Running head: CSA AND CHEMICAL DEPENDENCY 1. Are Children Who Have Experienced Childhood Sexual Trauma More Prone to Developing

Transcription

1 Running head: CSA AND CHEMICAL DEPENDENCY 1 Are Children Who Have Experienced Childhood Sexual Trauma More Prone to Developing Addictions or Have Higher Rates of Chemical Dependency Later in Life? A Research Paper Presented to The Faculty of the Adler Graduate School In Partial Fulfillment of the Requirements for The Degree of Master of Arts in Adlerian Counseling and Psychotherapy Jason Bartholomay Chair: William Premo Member: Herb Laube February 2016

2 CSA AND CHEMICAL DEPENDENCY 2 Abstract Children who experience sexual abuse undergo significant trauma that can impact them throughout the lifespan. Child sexual abuse can place children, adolescents, and adults at risk of a number of significant mental health problems, from depression and suicidal ideation to substance use disorders. Though children who experience sexual abuse often demonstrate other potential precursors for psychological and substance use disorders, the presence of sexual abuse trauma is one of the most significant indices of psychological disorders and comorbid substance abuse. Existing research on the topic of child sexual abuse in the United States often demonstrate the connection between child sexual abuse and risk factors for psychological and substance use disorders. Though the research does not always indicate causal relationships between child sexual abuse and substance use disorders, correlational studies show that child sexual abuse is a risk factor for a variety of psychological and psychosocial challenges, as well as an indicator of risk of a variety of substance use disorders. This literature review explores the broad array of research on the issue of child sexual abuse, with a specific focus on the impacts of trauma on the development of psychological and substance use disorders. This includes studies that reflect a connection between child sexual abuse and posttraumatic stress disorder and then the subsequent connection between posttraumatic stress disorder and substance use disorders. These elements are presented in the course of the exploration of studies on child sexual abuse and its implications through the lifespan.

3 CSA AND CHEMICAL DEPENDENCY 3 Acknowledgements I would like to thank my family and friends who have encouraged me and reminded me of my inner strength during this process. To my coworkers and friends Beth Gillman, Cindy Anderson, Traci Page, Dr. Veluvali and Marlene Burr who have continuously encouraged me to keep pressing ahead and provided me insight to many things like mental health and family relational issues. My hope would be to be as good as they are in my profession as they are in each of their own. I appreciate each of you sharing knowledge, experience and insight with me. To the Adler Graduate School staff, specifically Dr. William Premo, Dr. Herb Laube, Dr. Ruth Buelow, Dr. Susan Huber, Susan Brokaw, Dr. Marina Bluvshtein, and Gladys Folkers. Dr. Premo who firmly but gently kept me focused on my paper and his encouragement for me to keep writing. This was especially helpful during the high stress events that took place in my personal life during the time of this project. To my rock, my truly amazing wife Jennifer, who has sacrificed so much for me so that I could obtain my goals. She has stepped up and taken on a large portion of parenting our two wonderful children Madelynn and Ethan. She has encouraged me to continue on and finish this great endeavor at times when there were high levels of stress going on in each of our lives. By doing each of these great things you have allowed me to complete this chapter in my life.

4 CSA AND CHEMICAL DEPENDENCY 4 Table of Contents Problem Statement... 5 Significance of the Study... 6 Research Question... 7 Review of Literature... 8 Childhood Sexual Trauma Substance Use Posttraumatic Stress Disorder PTSD and Substance Use Criminality, Life Impacts, and HIV Addressing the Problem Conclusion References... 48

5 CSA AND CHEMICAL DEPENDENCY 5 Are Children Who Have Experienced Childhood Sexual Trauma More Prone to Developing Addictions or Have Higher Rates of Chemical Dependency Later in Life? Problem Statement Child sexual abuse (CSA) is a prevalent problem in the United States. Sexual abuse that occurs before or during adolescence has significant impacts on psychosocial functioning through the lifespan. Because sexual abuse in childhood has been identified as a potential risk factor for a variety of psychological disorders in adulthood, researchers have sought to determine the breadth and scope of its impacts on psychological and substance use disorders in adulthood (McLean, Morris, Conklin, Jayawickreme, & Foa, 2014). CSA has been defined as any forced or coerced sexual activity with a minor including noncontact abuse, sexual molestation, and rape (McLean et al., 2014, p. 559). Ratican (1992) defined CSA as: any sexual act, overt or covert, between a child and an adult (or older child, where the younger child s participation is obtained through seduction or coercion) (p. 33). CSA impacts a significant number of children in this country annually, with more than 135,300 children believed to be sexually abused each year, though many of these experiences go unreported (McLean et al., 2014). There are many possible negative impacts of CSA that can be noted through the lifespan, including, but not limited to psychosocial adjustment issues, low selfesteem, suicidal ideation, and substance use disorders (McLean et al., 2014). A common theme in the current literature on the problem of CSA is that few children who are sexually abused come out of it unscathed; most adults who experienced sexual abuse in childhood experience some psychological or psychosocial issues.

