Childhood Maltreatment and Substance Use Disorders Among Men and Women in a Nationally Representative Sample

Transcription

1 CanJPsychiatry 2012;57(11): Original Research Childhood Maltreatment and Substance Use Disorders Among Men and Women in a Nationally Representative Sample Tracie O Afifi, PhD 1 ; Christine A Henriksen, MA (PhD Candidate) 2 ; Gordon J G Asmundson, PhD 3 ; Jitender Sareen, MD 4 1 Assistant Professor, Departments of Community Health Sciences, Psychiatry, and Family Social Sciences, University of Manitoba, Winnipeg, Manitoba. Correspondence: S113 Medical Services Building, 750 Bannatyne Avenue, Winnipeg, MB R3E 0W3; T_Afifi@umanitoba.ca. 2 Student, Department of Psychology, University of Manitoba, Winnipeg, Manitoba. 3 Professor, Departments of Psychology and Anxiety and Illness Behaviours Laboratory, University of Regina, Regina, Saskatchewan. 4 Professor, Departments of Psychiatry, Community Health Sciences, and Psychology, University of Manitoba, Winnipeg, Manitoba. Key Words: child abuse, neglect, alcohol, drugs, nicotine, cannabis, cocaine, heroin, sedatives, opioids Received December 2011, revised, and accepted May Objective: To examine the association between a history of 5 types of childhood maltreatment (that is, physical abuse, sexual abuse, emotional abuse, physical neglect, and emotional neglect) and several substance use disorders (SUDs), including alcohol, sedatives, tranquilizers, opioids, amphetamines, cannabis, cocaine, hallucinogens, heroin, and nicotine, in a nationally representative US adult sex-stratified sample. Method: Data were drawn from the National Epidemiologic Survey of Alcohol and Related Conditions (NESARC), a nationally representative US sample of adults aged 20 years and older (n = ). Logistic regression models were conducted to understand the relations between 5 types of childhood maltreatment and SUDs separately among men and women after adjusting for sociodemographic variables and Diagnostic and Statistical Manual of Mental Disorders (DSM) Axis I and II mental disorders. Results: All 5 types of childhood maltreatment were associated with increased odds of all individual SUDs among men and women after adjusting for sociodemographic variables, with the exception of physical neglect and heroin abuse or dependence, emotional neglect, and amphetamines and cocaine abuse or dependence among men (adjusted odds ratio range 1.3 to 4.7). After further adjustment for other DSM Axis I and II mental disorders, the relations between childhood maltreatment and SUDs were attenuated, but many remained statistically significant. Differences in the patterns of findings were noted for men and women for sexual abuse and emotional neglect. Conclusions: This research provides evidence of the robust nature of the relations between many types of childhood maltreatment and many individual SUDs. The prevention of childhood maltreatment may help to reduce SUDs in the general population. W W W Objectif : Examiner l association entre des antécédents de 5 types de maltraitance dans l enfance (c est-à-dire, violence physique, abus sexuel, abus émotionnel, négligence physique, et négligence émotionnelle) et plusieurs troubles liés à l utilisation d une substance (TUS), notamment l alcool, les sédatifs, les tranquillisants, les opioïdes, les amphétamines, le cannabis, la cocaïne, les hallucinogènes, l héroïne, et la nicotine, dans un échantillon nationalement représentatif d adultes américains stratifié selon le sexe. Méthode : Les données ont été tirées de l enquête nationale épidémiologique sur l alcoolisme et les troubles associés (NESARC), un échantillon américain nationalement représentatif d adultes de 20 ans et plus (n = ). Des modèles de régression logistique ont été effectués pour comprendre les relations entre 5 types de maltraitance dans l enfance et les TUS séparément chez les hommes et les femmes, après ajustement pour les variables sociodémographiques et les troubles mentaux des axes I et II du Manuel diagnostique et statistique des troubles mentaux (DSM). Résultats : Les 5 types de maltraitance dans l enfance étaient tous associés à des probabilités accrues de tous les TUS individuels chez les hommes et les femmes, après ajustement pour les variables sociodémographiques, excepté la négligence physique et l abus ou la dépendance à l héroïne, la négligence émotionnelle, et l abus ou la dépendance aux amphétamines et à la cocaïne chez les hommes (rapport de cotes ajusté The Canadian Journal of Psychiatry, Vol 57, No 11, November 2012 W 677

