Impact and Relationship of Substance Abuse and Child Maltreatment: Risk and Resiliency Factors What Research Tells Us Martha Morrison Dore, Ph.D. Columbia University School of Social Work 622 West 113th Street New York, New York 10027 212/854-5461

Paper prepared for presentation at the conference entitled “Protecting Children in Substance Abusing Families,” September 28, 1998, sponsored by the Center for Advanced Studies in Child Welfare, University of Minnesota School of Social Work, Minneapolis, MN.

Researchers are just beginning to demonstrate empirically what child protective services workers have been observing for nearly two decades now: many, if not most, families who come to the attention of the child welfare system are involved with drugs or alcohol or both. Founded cases of child abuse and neglect have risen exponentially since the mid-1980s, when the crack form of cocaine, a cheap, easily used form of the drug, became widely available. Studies conducted since that time have identified substance abuse as a contributing factor in 40% to 80% of substantiated cases of child maltreatment (Curtis & McCullough, 1993; Magura & Laudet, 1996; Murphy, Jellinek, Quinn, Smith, Poitrast, & Goshko, 1991). Further, studies of substance abusing parents have found child-rearing beliefs and attitudes that heighten risk for child abuse (Williams-Peterson et al., 1994), as well as elevated rates of first-time reports to child protective services (Jaudes & Ekwo, 1995), re-reports (Wolock & Magura, 1996), and out-of-home placements of maltreated children (Nair et al., 1997). Substance abuse contributes to maladaptive parenting in three ways. First, there is the direct effect of the substance(s) used on parents’ behavior. As will be explored in this paper, different types of controlled and illicit drugs have different pharmacological effects on the organism. These effects may result in distortions of behavior that profoundly impact the individual’s ability to function as a parent. Good parenting requires sensitivity to the social, emotional, and physical needs of the dependent child and consistency in responding to those needs. Mind-altering and mood-altering chemicals profoundly impact the individual’s cognitive and affective functioning in ways that severely inhibit the capacity for sensitive and consistent parenting. The second way substance abuse leads to maladaptive parenting is its effects on the context in which parenting takes place. The partners a parent chooses, the physical environment in which a family resides, and the social interactions of a parent with the world outside the family, all contribute to the context for childrearing. A parent whose partner relationships revolve around substance use and abuse, whose addiction robs the family of necessary economic resources, and whose social network is severely truncated due to others’ rejection of his or her drug-using behavior, creates a childrearing context that has significant potential for child maltreatment. Recent studies show, for example, that although mothers are the most frequent perpetrators of child maltreatment, a genetically unrelated adult male in the

household such as a stepfather or mother’s paramour is the most likely perpetrator of fatal child abuse (Daly & Wilson, 1994; Sedlak & Broadhurst, 1996). As substance abusing women are more likely than men who are substance-involved to have a partner who also abuses drugs or alcohol and these partnerships are frequently serial relationships, the likelihood of having an unrelated adult male in a household where the mother is actively using is quite high. Other contextual factors associated with substance abuse and child maltreatment will be examined later on in this paper. Finally, a parent’s own early history of abuse and neglect, which studies have shown to be associated with drug and alcohol abuse in adolescence and adulthood, independently contributes to maladaptive parenting. Increasingly, research is showing the long-term effects of maltreatment in childhood on adult functioning, beginning with its effects on the individual’s ability to form lasting emotional attachments to others (Bryer, Nelson, Miller, & Krol, 1987; Chu & Dill, 1990). Recent research on physical and sexual trauma in childhood has found evidence of a biochemical effect that, depending on the severity of the trauma and the sensitivity of the individual, results in symptoms of Post-Traumatic Stress Disorder (PTSD). One of the characteristic sequelae of traumatic stress and a symptom of PTSD is emotional numbing and interference with cognitive problem-solving functions, both of which have been found to be associated with child maltreatment. In this paper, I will explore the research which supports the independent contributions of these three factors to impaired parenting and the resulting maltreatment of children in substance abusing families. My hypothesis is that the greater the degree of parental impairment in each of these three areas, the greater the likelihood that child maltreatment will take place and the greater the probable severity and impact of such maltreatment on the developing child. For example, research on childhood resilience suggests that a child who grows up in a two biological parent household, where one of the parents is a substance abuser but the other is sober and well-functioning, has a high probability of developing normally (Werner, 1989). However, if both parents are substance involved or if it is a single parent household with a using parent, chances for child resiliency are greatly diminished. Further, if the parent’s substance use undermines the social and economic resources available to the family, as when a heroinaddicted single mother spends most of her public assistance money and much of her time getting and using her drug, the likelihood of a positive outcome for the child is further lessened. And, if that same