6 CSA AND CHEMICAL DEPENDENCY 6 Significance of the Study In 2012, 62,939 cases of child abuse reported in this country were identified as sexual abuse cases (National Sex Offender Public Website [WSOPW], 2015). In the United States, 16% of men and 25-27% of women experienced some form of sexual abuse occurring before they reached the age of 18 (Perez-Fuentes, Olfson, Villegas, Morcillo, Wang & Blanco, 2013). Of children identified as having been sexually abused, more than 34% were younger than 9 years of age, and 26% were between the ages of (NSOPW, 2015). An overwhelming 1.8 million adolescents in this country are surviving as the victims of sexual trauma (NSOPW, 2015). That number extends from the fact that approximately 1 out of 6 boys and 1 out of 4 girls will be sexually assaulted before they reach the age of 18 years (NSOPW, 2015). More than 4/5 of the population of victims under the age of 18 of sexual assault is female, creating a significant population of female sexual abuse victims in this country (NSOPW, 2015). CSA plays a significant role in the onset of psychiatric disorders in childhood and later in life. Perez-Fuentes and colleagues (2013) maintained that CSA frequently leads to the onset of psychiatric disorders before the age of 18. CSA can be identified as a precursor to psychiatric disorders that begin in childhood in 47% of cases and in 26-32% of individuals demonstrating adult onset psychiatric disorders (Perez-Fuentes et al., 2013). Generally speaking, researchers have indicated that when children know their perpetrators, are violently sexually assaulted, or if abuse occurs with great frequency, the odds of developing a psychiatric disorder increase (Perez- Fuentes et al., 2013). Though statistics reflect what are believed to be actual numbers about abuse rates, reporting of sexual abuse in childhood occurs less than half the time (NSOPW, 2015). Often parents and care providers believe that children who have been sexually abused will act out or

7 CSA AND CHEMICAL DEPENDENCY 7 become hyper-sexualized; issues that sometimes occur but not always. Subsequently, many children, including male children who are victimized, may not demonstrate outward expressions of their sexual assault or even demonstrate a willingness to disclose their trauma (NSOPW, 2015). Victims often disclose sexual abuse many years later, after triggers or symptoms, including Post Traumatic Stress Disorder (PTSD) symptoms or substance use disorders, become problematic. Because sexual abuse in childhood often involves relatives or friends, and can sometimes occur because of a lack of family functioning that would protect a child from abuse, disclosure with family members can be challenging. Often times, disclosure occurs as a result of distinct long-term impacts of the sexual trauma, including PTSD symptoms, substance use disorders, or other comorbid mental health conditions that lead to the need for treatment or interventions. Research Question The research question for this project is: Are children who have experienced childhood sexual trauma more prone to developing addictions or higher rates of chemical dependency later in life? Other queries related to this overarching research question include: 1. Who experiences child sexual abuse? 2. How are symptoms of child sexual abuse manifested? 3. What is the connection between child sexual abuse and PTSD? 4. What is the connection between PTSD and substance abuse? 5. What other consequences of child sexual abuse related to substance use disorders are reported in existing studies? 6. What are the long-term implications of child sexual abuse and substance use disorders?

8 CSA AND CHEMICAL DEPENDENCY 8 7. How can information on child sexual abuse and substance use disorders be used to address long-term health implications of sexual abuse? 8. How can this information be used to direct prevention or treatment paradigms? Review of Literature The problem of CSA and its impact on adult populations is difficult to assess. There are a variety of issues that researchers have identified as problematic in the assessment of CSA and the long-term implications, not the least of which is the fact that many children who are abused do not report their abuse (Lipsky, Kernic, Qiu, Wright, & Hasin, 2014). Though researchers have identified a range of risk factors for sexual abuse before the age of 18, they also reflect the belief that there can be cycles of unreported sexual abuse that make detection and intervention for victims difficult (Perez-Fuentes et al., 2013). Correspondingly, even in cases where reporting occurs, the accuracy, completeness and verifiability of sexual assault reports by children can be influenced by a variety of factors. Researchers have maintained that some research suggests that children can be influenced by those interviewing them to report aspects of sexual abuse that may or may not have occurred (Perez-Fuentes et al., 2013). Subsequently, the lack of accurate data about sexual abuse can create challenges when attempting to address this problem. Research indicates that CSA often occurs as a result of a variety of risk factors, including parental environment, parental substance use disorders, history of family violence, and parental history of CSA (Lipsky et al., 2014). Research also indicates that there are cyclical elements to the risk factors for both childhood sexual and substance abuse that support comorbid psychological disorders in at-risk populations (Perez-Fuentes et al., 2013). There is also evidence that even in families where dysfunction is not prevalent, other conditions, including marital dissolution, can result in the introduction of abusers into the home. Maternal substance