2 Original Research de 1,3 à 4,7). Après des ajustements additionnels pour d autres troubles mentaux des axes I et II du DSM, les relations entre la maltraitance dans l enfance et les TUS s atténuaient, mais beaucoup demeuraient statistiquement significatives. Les différences de modèles des résultats ont été notées pour les hommes et les femmes en ce qui concerne l abus sexuel et la négligence émotionnelle. Conclusions : Cette recherche offre des données probantes de la nature robuste des relations entre de nombreux types de maltraitance dans l enfance et bien des TUS individuels. La prévention de la maltraitance dans l enfance peut contribuer à réduire les TUS dans la population générale. Child maltreatment is a serious global public health problem. It is estimated that millions of children are maltreated every year. 1 Nationally representative data have indicated that childhood maltreatment is prevalent in the general US population, with 18% of adults reporting a history of physical abuse, 11% reporting sexual abuse, 8% reporting emotional abuse, 24% reporting physical neglect, and 9.4% reporting emotional neglect. 2 To date, numerous studies 3 14 have found a significant link between childhood maltreatment and an increased likelihood of SUDs. More specifically, data from various samples have indicated that many forms of childhood maltreatment are associated with an increased likelihood of early age of onset for using alcohol or drugs. 10,15 21 In addition to earlier age of onset for substance use, many types of childhood maltreatment have been linked to binge drinking and regular alcohol use in adolescent samples. 15,16,22 With an increased likelihood of earlier and excessive use of alcohol and drugs, it may not be surprising that childhood maltreatment is also related to SUDs in adolescence and adulthood. For example, in a population-based sample from New Zealand, childhood sexual abuse was associated with substance dependence in young adulthood after adjusting for several social, family, and individual factors. 23 In a national longitudinal US sample of adolescents, childhood physical abuse, but not sexual abuse, was associated with past-year alcohol abuse, marijuana abuse, and other drug abuse in young adulthood. 24 In addition to alcohol and drug use, some studies have examined the relation between childhood maltreatment and nicotine use. Research examining adolescent and adult samples has indicated that childhood maltreatment is associated with an early age of onset of smoking, 25,26 an increased likelihood of smoking in adulthood, 18,25,27,28 and adulthood nicotine dependence or withdrawal. 18,29 Childhood maltreatment in a low-income sample also predicted later daily cigarette smoking in adulthood, and the relation was equally strong for men and women. 30 Clinical Implications Child maltreatment is associated with SUDs independent of sociodemographic variables and Axis I and II mental disorders. A different pattern of findings were noted for men and women for sexual abuse and emotional neglect. Clinical interventions for people with a childhood maltreatment history that are effective in reducing SUDs are needed. Limitations The cross-sectional nature of the data does not allow for inferences regarding causation. Data on childhood maltreatment were collected retrospectively, which may introduce some sampling error owing to recall and reporting bias. Some studies have found significant relations between childhood maltreatment and substance use in women samples. 31,32 When stratifying according to sex, some studies do not find sex differences, 30 while others do note differences. 14 For example, in a cocaine treatment-seeking sample, greater severity of childhood emotional abuse increased the likelihood of cocaine relapse for women, but not for men. 33 In another US study, 34 childhood maltreatment among women, but not men, was associated with alcohol abuse or dependence in early adulthood, which was linked to excessive drinking in later adulthood. In a Midwestern US study, an increased likelihood of drug use problems was noted among women and not men. 14 Importantly, other research has found a significant relation between childhood maltreatment and substance use among males, yet the magnitude of the relation has been found to be stronger among females. 12 Past studies 35 indicate that the relation between childhood maltreatment and substance use may be especially strong for females; however, more detailed examinations of these relations are necessary to uncover the specific links between particular types of childhood maltreatment and individual substances and how these relations may vary according to sex. Abbreviations AUDADIS-IV Alcohol Use Disorder and Associated Disabilities Interview Schedule DSM, Fourth Edition DSM Diagnostic and Statistical Manual of Mental Disorders NESARC National Epidemiologic Survey of Alcohol and Related Conditions SUD substance use disorder Childhood maltreatment and SUDs have also both been found to be highly associated with mood, anxiety, and personality disorders 2 5,11,12,36 41 ; however, few studies have included Axis I and II disorders as control subjects when examining the independent relation between childhood maltreatment and SUDs. A study using a sample of psychiatric inpatients found that childhood abuse (that is, physical or sexual abuse) was associated with a 2- to 3-times increased likelihood of opiate use after adjusting for sociodemographic variables and 678 W La Revue canadienne de psychiatrie, vol 57, no 11, novembre