single mother was herself abused and/or neglected as a child and, as a result, has limited capacity for meeting the emotional needs of a dependent child, maltreatment becomes probable. Conceptualizing the effects of substance ase on the parenting role, and its contribution to child maltreatment, as a complex interaction of these three factors enables us to refine our approach to assessment and intervention in substance abusing families. Many programs that seek to intervene in substance abusing families fail to appreciate the complexity of factors that may contribute to the failure of parenting in such families. Interventions are often designed to assess and address only the substance abusing behavior, or at best, the substance abuse along with a variety of environmental factors. Seldom is there appreciation for, and efforts to assess and address, the effects of the parent’s own early history of trauma. The implications of the three-dimensional model described here for assessment and intervention will be discussed later in this paper. In order to better understand the effects of substance abuse on parenting, we must first look at what is required in the parenting function. What behaviors and attributes mark competent parenting? How do these change as the child develops psychosocially? Current ideas and beliefs regarding parenting are examined in the following section. Attributes of competent parenting Parenting is a complex endeavor, particularly if it is to be carried out in a manner that enhances psychosocial outcomes for children. Those who study the parenting process have identified core behaviors or attributes that are associated with optimal child development at various stages of growth (Baumrind, 1978, 1989; Belsky, 1984). For example, there is a growing body of research on the emotional attachment between the infant and the primary caregiver, usually the mother, and its influence on child functioning at later developmental stages (Calkins & Fox, 1992; Greenberg, Speltz, & DeKlyen, 1993). This research suggests that secure early attachments are mostly likely to be formed when the mother is sensitively attuned and appropriately responsive to the infant’s social cues (Crockenberg, 1981; Belsky, Rovine, & Taylor, 1984; Isabella, 1993; Smith & Pederson, 1988; Susman-Stillman, Kalkoske, Egeland, & Waldman, 1996). In the very young infant, these cues are often subtle: the pitch of a cry, the turn of a head, the shift in eye focus (Seifer & Schiller, 1995). It is not difficult to see how a parent whose mind and mood are affected by drugs or alcohol might miss such cues.

As the child develops, she becomes more responsive to the parent’s own cues and a genuinely reciprocal process takes place. Studies have shown, for example, that infants of depressed mothers begin to mirror the mother’s depressed affect as early as the first few months of life (Field, 1992). In these first months, the mother’s sensitivity and responsiveness establish a pattern of attachment that may predict the child’s later social relationships with peers and others (Jacobson & Wille, 1986). A mother who is unable to attend to her young child sensitively and appropriately because she is using drugs may establish a negative pattern of attachment with her child that will detrimentally affect his functioning over time. In toddlerhood, a child begins to explore his environment in earnest and, through this process, to develop cognitive understanding of spacial relationships, time sequences, and other building blocks for future learning. A parent must be able to provide support and guidance for this exploratory process as well as to set appropriate behavioral limits which the child can begin to internalize. Supportive parenting in the preschool years includes: (a) parental warmth toward the child, (b) use of inductive disciplinary techniques, (c) interest and involvement in facilitating the child’s peer relationships, and (d) proactive teaching of social skills to the child (Pettit, Bates, & Dodge, 1997). Pettit and colleagues found a positive relationship between supportive parenting and children’s later school adjustment. Further, they found that supportive parenting helped to buffer risk factors such as living in a single parent family and being poor that are frequently found to predict poorer developmental outcomes for children. These findings are supported by a study by Elder, Eccles, Ardelt, and Lord (1995), who looked at parenting practices of white and African-American inner city parents who lived in high risk neighborhoods. All were under significant economic pressure due to job instability and job loss which has been found to have a direct, negative effect on the parenting process (Conger et al., 1992; McLoyd, 1990). Parents who felt a sense of self-efficacy despite the pressures and stresses to which they were subjected were able to employ parenting strategies designed to promote positive experiences for their children and to develop their children’s individual skills and interests. They also used preventive strategies that helped to minimize behavioral risks and negative outcomes for children, despite hostile environments. Given that the research literature on parenting suggests that a sense of self efficacy and the ability to engage sensitively and responsively with a child are essential to competent parenting, what