9 CSA AND CHEMICAL DEPENDENCY 9 use disorders can become a bridge between an abuser and a child (Chen, Murad, Paras, Colbenson, Sattler, Gorasnson, & Zirakzadeh, 2010). Chen and colleagues (2010) conducted as systematic review of existing studies of the connection between sexual abuse and diagnoses of somatic disorders through the lifespan. These researchers evaluated longitudinal studies, including case-control and cohort studies, in which somatic disorders were identified in conjunction with a history of sexual abuse. The authors explored a total of 23 studies out of a total of 4640, identifying specific associations and the presence of physical and psychological conditions. After extensive assessment, sexual abuse during childhood was clearly linked to lifetime diagnosis of a range of conditions, ranging from gastrointestinal disorders to fibromyalgia (Chen et al., 2010). This corresponds with findings by a range of researchers about the connection between CSA and the diagnosis of conditions that can have a vast impact on quality of life. Maniglio (2010) defined a connection between child sexual abuse and the foundational factors influencing the onset of depression, especially in children. Maniglio (2010) conducted a systematic review of research on the impacts of CSA on depressive symptoms and the onset of depression in both childhood and adulthood. Early abuse in childhood is not only a risk factor for the onset of depressive symptoms, but can also be a predictor for the early onset of depression (before the age of 18). More completely, though, child sexual abuse was one of the most prevalent predictors in women reporting pervasive depressive symptoms, regardless of the point of onset (Maniglio, 2010). Subsequently, any study of CSA should reflect an awareness of the connection between CSA and potential psychiatric conditions later in life. Research also indicated that some of the conditions that lead to CSA can also be predictors of health issues, and these associations have been considered as a part of research into

10 CSA AND CHEMICAL DEPENDENCY 10 the impact and long-term effects of CSA (Perez-Fuentes et al., 2013). Specifically rates of CSA were higher in homes where substance abuse is prevalent and mothers who experienced sexual abuse as children were more likely to create unsafe home situations in which sexual abuse could occur to their children (Lipsky et al., 2014). In addition, maternal factors, including maternal substance use disorders, maternal depression, and maternal victimization, could create unsafe conditions in which children were victimized (Lipsky et al., 2014). Specifically, CSA was also perceived as a precursor to conditions that place others at risk of childhood trauma, including maternal childhood victimization and its impacts on family dysfunction and the connection between CSA and substance use disorders (Lipsky et al, 2014). CSA as a predictor of a range of health problems has emerged in current literature (Lipsky et al., 2014; Perez-Fuentes et al., 2013). Studies that have been conducted about the variety of health problems associated with sexual victimization in childhood make clear connections between CSA and factors that impact self-esteem, emotional stability, and social cognitive functioning. Rohde, Ichikawa and Simon (2008) reflected the fact that victimization of children can lead to long-term health problems, from psychological issues to obesity. These researchers maintained that high body mass index and depression were linked to abuse in childhood, especially in women (Rohde et al., 2008). Initially, the authors demonstrated the connection in existing research between depression and obesity, and then the connections among depression, obesity, and childhood maltreatment. In female populations, strong associations between self-reported CSA and obesity and depression were noted (Rohde et al., 2008). CSA was also positively associated with low self-esteem, powerlessness, social isolation, delinquency, teen pregnancy, and poor academic performance, all of which had links to depression and obesity in female populations.

11 CSA AND CHEMICAL DEPENDENCY 11 Rohde and colleagues (2008) also maintained that CSA could be understood as a separate form of abuse that had distinct predictive levels in terms of obesity. While both CSA and maltreatment in childhood were positively linked to both depression and obesity, adults who were sexually abused as children are more likely to be obese than those who were physically abused in other ways (Rohde et al., 2008). While researchers have sometimes placed CSA in the same category of physical abuse in childhood, Rohde and colleagues (2008) maintained that sexual abuse needs to be categorized separately and its impact related separately. Children who are sexually abused have emotional, psychological, and physical injuries that influence their capacity for normative social and sexual functioning (Freisthler, 2011). Correspondingly, the discussions about the nature of sexual abuse and its impact on the onset of substance use disorders, including eating disorders and drug or alcohol addiction, extend from the discussion about the different types of abuse related by Rohde and colleagues (2008) and separation of sexual abuse as a unique form. Researchers have indicated that substance abuse by perpetrators is a major contributory factor to child physical and sexual abuse (Freisthler, 2011). Frequently, sexual abusers utilize substances prior to abusing their victims, and in some cases, use drugs or alcohol as a part of the strategy to abusing their victims. In 2006, Freisthler (2011) reported, about 1.9 of every 1,000 children were physically abused in some manner in their homes, by family members, and that this abuse occurred most frequently in houses where substance abuse was taking place. Child maltreatment and abuse were distinctly linked to substance abuse, with research indicating that heavy drinking in particular was a major contributory factor to the actions of abusers (Freisthler, 2011). Parents identified as substance abusers were almost five times more likely to abuse their children in some manner than those who were not using drugs or alcohol (Freisthler, 2011).