3 Childhood Maltreatment and Substance Use Disorders Among Men and Women in a Nationally Representative Sample some mental disorders, including schizophrenia, depression, mania, and borderline personality disorder. 42 Data from a representative US sample indicated that depression mediated the relation between physical abuse and current alcohol and drug abuse. 24 One study 43 found that mood and anxiety disorders partially mediated the relations between childhood adversity (measured as severe physical abuse, sexual abuse, and witnessing violent crime during childhood) and substance dependence (including alcohol, cocaine, and [or] opioid dependence). Collectively, these findings are important because they indicate that comorbid mental disorders may help to partially explain the relation between childhood maltreatment and SUDs. Detailed examinations of specific types of childhood maltreatment and individual substances are necessary to inform intervention and prevention strategies. Although large literature exists on the relation between childhood maltreatment and SUDs, what is still not well understood is whether the relation between childhood maltreatment and SUDs varies according to sex, type of childhood maltreatment, and specific substance used. These gaps in our knowledge remain as many studies examining the relation between childhood maltreatment and substance use are limited owing to reliance on unrepresentative clinical, community, or at-risk samples; an inability to examine effects separately for males and females owing to limited statistical power; a narrow investigation of only 1 form of childhood maltreatment or a combination of several types of childhood maltreatment into 1 category; the inclusion of only broad categories of alcohol or drugs without investigating several individual substances; and failure to account for diagnoses of mood, anxiety, and personality disorders. Our investigation aimed to examine the association between a history of 5 types of childhood maltreatment (that is, physical abuse, sexual abuse, emotional abuse, physical neglect, and emotional neglect) and lifetime SUDs (including alcohol, sedatives, tranquilizers, opioids, amphetamines, cannabis, cocaine, hallucinogens, heroin, and nicotine after adjusting for sociodemographic variables and lifetime mood, anxiety, and personality disorders) in a US nationally representative adult sex-stratified sample. Method Survey We used Wave 2 of the NESARC. The NESARC is based on a nationally representative US sample of civilian, noninstitutionalized adults aged 20 years and older. 44,45 Wave 1 was completed by respondents in 2001 and Among the eligible respondents, respondents participated in Wave 2, resulting in a good response rate of 86.7%. 44 Wave 2 data were collected from 2004 to 2005 through face-to-face computer-assisted interviews conducted by trained lay interviewers. Detailed information regarding Waves 1 and 2 of the NESARC can be found elsewhere. 45,46 Measures Childhood Maltreatment Questions assessing 5 types of childhood maltreatment occurring before the age of 18 years were from an abbreviated adapted version of items from the Conflict Tactics Scale 47,48 and the Childhood Trauma Questionnaire. 49 Wording of the items are provided below. We used similar definitions from previous studies. 6,50 People were classified as having experienced emotional abuse if they responded fairly often or very often to any question assessing how often a parent or other adult living in the home swore at, insulted, or said hurtful things to the respondent; threatened to hit or throw something at the respondent; or acted in any other way that made the respondent afraid he or she would be physically hurt or injured. Respondents were classified as having experienced childhood physical abuse if they responded sometimes, fairly often, or very often to either of the following questions: How often did a parent or other adult living in your home push, grab, shove, slap, or hit you? and How often did a parent or other adult living in your home hit you so hard that you had marks or bruises or were injured? Sexual abuse was assessed with 4 questions examining how often an adult or other person sexually touched or fondled the respondent; had the respondent sexually touch the adult or other person; attempted to have sexual intercourse; or had sexual intercourse with the respondent when the respondent did not want the act or was too young to understand what was happening. 