effects might substance abuse and dependence have on these competencies? Next, the physical and psychological effects of alcohol and other drugs are explored to see how they interfere with competent parenting. Direct effects of substance abuse on the parenting function Different chemical substances have different physiological effects on the user and therefore affect the user’s behavior in various ways. For example, drugs such as amphetamines and opioids, including cocaine, are stimulants to the central nervous system. They release dopamine which results in the euphoric high that is part of the addictive process (Jaffe, 1992). With amphetamines the user is mentally and physically stimulated to the point of requiring little sleep. He or she feels full of energy, sometimes to bursting. Because their own sleep-wake cycle is so distorted by the drug, a parent on amphetamines may be unable to attend to a child’s need for structure and pattern that is so essential to optimal physical and psychological growth. Further, the parent may become impatient or irritated with the child who is unable to adapt to the parent’s level of energy. Also accompanying the influx of energy is suppression of appetite which is why amphetamines have been prescribed as diet pills. When a parent is not hungry and therefore not preparing meals for herself, she may also fail to appreciate a child’s hunger and not insure that he is fed on a regular basis. Cocaine has a somewhat different effect on both the physiology of the organism and on the parenting function. In addition to an influx of energy, cocaine also heightens the senses. Colors are brighter, smells are stronger, noises are louder. Thus, a child’s crying, which may be only a mild annoyance to a non-using parent, is magnified in its intensity to the parent on cocaine. Because of its biological effects, particularly after prolonged use, cocaine also increases irritability and aggression in the user. It can also result in psychotic distortions of thought such that the user imagines and acts on projections to others of his or her own aggression. Further, cocaine, particularly in the smokeable form known as crack, cycles rapidly through the body so that the high that is so physically and psychologically satisfying vanishes quickly, within 5 to 15 minutes in the case of crack, leaving in its wake anxiety, depression, and paranoia, as well as an intense craving for a return to the euphoric state (Gold, 1992). Crack is cheap to buy and easy to use, making it both more accessible and acceptable to people with limited economic resources. It also heightens feel-

ings of power and control over one’s life, feelings that may be sorely lacking in those belonging to oppressed social groups. Since it was widely introduced in the mid-1980s, crack has become the scourge of low-income inner-city communities. It is also the most addictive form of cocaine, producing damaging physiological effects after only brief use that are usually seen only after long-time intranasal use of powdered cocaine. Child protective services workers are well acquainted with the thousands of cases each year in which a parent addicted to crack leaves an infant or toddler alone for hours or sometimes days at a time to pursue the drug. CPS workers frequently investigate maltreatment reports in homes barren of furniture and appliances that have been sold to purchase crack and other drugs. The absence of food in the refrigerator or cupboards further attests to the parent’s drug-induced inability to attend to her child’s most basic needs. Recovering crack addicts testify to the ability of the drug to take over their lives, to dull them to any other need or responsibility except the getting and using of the drug. Some describe doing whatever it took to pursue their habit, even to sacrificing the health and well-being of loved ones. It is likely also that crack has contributed to a significant increase in sexual abuse of young children in two ways. One is that the heightened physical sensations induced by crack lead users to seek out sexual encounters. A child who is available and unprotected by a functioning adult, as when children accompany parents to so-called crack houses, is an easy target for sexual abuse by an individual high on crack. In addition, there are numerous reports of very young children, even babies, being prostituted by their crack-addicted parents desperate to obtain the drug. Another factor that influences the substance-involved parent’s ability to nurture her child is the effects of drugs or alcohol used during pregnancy on the neonate’s neurobehavioral functioning. Although there is now some evidence that the long term consequences of prenatal drug use is not as uniformly dire as once thought, there are significant short-term effects that make parenting a drugexposed infant more challenging. For example, cocaine-exposed neonates frequently demonstrate poorer state regulation, greater irritability, and greater sensitivity to stimulation than non-exposed infants (DiPietro, Suess, Wheeler, Smouse, & Newlin, 1995; Hawley & Disney, 1992). Such babies are often difficult to comfort and console. Their irritable crying may frustrate and enrage a substance-using parent whose tenuous self-control is already loosened by the effects of the drugs he is using. If a parent’s