12 CSA AND CHEMICAL DEPENDENCY 12 McLaughlin and colleagues (2010) argued that adversities impacting children have been widely documented and were viewed as foundational reasons for the onset of a range of psychiatric disorders. These researchers conducted community-based surveys and found that in families in which maladaptive family functioning occurred, either because of the presence of mental illness in parents or because of substance use disorders, family violence, or physical or sexual abuse or neglect, children were more likely to develop psychiatric symptomology than the children in families without maladaptive functioning. Abuse cycles, especially in regards to sexual and physical abuse, often reflected the presence of maladaptive family situations in the history of subsequent abusers. Determining the connection in the cycle of abuse, which included both CSA and substance use disorders, required some consideration of the cyclical nature of abuse and substance use disorders. The experience of patterned behaviors, and the psychological, social, and emotional responses of those who have been sexually abused in childhood in order to gain insight into this overwhelming problem was time consuming and difficult (Sugaya et al., 2012). Childhood Sexual Trauma CSA is often related in terms of abuse in general, while there are distinct elements argued by researchers including Sugaya and colleagues (2012) that must be separated out. Specifically, childhood sexual trauma is a significant issue in the United States, though the exact number of children being abused in this manner in a given period of time is difficult to calculate. Children in the United States who have been sexually abused or traumatized often do not report their experiences, and there is a general lack of understanding of how impactful sexual trauma in childhood can be (Sugaya et al., 2012). Sexual trauma can occur in a variety of home situations, but once reported, can lead to familial dissolution which can have a negative impact on the child.

13 CSA AND CHEMICAL DEPENDENCY 13 One of the major reasons for a lack of reporting is the fear that they will be removed from their homes and placed in foster care, or fear of repercussions from or for the abuser (NSOPW, 2015). When children are removed from their home and placed in foster care after childhood sexual assault, they may experience a range of conditions in foster care that are as problematic as those they left behind. Sexual trauma in childhood is often exacerbated by the conditions of foster care or the efforts made within law enforcement to address their victimization (Sugaya et al., 2012). Children who experience sexual trauma may be placed in foster care, defined by Leve and colleagues (2012) as a kin or no kin family home other than the biological parent (p. 1197). Keeping in mind that not all sexual trauma in children occurs at the hands of their parents, responding to sexual trauma by removing children from their home can add insult to injury. While foster home settings are designed to support children who have been abused in their homes, children in these settings are at an increased risk of specific negative health outcomes. These risks include emotional and behavioral deficits, challenges related to cognitive and neurobiological development, and deficits that impact their capacity for social relationships (Leve et al., 2012). Subsequently, adults who were victimized as children are more likely to have a variety of negative long-term outcomes, including vulnerability for poverty, interpersonal violence, substance use, criminality, victimization, and domestic violence (Leve et al., 2012). Specific at-risk populations have been noted in regards to issues like sexual victimization in childhood and substance abuse issues that correspond. African American and Hispanic children are more likely than white children to be parented by a single parent, usually a mother, and are more likely to experience adverse events in the home that can result in removal (Wilson & Widom, 2008). Wilson and Widom (2008) recognized that children who are raised by single

14 CSA AND CHEMICAL DEPENDENCY 14 mothers do not always live in unsafe homes, but the prevalence of abuse in these homes creates considerable concern in regards to questions of childhood sexual victimization. Use of measures to protect children, including removing them from their family home, can also result in adverse events that can impact how CSA is perceived by the child who has been victimized. This extends from the belief that children who are removed from their homes may be doubly traumatized, first by the abuse and then by the events surrounding removal of the child and placement in foster care. Statistical data about the outcomes of adverse events in childhood demonstrate that children who are removed from their home after reporting abuse are more likely to participate in sexual risk-taking, transactional sex, interpersonal violence, criminality, and support a cycle of poor choices, including behaviors that lead to interpersonal violence, abuse, and family dissolution (Wilson & Widom, 2008). Children who have lived through sexual abuse often experience traumatic negative events in their homes and many start life with significant challenges because of a variety of familial conditions that contribute to abuse (Leve et al., 2012). For example, children who have experienced abuse are more likely than their counterparts to have experienced multiple family placement changes during their early life, including the presence of multiple parental figures or varied family dynamics (step parents, multiple maternal boyfriends, etc.) as well as prenatal exposure to substance use (Leve et al., 2012). These are significant contributory factors for risk of deficits in decision-making and stability in the home that result in conditions that lead to abuse (Leve et al., 2012). Green, McLaughlin and Berglund (2010) maintained that childhood adversities, especially sexual abuse, were often the result of parental mental illness and substance abuse, resulting in the creation of unsafe home environments. Parents who utilized substances, reported