51 People who answered with any response other than never to any of the aforementioned questions were classified as having experienced childhood sexual abuse. Physical neglect was also assessed with a series of 4 questions. These questions examined how often the respondent was left alone or unsupervised before the age of 10 years; went hungry; went without needed clothes, shoes, or school supplies; and went without needed medical treatment. Any respondent who answered anything other than never to any of the aforementioned questions were classified as having a history of childhood physical neglect. Five questions were used to assess childhood emotional neglect. These questions asked respondents whether someone in their family believed in them, wanted them to be a success, helped them feel important or special, provided support, and if the respondent had a close-knit family. The 5-point Likert scale for responses included never true, rarely true, sometimes true, often true, and very often true. These items were reverse-scored and summed, with higher scores indicating greater levels of emotional neglect. We based our assessment of emotional neglect on the definition used in the Adverse Childhood Experiences Study, where respondents scoring 15 or higher on these 5 items were classified as having experienced moderateto-extreme levels of emotional neglect according to the Childhood Trauma Questionnaire clinical scale. 6,50 The Canadian Journal of Psychiatry, Vol 57, No 11, November 2012 W 679

4 Original Research Table 1 Association between childhood physical abuse and SUD No abuse Abuse Abuse Lifetime SUDs Sex n (%) a n (%) a AOR1 (99% CI) b AOR2 (99% CI) c Alcohol Male 5317 (45.6) 1582 (57.4) 1.7 ( ) d 1.4 ( ) d Female 3214 (20.3) 1132 (33.7) 2.0 ( ) d 1.6 ( ) d Sedative Male 154 (1.4) 92 (3.9) 3.0 ( ) d 2.0 ( ) d Female 101 (0.6) 69 (2.0) 3.2 ( ) d 1.7 ( ) e Tranquilizer Male 142 (1.3) 90 (3.8) 3.0 ( ) d 2.0 ( ) d Female 96 (0.6) 68 (2.2) 3.5 ( ) d 1.9 ( ) f Opioid Male 216 (2.1) 133 (5.7) 2.9 ( ) d 2.0 ( ) d Female 165 (1.0) 105 (3.1) 3.0 ( ) d 1.7 ( ) f Amphetamine Male 256 (2.2) 129 (5.2) 2.5 ( ) d 1.7 ( ) d Female 189 (1.2) 119 (3.7) 3.0 ( ) d 1.9 ( ) d Cannabis Male 1332 (11.8) 583 (21.5) 2.3 ( ) d 1.8 ( ) d Female 809 (5.2) 362 (10.7) 2.2 ( ) d 1.5 ( ) d Cocaine Male 405 (3.6) 216 (7.8) 2.4 ( ) d 1.7 ( ) d Female 279 (1.7) 157 (4.1) 2.3 ( ) d 1.5 ( ) f Hallucinogen Male 243 (2.2) 128 (4.9) 2.5 ( ) d 1.7 ( ) d Female 115 (0.8) 68 (2.7) 3.7 ( ) d 2.2 ( ) d Heroin Male 28 (0.3) 24 (0.7) 2.6 ( ) f 1.6 ( ) Female 16 (0.1) 24 (0.5) 4.3 ( ) d 2.6 ( ) f Nicotine Male 2731 (24.5) 921 (34.7) 1.7 ( ) d 1.4 ( ) d Female 2818 (18.1) 1049 (31.2) 2.0 ( ) d 1.5 ( ) d a Unweighted n, weighted percentage b Adjusted for age, ethnicity, marital status, income, education c Adjusted for age, ethnicity, marital status, income, education, any lifetime mood or anxiety disorder, and any lifetime personality disorder d P 0.001; e P 0.05; f P 0.01 Substance Use Disorders The NESARC used the AUDADIS-IV to assess lifetime SUDs according to DSM-IV criteria. 46,52 The AUDADIS-IV is a standardized, fully-structured diagnostic interview to diagnose the abuse of, or dependence on, alcohol, sedatives, tranquilizers, opioids, amphetamines, cannabis, cocaine, hallucinogens, and heroin, as well as the dependence on nicotine. The psychiatric modules of the AUDADIS-IV were shown to have fair-to-good test retest and interrater reliability. 53,54 Mental Disorders The AUDADIS-IV was used to assess the lifetime presence of mood (major depression, dysthymia, mania, and hypomania), anxiety (panic disorder, specific phobia, social phobia, agoraphobia, generalized anxiety disorder, and posttraumatic stress disorder), and personality disorders (paranoid, schizoid, schizotypal, antisocial, borderline, histrionic, narcissistic, obsessive compulsive, dependent, and avoidant) according to DSM-IV criteria. 46,52 These diagnoses were used to create any lifetime mood disorder, anxiety disorder, and personality disorder variables. The AUDADIS-IV was found to have good to excellent convergent validity for mood and anxiety disorder diagnoses W La Revue canadienne de psychiatrie, vol 57, no 11, novembre 2012 Sociodemographic Variables The following variables were used as covariates in the logistic regression models: age, ethnicity, income, marital status, and education. Age was measured in years. Ethnicity was categorized as White, Asian, Hispanic, Black, and American Indian or Alaska Native. Household income was categorized as $0 to $19 999, $ to $34 999, $ to $59 999, and $ or more. Marital status was categorized as married; never married (single); and widowed, divorced, or separated. Education was categorized as less than high school, high school or equivalent, and some college or more. Statistical Methods Taylor series linearization method was conducted. 