substance abuse, and attention should be given to parental alcohol abuse as well as degree to which adolescents perceive benefits from their alcohol or drug use. (Author/NB)
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