15 CSA AND CHEMICAL DEPENDENCY 15 sexual or physical abuse, or who lived in homes where interpersonal violence occurred often do not provide adequate protection for their children, or may even be the perpetrators of sexual abuse (Green et al., 2010). The presence of family history of CSA is a predictor of the creation of unsafe home environments in subsequent generations. Instability in familiar relationships creates conditions that can lead to child sexual trauma. Leve and colleagues maintained, for example, that single-parent families, especially families that are headed by mothers, can create situations in which different adults enter the home in pseudo-parental roles. Sexual predators commonly look for single mothers with children and make decisions about engaging in relationships in order to support their sexual proclivities with young children. Correspondingly, it is not uncommon for women to make choices regarding dating behaviors in a manner that does not adequately take into consideration potential risks for their children (Burnette et al., 2008). Children are subsequently victimized in family settings by individuals who were brought into the family by gaining trust with other family members and creating expectations of an acceptable level of interpersonal contact with the child (Leve et al., 2012). Leve and colleagues (2012) maintained that mental health issues were also prevalent in children who have experienced abuse, likely the result of emotional and behavioral factors influencing development (Leve et al., 2012). Frequently, the child developed a relationship with the perpetrator of sexual abuse; a relationship that involved trust which could exacerbate the sense of trauma when sexual abuse occurred. In a National Survey of Child and Adolescent Well-Being, researchers found that in a study of 6,200 children in the welfare system, almost half had demonstrated signs of emotional and behavioral challenges, many of whom also demonstrated the early presence of psychiatric disorders (Leve et al., 2012). These disorders

16 CSA AND CHEMICAL DEPENDENCY 16 included depression, conduct disorder, attention deficit/hyperactivity disorder, anxiety disorders, and PTSD (Leve et al., 2012). Children who have experienced abuse, especially populations of ethnic minorities, are more likely to demonstrate long-term risk-taking behaviors, including participation in transactional sex as adolescents and young adults (Ahrens, Katon, McCarthy, Richardson, & Courtney, 2012). Transactional sex is when individuals trade sex for drugs or money, and this type of behavior also places individuals at risk of victimization, sexually transmitted diseases, physical injury, and poor mental health outcomes (Burnette et al., 2008). Children and young adults who participate in transactional sex have often experienced CSA (molestation or rape), substance use issues, and poor levels of social functioning and academic achievement. These factors can lead to long-term impacts of abuse, including PTSD, substance use disorders, poor health outcomes, risk-taking behaviors, and long-term psychological and social challenges. Researchers have also indicated that CSA can result in a range of problems that can impact functioning and can lead to other psychological and psychosocial issues. Survivors of CSA often experience sexual difficulties that can emerge in childhood and shape childhood behaviors. For example, children who have been sexually traumatized may demonstrate dissociative patterns of interactions, may be hyper-sexualized, and may demonstrate a range of sexual symptoms in adolescence or early adulthood (Hall & Hall, 2011). For example, girls who have been sexually traumatized in childhood may demonstrate an overt interest in sex when they are very young, and then go on to avoid or fear sexual contact as they get older (Hall & Hall, 2011). Others may be emotionally distant, participate in inappropriate sexual behaviors, or have trouble establishing sexual boundaries (Hall & Hall, 2011). Male victims of CSA may experience erectile dysfunction, premature ejaculation, and low sexual desire, and they found

17 CSA AND CHEMICAL DEPENDENCY 17 that women were more likely to have arousal disorders (Hall & Hall, 2011, p. 3). In many cases, the impacts of CSA are less overt and tend to impact how individuals function in relationships and how they demonstrate responses to stress or triggers. One of the most significant areas of study in relation to sexual abuse is the prevalence of substance use disorders and the connection between substance abuse and physical abuse. Researchers consider both the presence of substance abuse as a contributory factor in the initiation of sexual abuse and the significance of substance abuse by victims as a coping mechanism for sexual abuse related trauma. Each of these elements can be considered in relation to the larger issue of sexual abuse and its impacts. Substance Use The Diagnostic and Statistical Manual of Mental Disorders, (5 th ed.; DSM-V) of the American Psychiatric Association (2013) did away with the diagnostic category of substance abuse, and instead focused on defining substance use disorders. Substance use disorders refer to a pattern of use of any number of intoxicating substances that can lead to clinically significant impairment, in which the individual demonstrates at least two of the following in a 12 month period: The substance is often taken in larger amounts or over a longer period than was intended. There is a persistent desire or unsuccessful effort to cut down or control use of the substance. A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects. Craving, or a strong desire or urge to use the substance.

18 CSA AND CHEMICAL DEPENDENCY 18 Recurrent use of the substance resulting in a failure to fulfill major role obligations at work, school, or home. Continued use of the substance despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of its use. Important social, occupational, or recreational activities are given up or reduced because of use of the substance. Recurrent use of the substance in situations in which it is physically hazardous. Use of the substance is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance. Tolerance in the presence of the substance and/or withdrawal in its absence (American Psychiatric Association, 2013). The presence of substance use disorders in parents has been identified as a risk factor for CSA in their children, and children who were sexually abused have an increased risk of developing substance use disorders later in life (Afifi, Henriksen, Asmundson, & Sareen, 2012). A variety of studies have linked CSA history with substance abuse in varied populations (Afifi, et al., 2012; Brems, Johnson, Neal, & Freemon, 2004; Miron, Orcutt, Hannan, & Thonpson, 2014). Even pivotal studies conducted of expansive populations more than a decade and a half ago reflect the connection between child sexual abuse and substance abuse problems in adulthood (Downs & Harrison, 1998). Researchers have maintained that children, who are exposed to physical abuse and trauma, including CSA, demonstrate psychological and social problems starting in adolescence, many of which follow them into adulthood (Downs & Harrison, 1998).