60 This variance estimation procedure accounts for the complex sampling design of the NESARC and ensures all analyses are representative of the US general population. First, the sample was sex stratified. Second, cross-tabulations were conducted to describe the sociodemographic variables with childhood maltreatment variables. Third, we used 2 adjusted logistic regression models to examine the relation between each type of childhood maltreatment and each SUD (model 1 adjusting for sociodemographic variables and

5 Childhood Maltreatment and Substance Use Disorders Among Men and Women in a Nationally Representative Sample Table 2 Association between childhood sexual abuse and SUDs No abuse Abuse Abuse Lifetime SUDs Sex n (%) a n (%) a AOR1 (99% CI) b AOR2 (99% CI) c Alcohol Male 6401 (47.2) 486 (57.6) 1.6 ( ) d 1.2 ( ) Female 3312 (20.3) 1021 (35.2) 2.0 ( ) d 1.4 ( ) d Sedative Male 204 (1.6) 43 (5.5) 3.4 ( ) d 1.8 ( ) e Female 97 (0.6) 71 (2.1) 3.1 ( ) d 1.6 ( ) e Tranquilizer Male 195 (1.6) 37 (5.3) 3.4 ( ) d 1.8 ( ) e Female 95 (0.6) 67 (2.3) 3.1 ( ) d 1.6 ( ) e Opioid Male 300 (2.5) 50 (7.3) 2.9 ( ) d 1.7 ( ) e Female 161 (0.9) 106 (3.9) 3.6 ( ) d 2.1 ( ) d Amphetamine Male 332 (2.6) 51 (6.1) 2.5 ( ) d 1.4 ( ) Female 173 (1.1) 131 (4.9) 4.1 ( ) d 2.6 ( ) d Cannabis Male 1705 (12.9) 205 (24.3) 2.3 ( ) d 1.5 ( ) f Female 777 (4.8) 391 (13.6) 2.8 ( ) d 2.0 ( ) d Cocaine Male 544 (4.1) 79 (9.5) 2.4 ( ) d 1.5 ( ) e Female 254 (1.4) 180 (5.7) 3.5 ( ) d 2.2 ( ) d Hallucinogen Male 321 (2.6) 51 (5.6) 2.4 ( ) d 1.3 ( ) Female 107 (0.8) 76 (3.2) 4.1 ( ) d 2.4 ( ) d Heroin Male 39 (0.3) 14 (1.2) 4.2 ( ) d 2.2 ( ) e Female 20 (0.1) 20 (0.4) 3.0 ( ) e 1.7 ( ) Nicotine Male 3356 (25.7) 288 (37.7) 1.8 ( ) d 1.3 ( ) e Female 2895 (18.0) 952 (33.2) 2.0 ( ) d 1.5 ( ) d a Unweighted n, weighted percentage b Adjusted for age, ethnicity, marital status, income, education c Adjusted for age, ethnicity, marital status, income, education, any lifetime mood or anxiety disorder, and any lifetime personality disorder d P 0.001; e P 0.05; f P 0.01 model 2 further adjusting for any lifetime mood, anxiety, and personality disorders). Ninety-nine per cent confidence intervals were reported for all models. Results Table 1 presents the findings for the relation between childhood physical abuse and SUDs. For both men and women, a history of childhood physical abuse was associated with increased odds of all SUDs, after adjusting for sociodemographic variables. These associations remained significant after the additional adjustment for mental disorders, with the exception of heroin abuse or dependence in men. Table 2 presents the findings for the association between childhood sexual abuse and SUDs. For men and women, childhood sexual abuse was associated with an increased likelihood of all lifetime SUDs after adjusting for sociodemographic variables. For women, childhood sexual abuse remained significantly associated with all SUDs, with the exception of heroin abuse or dependence, after further adjustment for Axis I and II mental disorders. For men, the associations between childhood sexual abuse and alcohol, amphetamine, and hallucinogen abuse or dependence were no longer significant in the fully adjusted models. Table 3 presents the results of the models examining the association between childhood emotional abuse and lifetime SUDs. Among men, childhood emotional abuse was associated with increased odds of all SUDs after adjusting for sociodemographic variables and Axis I and II mental disorders. A similar pattern of results emerged for women; after adjusting for sociodemographic variables, childhood emotional abuse increased the likelihood of all SUDs. Nearly all associations, with the exception of tranquilizer and heroin abuse or dependence, remained significant after further adjustment for mood, anxiety, and personality disorders. Table 4 presents the results of models examining the relation between childhood physical neglect and SUDs. Among men, physical neglect was associated with increased odds of having all SUDs with the exception of heroin abuse or dependence. These associations remained significant after adjusting for sociodemographic variables and mental disorders. For women, a history of childhood physical neglect was associated with an increased likelihood of all SUDs after adjusting for sociodemographic variables. In the case of heroin abuse or dependence, the addition of mental disorders attenuated this relation, while all other relations remained significant in fully adjusted models. The Canadian Journal of Psychiatry, Vol 57, No 11, November 2012 W 681

6 Original Research Table 3 Association between childhood emotional abuse and SUDs No abuse Abuse Abuse Lifetime SUDs Sex n (%) a n (%) a AOR1 (99% CI) b AOR2 (99% CI) c Alcohol Male 6197 (46.4) 693 (65.3) 2.1 ( ) d 1.6 ( ) d Female 3680 (21.2) 661 (36.8) 2.1 ( ) d 1.4 ( ) d Sedative Male 194 (1.6) 53 (5.4) 3.2 ( ) d 1.8 ( ) e Female 118 (0.6) 52 (2.6) 3.4 ( ) d 1.6 ( ) e Tranquilizer Male 177 (1.5) 55 (5.4) 3.2 ( ) d 1.8 ( ) f Female 114 (0.7) 51 (2.8) 3.3 ( ) d 1.6 ( ) Opioid Male 280 (2.4) 70 (7.2) 2.7 ( ) d 1.6 ( ) e Female 280 (2.4) 70 (7.2) 3.3 ( ) d 1.7 ( ) f Amphetamine Male 313 (2.4) 72 (7.2) 2.9 ( ) d 1.7 ( ) e Female 225 (1.4) 83 (4.8) 3.1 ( ) d 1.7 ( ) f Cannabis Male 1619 (12.5) 295 (27.2) 2.6 ( ) d 1.7 ( ) d Female 933 (5.5) 234 (13.1) 2.4 ( ) d 1.5 ( ) d Cocaine Male 508 (3.9) 114 (10.3) 2.6 ( ) d 1.7 ( ) d Female 325 (1.8) 111 (5.2) 2.5 ( ) d 1.4 ( ) e Hallucinogen Male 298 (2.4) 74 (7.0) 2.9 ( ) d 1.7 ( ) f Female 137 (0.9) 46 (3.4) 3.4 ( ) d 1.8 ( ) f Heroin Male 34 (0.3) 18 (1.3) 4.7 ( ) d 2.5 ( ) e Female 26 (0.1) 14 (0.5) 3.0 ( ) e 1.6 ( ) Nicotine Male 3183 (24.9) 468 (44.6) 2.2 ( ) d 1.6 ( ) d Female 3196 (18.6) 664 (38.2) 2.4 ( ) d 1.7 ( ) d a Unweighted n, weighted percentage b Adjusted for age, ethnicity, marital status, income, education c Adjusted for age, ethnicity, marital status, income, education, any lifetime mood or anxiety disorder, and any lifetime personality disorder d P 0.001; e P 0.05; f P 0.01 Table 5 presents the results of the analyses examining the association between childhood emotional neglect and SUDs. Among men, emotional neglect was associated with all SUDs after adjusting for sociodemographic variables, with the exception of amphetamine and cocaine abuse or dependence disorders. When further adjusting for mental disorders, only the relations between emotional neglect and cannabis abuse or dependence and nicotine dependence remained significant. Among women, emotional neglect was associated with all SUDs after adjusting for sociodemographic variables. When also adjusting for mental disorders, significant relations remained for alcohol, opioid, amphetamine, cannabis, and hallucinogen abuse or dependence disorders. Discussion Our findings are consistent with the extant literature showing a significant link between childhood maltreatment and SUDs. 3,5,6,12,13,61 Importantly, several novel findings of our study advance our knowledge on the link between childhood maltreatment and SUDs in a general population. More specifically, all 5 types of childhood maltreatment were associated with increased odds of all 10 individual SUDs among men and women 682 W La Revue canadienne de psychiatrie, vol 57, no 11, novembre 2012 after adjusting for sociodemographic variables, with the exception of physical neglect and heroin abuse or dependence and emotional neglect, and amphetamines and cocaine abuse or dependence among men. Also, after further adjustment for other Axis I and II mental disorders, the relations between childhood maltreatment and SUDs were attenuated, but most remained statistically significant. One exception was that many significant findings between emotional neglect and individual SUDs became nonsignificant after adjusting for mental disorders. Finally, differences in the patterns of findings were noted for men and women for sexual abuse and emotional neglect. The robust nature of the link between childhood maltreatment and SUDs is evident in the significant relations between all 5 types of childhood maltreatment and all 10 SUDs for men (with 3 exceptions) and women, after adjusting for sociodemographic variables. The stresscoping models of addiction indicate that in the context of high life stress and low healthy coping resources, substances may be used to improve affect. 62,63 Childhood maltreatment is an extremely stressful life event that is often chronic and enduring. Children who are abused and neglected live in a stressful family environment that often

7 Childhood Maltreatment and Substance Use Disorders Among Men and Women in a Nationally Representative Sample Table 4 Association between childhood physical neglect and SUDs No abuse Abuse Abuse Lifetime SUDs Sex n (%) a n (%) a AOR1 (99% CI) b AOR2 (99% CI) c Alcohol Male 4789 (45.5) 2089 (53.9) 1.5 ( ) d 1.3 ( ) d Female 3009 (20.4) 1332 (30.0) 1.8 ( ) d 1.4 ( ) d Sedative Male 141 (1.4) 106 (3.0) 2.1 ( ) d 1.5 ( ) e Female 85 (0.5) 85 (1.8) 3.1 ( ) d 1.8 ( ) f Tranquilizer Male 131 (1.4) 100 (2.9) 2.1 ( ) d 1.5 ( ) e Female 81 (0.5) 83 (2.0) 3.5 ( ) d 2.1 ( ) d Opioid Male 206 (2.2) 144 (4.6) 2.1 ( ) d 1.6 ( ) e Female 146 (0.9) 123 (2.9) 3.0 ( ) d 1.9 ( ) d Amphetamine Male 228 (2.1) 157 (4.4) 2.1 ( ) d 1.6 ( ) f Female 191 (1.3) 