19 CSA AND CHEMICAL DEPENDENCY 19 In a study of retrospective and prospective studies published in 1998, Downs and Harrison compiled an exhaustive report that showed that even discrepancies that emerged between studies up to that time did not negate the significant correlation between CSA and common mental disorders (depression, anxiety, and suicidal ideation). This included adult risk of substance use disorders and abuse of drugs and alcohol. These researchers demonstrated positive associations between the mental health disorders extending from CSA and increased risk of substance use disorders, maintaining that the risk of substance use disorders arose from the specific conditions of child abuse, neglect, or CSA and the impacts of adverse family conditions (Downs & Harrison, 1998). Maniglio (2011) considered the role that CSA plays in the etiology of substance use disorders, and explored how common or prevalent CSA is in relation to the onset of these disorders. The author conducted a systematic review of articles on CSA and risk for the development of substance use disorders in adolescence and adulthood. After conducting an exhaustive search of databases and locating more than 200 studies, the researcher reviewed the studies and found that there was a statistically significant connection between CSA and substance use disorders. Subsequently, Maniglio maintained the importance of including CSA as a risk factor for the onset of substance use disorders, especially in childhood and adolescence. The author also reflected on the fact that CSA can be considered a mitigating factor for longterm substance use disorders (Maniglio, 2011). What should be noted in relation to the findings of the study by Downs and Harrison (1998) as well as in the reviews conducted by Maniglio (2011) is that substance use issues for victims of CSA often extend from parental modeling of substance use as a coping mechanism for personal stress. In response to issues like depression or anxiety, parental modeling of substance

20 CSA AND CHEMICAL DEPENDENCY 20 use and the presence of substance use as a coping mechanism can play a two-fold role in terms of CSA: It can create the environment in which unsafe behaviors occur and it can also create a modeled behavior for coping with the trauma of sexual assault (Downs & Harrison, 1998). Disordered substance use, as previously defined by the American Psychiatric Association, has contributed to the conditions in which children are sexually abused, and can also become a predictor of adult behavior later in life (Maniglio, 2011). This is an underlying reason that there is a link between the cyclical nature of CSA in families and the conditions, including substance abuse, that are also passed along in families. Current studies support the connection between child maltreatment and substance use disorders. Afifi and colleagues (2012) maintained the importance of recognizing CSA as one of a number of forms of child maltreatment, sometimes existing concurrently, that can lead to poor psychosocial and psychological development, risk-taking behaviors, and substance use disorders. These researchers assessed the connection between five different types of childhood issues, including physical abuse, sexual abuse, neglect and emotional abuse or neglect, and the use and abuse of a variety of substances, both legal and illegal (Afifi et al., 2012). Their research showed the connection between different types of abuse in childhood and specific types of substance use disorders, and further exemplified the prevalent connection between CSA and the use and abuse of alcohol and heroin. They also maintained that gender differences emerged in their study in relation to the type of substance use disorders and the correlation of mental health issues that emerged for people who were sexually abused as children (Afifi et al., 2012). This underscores the need to consider CSA as an issue that may have different impacts for men and women through the lifespan, creating the need to consider gender as a variable when assessing the impacts of CSA (Afifi et al., 2012).

21 CSA AND CHEMICAL DEPENDENCY 21 Maikovich-Fong and Jaffee (2010) maintained that how children respond to CSA and how it impacts their lives as adults differ based on a variety of factors, including gender and family status. Despite information about the nature of sexual abuse occurring for both male and female victims, there continues to be less research about the impact of sexual abuse on boys who are victimized. In many cases, researchers have suggested that this occurs because male adults who have been sexually abused often do not report their abuse (Maikovich-Fong & Jaffee, 2010). These researchers maintain that a disproportionate number of studies about the impacts of CSA and long-term implications are based on female-only abuse populations. Victimization occurs in males and there is clearly a gap in the research about the lasting implications of CSA for this population. Maikovich-Fong and Jaffee (2010) also maintained that one of the challenges in creating a representative study of the impact of CSA is that male populations are traditionally even more underreported than females, and males who do report are often included in studies about alternative sexual orientation or individuals with altered psychosexual functioning (Maikovich- Fong & Jaffee, 2010). There are specific reasons that underreporting is common in male populations, including the fact that if abusers are male, boys may not want to report for fears they will be considered gay. In addition, Maikovich-Fong and Jaffee (2010) reported cultural associations with early sexual experience which can confuse boys about the nature of abuse if the abuser is a woman. Finally, boys are more frequently threatened with violence against themselves or others if they disclose the abuse, and may carry this threat with them longer than female victims (Maikovich-Fong & Jaffee, 2010). Some researchers have indicated that one of the major challenges in regards to the reporting of CSA is that many victims do not report their abuse as children, and instead identify