116 (2.9) 2.2 ( ) d 1.4 ( ) e Cannabis Male 1226 (11.9) 683 (18.1) 1.7 ( ) d 1.4 ( ) d Female 736 (5.0) 433 (10.0) 2.1 ( ) d 1.6 ( ) d Cocaine Male 385 (3.7) 237 (6.2) 1.7 ( ) d 1.3 ( ) e Female 266 (1.7) 169 (3.4) 2.0 ( ) d 1.3 ( ) e Hallucinogen Male 214 (2.1) 158 (4.6) 2.3 ( ) d 1.7 ( ) f Female 102 (0.8) 80 (2.2) 2.7 ( ) d 1.8 ( ) f Heroin Male 33 (0.3) 19 (0.4) 1.2 ( ) 0.8 ( ) Female 18 (0.1) 22 (0.3) 2.4 ( ) f 1.5 ( ) Nicotine Male 2519 (24.8) 1127 (30.6) 1.4 ( ) d 1.2 ( ) f Female 2667 (18.4) 1196 (26.9) 1.6 ( ) d 1.3 ( ) d a Unweighted n, weighted percentage b Adjusted for age, ethnicity, marital status, income, education c Adjusted for age, ethnicity, marital status, income, education, any lifetime mood or anxiety disorder, and any lifetime personality disorder d P 0.001; e P f P 0.01 is not conducive to learning, attaining, or accessing healthy coping mechanisms. Dube et al 21 have suggested that the relation between childhood adversity and alcohol use may exist because the stress from childhood adversities may have an impact on neurodevelopment and physiological changes, which may impede coping abilities and lead to reliance on alcohol to regulate emotional states. 21 This theory has been supported in a study 20 that indicated that emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect were associated with an increased likelihood of drinking alcohol to cope. It is likely that substances other than alcohol are also used in a similar way as a means of coping. For example, a recent review of the cannabis use literature indicates that cannabis is used as a stress-coping strategy among people experiencing family dysfunction, negative life events, and trauma. 64 In addition, researchers have found that people seeking treatment for an SUD frequently report using drugs and alcohol as a way of coping with negative emotions, stress, and traumatic events. 65,66 Min et al 67 found that use of avoidant coping partially mediated the association between childhood trauma and substance abuse among women. Similarly, Goldstein et al 68 found that the motivation to drink alcohol for coping mediated the relation between childhood maltreatment and problematic drinking, and this relation may be more pronounced in women. Further investigation of the relation between specific types of childhood maltreatment and the use of various individual substances as a coping mechanism is necessary using representative samples of men and women. However, it should also be noted that not all people who experience childhood maltreatment will develop SUDs, which may be due to underlying protective factors in their environment, genes, or adaptive coping styles. When adjusting for sociodemographic variables, very few sex differences were noted in the pattern of results. When further adjustments were made for Axis I and II mental disorders, a similar pattern of results for men and women was noted for physical abuse and neglect, with associations being attenuated, but remaining significant for all substances with the exception of physical neglect and heroin abuse or dependence for men and women, and physical abuse and heroin abuse or dependence for men only. For some nonsignificant heroin models where high odds ratios and wide confidence intervals are noted, the nonsignificant findings may be due to reduced statistical power. Heroin is a substance that fewer people use, making research across 5 childhood maltreatment types difficult. Further research is necessary before conclusions can be made regarding these relations. Nonetheless, some differences in the pattern of The Canadian Journal of Psychiatry, Vol 57, No 11, November 2012 W 683

8 Original Research Table 5 Association betfemaleeen childhood emotional neglect and SUDs No abuse Abuse Abuse Lifetime SUDs Sex n (%) a n (%) a AOR1 (99% CI) b AOR2 (99% CI) c Alcohol Male 6247 (47.4) 642 (51.9) 1.3 ( ) d 1.1 ( ) Female 3736 (21.9) 598 (27.5) 1.5 ( ) e 1.2 ( ) f Sedative Male 207 (1.7) 41 (3.1) 1.7 ( ) f 1.1 ( ) Female 124 (0.7) 44 (1.9) 2.7 ( ) e 1.5 ( ) Tranquilizer Male 190 (1.6) 43 (3.6) 2.0 ( ) d 1.4 ( ) Female 119 (0.7) 44 (1.9) 2.3 ( ) e 1.3 ( ) Opioid Male 301 (2.6) 50 (5.0) 1.8 ( ) d 1.3 ( ) Female 204 (1.2) 64 (3.0) 2.5 ( ) e 1.6 ( ) f Amphetamine Male 335 (2.6) 50 (4.0) 1.4 ( ) 1.0 ( ) Female 232 (1.4) 74 (3.6) 2.7 ( ) e 1.7 ( ) d Cannabis Male 1685 (13.1) 230 (18.8) 1.7 ( ) e 1.3 ( ) f Female 966 (5.7) 201 (9.4) 2.0 ( ) e 1.4 ( ) d Cocaine Male 553 (4.3) 72 (5.4) 1.3 ( ) 0.9 ( ) Female 347 (1.9) 89 (3.6) 2.0 ( ) e 1.3 ( ) Hallucinogen Male 313 (2.6) 61 (4.7) 2.0 ( ) e 1.4 ( ) Female 139 (1.0) 43 (2.3) 2.8 ( ) e 1.8 ( ) f Heroin Male 41 (0.3) 12 (0.9) 2.9 ( ) d 2.1 ( ) Female 25 (0.1) 15 (0.5) 3.3 ( ) d 2.2 ( ) Nicotine Male 3244 (25.7) 406 (34.1) 1.5 ( ) e 1.2 ( ) f Female 3294 (19.6) 562 (26.4) 1.4 ( ) e 1.1 ( ) a Unweighted n, weighted percentage b Adjusted for age, ethnicity, marital status, income, education c Adjusted for age, ethnicity, marital status, income, education, any lifetime mood or anxiety disorder, and any lifetime personality disorder d P 0.01; e P 0.001; f P 0.05 findings among men and women were noted for sexual abuse and emotional neglect after adjusting for Axis I and II mental disorders. However, results from this research are not able to explain why these differences exist. Findings from the final adjusted models indicate that mental disorders are accounting for some of the variance in the relations between childhood maltreatment and SUDs. The attenuated but significant relations indicate that the relations between childhood maltreatment and SUDs exist independent of other mood, anxiety, and personality disorders. However, diagnosis of other disorders may be especially important for understanding the relations between emotional neglect and SUDs, as many of these relations became nonsignificant after adjusting for mood, anxiety, and personality disorders. It may be that emotional neglect has an impact on emotional dysregulation, which is characteristic of a range of Axis I and II mental disorders. The findings from our study have several policy and clinical implications. Regarding policy, these findings are further evidence for the ongoing need to develop effective strategies to prevent the occurrence of childhood maltreatment. When childhood maltreatment does occur, attention needs to be placed on understanding if these people are using substances in childhood, adolescence, 684 W La Revue canadienne de psychiatrie, vol 57, no 11, novembre 2012 or adulthood. Effective strategies that are able to prevent the initial use of substances or reduce and eliminate the reliance on substances are necessary for adaptive outcomes following childhood maltreatment. It is possible that effective strategies to reduce childhood maltreatment in the general population may also yield reduction in SUDs. From a clinical perspective, it is important to be aware that childhood maltreatment is associated with increased odds of using many individual substances. Clinician inquiry beyond alcohol and the more commonly used illicit substances is necessary. Mood, anxiety, and personality disorders may also have an impact on the relation between childhood maltreatment and SUDs, especially in the case of emotional neglect. Clinical interventions for people with a childhood maltreatment history that are effective in reducing SUDs are needed. Limitations of our study should be noted. First, the crosssectional nature of the data does not allow inferences regarding causation. Second, data on childhood maltreatment were collected retrospectively, which may introduce some sampling error owing to recall and reporting bias. However, there is evidence that supports the validity of accurate recall of adverse childhood events. 69 Third, it was not possible to examine severity of childhood maltreatment owing to

9 Childhood Maltreatment and Substance Use Disorders Among Men and Women in a Nationally Representative Sample limited statistical power when looking at individual SUDs stratified according to sex. Readers should be aware of the possibility that the measures could have conflated milder incidents with more severe adversities, which are more likely to cause sequelae. Fourth, the assessment of disorders were based on a reliable, fully structured diagnostic interview conducted by lay interviewers and may not be exactly the same as diagnoses made by trained clinicians. 53,54 Finally, although several mental disorders were included in our analysis as covariates, not all Axis I disorders were assessed (for example, psychotic disorders or obsessive compulsive disorder). These limitations provide several directions for future research in this area. Conclusions To summarize, all 5 types of childhood maltreatment examined were associated with abuse or dependence on alcohol, sedatives, tranquilizers, opioids, amphetamines, cannabis, cocaine, hallucinogens, heroin, and nicotine among men and women in a representative sample. This research provided evidence of the robust nature of the relations between several types of child maltreatment and individual SUDs. The prevention of childhood maltreatment may help to reduce SUDs in the general population. Further, intervention for people who experience childhood maltreatment that can effectively reduce the likelihood of initiation of substance use and developing SUDs is needed. Acknowledgements This research was funded through PreVAiL, a Canadian Institutes of Health Research (CIHR) funded centre for the prevention of violence across the lifespan. 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