22 CSA AND CHEMICAL DEPENDENCY 22 as having been victimized in adulthood (Maikovich-Fong & Jaffee, 2010). Because of questions about therapeutic interactions that have resulted in adult disclosure of CSA and claims of inaccuracies in these reports, some questions have arisen about CSA victimization and the potential impacts of adult disclosure. In an American Counseling Association report, Hall and Hall (2011) maintained the importance of creating a clear cut approach to supporting victims of CSA that does not include implanting memories or guiding those reporting towards specific conclusions. Researchers have also recognized that the impacts of sexual abuse in childhood can begin early and this is especially true in adolescent girls demonstrating early risk-taking behaviors (Sartor et al., 2013). One of the struggles experienced by researchers in regards to identifying the specific impacts of CSA is that studies have shown that parental and familial substance use disorders are also predictors of early substance use in adolescence, and so controls had to be applied for addressing the contribution of family substance use disorders which may also exist for children who were sexually abused (Sartor et al., 2013). After controlling for family substance use issues, Sartor and colleagues (2013) maintained that sexual abuse in childhood was considered a risk factor for the onset of early alcohol use, as well as the use of cigarettes and cannabis by young adolescent girls. The regression analysis produced by these researchers and the application of the information to predict onset of substance use in adolescent girls determined that CSA was a major predictor associated with early onset of use (use of substances prior to the age of 19 years for cigarettes and prior to 21 for alcohol and cannabis). History of CSA was determined to be a factor that contributed to the risk of early use of cannabis and cigarettes and early first consumption of alcoholic beverages (Sartor et al., 2013). The study by Sartor and

23 CSA AND CHEMICAL DEPENDENCY 23 colleagues (2013) underscored the importance of recognizing CSA as a contributory factor for substance use disorders because of its influence on early onset of substance use. Self-medication is a premise that commonly comes into play when addressing substance use disorders in response to specific psychological trauma (Sartor et al., 2013). The use of substances as a means of reducing responsivity and creating a buffer between self and emotions is a common process (Hall & Hall, 2011). Depending on the type of substance, specific desired effects can be achieved that correspond with the concept of self-medication with substances ranging from alcohol to nicotine (Sartor et al., 2013). The research by Sartor and colleagues (2013) underscored the fact that substance use issues that occur as a result of CSA can include a variety of different components, including substances that are perceived as a means of controlling anxiety (e.g. nicotine), addressing depression (caffeine), creating avoidance (heroin or cannabis), or creating a dulling affect (cannabis or alcohol). The assumption that each of these substances will have the same level of impact on the individual using or abusing substances in response to sexual assault is misleading; variations in use, substance type, and the impacts of substance abuse can reference variables like age at the time of victimization, age at the time of disclosure, and the environment in which the individual lives or experienced victimization (and the type of coping substances utilized; Sartor et al., 2013). In addition, self-medication using substances like alcohol and narcotics extend from the beliefs that the substance can reduce memories of the victimization. Frequently, as is true of individuals with anxiety disorders, the use of substances to mitigate for reactivity can create more problems than it resolves. Duncan and colleagues (2008) recognized that drug use in adolescence can result from the desire to control for the symptoms related to childhood abuse, both physical and sexual. After controlling for familial risk factors for drug use, including

24 CSA AND CHEMICAL DEPENDENCY 24 parental substance use, Duncan and colleagues explored the connection between CSA, childhood physical abuse (CPA) and the abuse and dependence on cannabis in adolescent and young adult female populations. These researchers found that children who experienced sexual abuse were more likely to develop addiction or dependence to cannabis early in life even after controlling for parental involvement, including parental alcohol or cannabis dependence in the home (Duncan et al., 2008). The conclusions derived from this study are that while genetic and familial environmental risk plays a role in the development of drug dependency, sexual and physical trauma in childhood is a more significant single indicator of the onset of substance use disorders than parental participation in substance use alone. Similarly, Sarin and Nolen-Hoeksema (2010) maintained that there is a connection between maladaptive behaviors related to substance use and the impacts of CSA. These researches not only considered the impacts of sexual abuse in childhood on substance use, but also on the development of other consumptive disorders, including the use of food, alcohol, caffeine, nicotine, and a variety of different drugs (Sarin & Nolen-Hoeksema, 2010). Though studies have identified a variety of different types of substance use disorders that extend from the presence of CSA, Sarin and Nolen-Hoeksema (2010) maintained that the coping mechanisms related to a range of substance use disorders are essentially similar. They described this as consumptive coping, (p. 72) or the use of substances as a means of addressing distress and emotional responsivity related to sexual trauma memories from childhood. CSA, then, is a significant precursor or risk factor for consumptive coping. One method used for assessing the impacts of CSA on substance use disorders is by applying a retrospective approach to evaluating CSA prevalence in populations receiving treatment in rehabilitation facilities, including those providing detoxification services (Brems et

25 CSA AND CHEMICAL DEPENDENCY 25 al., 2004). In an early study of the connection between CSA and substance abuse, Brems and colleagues (2004) applied this retrospective strategy to an evaluation of individuals receiving detoxification services to determine if patterns of CSA existed. This study provided interesting and important structure for subsequent studies because it demonstrated methods for assessing CSA in substance abusing populations to determine the level of prevalence for patients who have already demonstrated substance abuse disorders. Brems and colleagues found that sexual abuse in childhood was prevalent in populations who abused substances (both male and female). Women reported a much higher level of sexual or physical abuse in childhood than men, but the prevalence rates were startling for both men and women. About 20% of men and 50% of women receiving treatment for substance use disorders (detoxification services) noted being either physically or sexually abused during childhood, and patients reporting sexual abuse experienced an earlier age of onset of drinking, earlier psychopathology, and early criminality than other populations (Brems et al., 2004). Childhood victimization was identified as one of the primary mitigating factors in the onset of substance use disorders requiring hospitalization and detoxification services in adulthood (Brems et al., 2004). This research indicated the importance of early services for children who have been victimized as a means of addressing the long-term problems associated with childhood trauma and sexual victimization. Perez-Fuentes and colleagues (2013) maintained that interventions could be especially challenging because many children who were sexually victimized came from dysfunctional families not conducive to early interventions. The researchers maintained, for example, that parental involvement in the abuse was a significant deterrent to the application of effective strategies to intervene for young victims (Perez-Fuentes

26 CSA AND CHEMICAL DEPENDENCY 26 et al., 2013). This was an underlying reason why CSA, even when reported, can lead to clinical manifestations of mood and substance use disorders (Perez-Fuentes et al., 2013). Lack of intervention in childhood can lead to the development of anxiety disorders, including PTSD, and psychotic symptoms that reflect memories of the sexual abuse (Perez- Fuentes et al., 2013). Conflicted reports on CSA details and lack of distinct methods to determine correlations to psychiatric disorders have led to a lack of a full understanding of how compelling studies of CSA and PTSD could be (Perez-Fuentes et al., 2013). These researchers assessed the history of CSA as a predictor for significant health problems, and found that lifetime psychiatric disorders like PTSD and mood disorders, as well as substance use disorders, were strongly associated (Perez-Fuentes et al., 2013). Miron et al. (2014) supported the argument that a history of CSA increases the risk for mental health, social, and substance use difficulties throughout adult life. CSA is not only linked to problematic behaviors in adulthood, but to increased risk of sexual assault in adolescence, especially in female populations. In a study of female college students, Miron and colleagues (2014) sought to assess the impacts of CSA on sexual risk taking, alcohol and drug use, and risk of sexual abuse. The researchers also sought to understand the role of psychosocial functioning in understanding why college-aged females who were abused as children use alcohol as a moderating factor during social and sexual interactions. Miron and colleagues (2014) recognized that female adults who were sexually abused as children tended to experience a high level of self-blame following trauma exposure and addressing this issue as one method of mitigating for CSA in early adulthood. An interesting component of the study by Miron and colleagues was that it reflected the connection between behaviors and emotional manifestations of post-abuse psychopathology. Subsequently, this study underscored the need for interventions that can

27 CSA AND CHEMICAL DEPENDENCY 27 address the psychological and social responses of adult victims of CSA to mitigate for selfinjurious behaviors (e.g. substance abuse, sexual risk-taking) that can result in new traumatic experiences. Taplin, Saddichha, Li and Krausz (2014) reflected on the impacts of childhood trauma on the onset of substance abuse, recognizing that some overlapping conditions can contribute to the connection between childhood abuse (including CSA) and substance use disorders. These researchers recognized that children who are sexually abused can come from families in which substance use disorders are prevalent, creating some question as to the connection between substance use as a modeled behavior and substance use disorders resulting from the impacts of childhood physical or sexual abuse (Taplin, et al., 2014). The researchers utilized a cohort study approach to evaluate the perspectives of populations that reported childhood abuse, including physical and/or sexual abuse. Evaluations of childhood trauma and addiction were conducted in order to understand potential factors related to addiction, substance use, and childhood abuse experiences (Taplin et al., 2014). In an assessment of 87 subjects who were being treated for opiate addiction, the researchers evaluated their statements regarding childhood abuse, with specific trends emerging. Taplin and colleagues (2014) found that subjects who had mothers who used alcohol or drugs were more likely to experience CSA and concurrent emotional abuse and physical neglect, than those who did not report maternal drug and alcohol use (Rodi et al., 2015). In contrast to this, families in which fathers were substance users, and mothers were not were more likely to experience physical abuse (rather than sexual abuse) as compared to families with maternal users. Taplin and colleagues (2014) concluded that maternal protective capabilities appear to be diminished in the presence of substance use disorders, creating an avenue for the presence of sexual abuse. This study suggests specific factors that can influence