aggressive impulses are heightened by alcohol or other drugs (Bushman & Cooper, 1990), the potential is rife for abusive behavior. In addition to the physiological effects of drugs and alcohol on the organism, over a period of time the use of mind-altering and mood-altering substances seems to inhibit normal personality development. Those who treat persons with chemical addictions, particularly individuals who began their substance use in adolescence, frequently note that the addict’s psychosocial development appears to have stopped at an earlier developmental stage. They often exhibit ways of thinking and behaving in recovery similar to those of a young adolescent. It seems logical that a person whose life experiences since the teen years have been shaped by mind-altering and mood-altering chemicals would have failed to incorporate information and experiences into her cognitive schema in normative ways. Social relationships involving getting and using drugs or alcohol distort the very information received from the external environment. The drug culture is one of mutual distrust, exploitation, and deception as well as selfabsorption. As a result, those working with addicted parents find that they lack even the most basic understanding of reciprocal interpersonal processes (Lief, 1985). They are often out of touch with their own emotions, except perhaps for sadness, rage and pain, even in recovery, and are therefore unable to draw on information from their own emotional lives to understand and empathize with their children’s experiences. Because the drug-using life style is chaotic and unpredictable, substance abusing parents may have little understanding of, or ability to meet, a young child’s need for structure and consistency (Bauman & Dougherty, 1983). And, because of inhibition in cognitive development that may result from using mind-altering chemicals over time, substance abusing parents often fail to develop problem-solving skills and the strategies for coping with stress and frustration required for effective parenting (Davis, 1990). As a result, they may rely on the kinds of harsh, punitive, and emotionally reactive disciplinary measures that they experienced as children, even while recognizing the pain such responses caused in their own lives. In addition to these direct negative effects of substance abuse on the ability to function in the parent role, the micro and meso environments created by a substance-involved parent also contribute to the probability of child maltreatment. This second element in the relationship between parental substance abuse and child maltreatment is explored more fully in the following section.

Contextual factors in the relationship between parental substance abuse and child maltreatment According to current developmental theory, a child’s psychosocial functioning is a product of the ongoing interaction of factors in the child, the family, and the larger social environment (Bronfenbrenner, 1979; Lerner, 1991; Sameroff, 1993). Earlier we saw that a parent’s drug or alcohol use during pregnancy can have detrimental effects on the functioning of the newborn. It is now believed that the long-term sequelae of these effects may depend a great deal on the family and social contexts in which the child is raised. Researchers who have followed drug-affected newborns into the preschool years with mixed findings regarding psychosocial development have concluded that the effects of prenatal drug exposure are mediated by environmental factors such as poverty, family structure, and parenting competence (Azuma & Chasnoff, 1993; Zuckerman & Frank, 1992). We have already noted the detrimental effects of substance use on the parenting function. The family and social context are likely to be negatively affected by the parent’s substance abuse as well. It is also likely that the ways in which these contexts are affected make child maltreatment more probable. For example, research shows that substance abusing women are often socially isolated. They may have few, if any, social relationships that do not revolve around getting and using drugs or alcohol. Further, when a male partner is present, he is usually also substance-involved, making achieving and maintaining sobriety for the woman much more difficult (Reed, 1985). When a sober male partner is present in a substance abusing woman’s life, he is much more likely than a sober female partner of an addicted male to abandon the relationship (Kane-Caviola & Rullo-Cooney, 1991). Substance abusers also have documented difficulties in keeping and sustaining positive interpersonal relationships, including family relationships (Bell & Legow, 1996). Consequently, a high proportion of substance abusing mothers are socially isolated single parents. And single parents, as we know from demographic studies, are more likely to be poor and to live in high stress environments. They are also more likely to abuse and neglect their children (Gelles, 1989; Sack, Mason, & Higgins, 1985; Straus & Gelles, 1986). Research also tells us that family social isolation and child maltreatment are associated (Kugler & Hansson, 1988; Polansky, Ammons, & Gaudin, 1985; Salzinger, Kaplan, & Arteyeff, 1983; Testa, 1992; Wahler, 1980). Isolated mothers who lack emotionally gratifying and supportive relationships with other adults may seek nurturing from their children. When their young children are developmen-

tally unable to meet these emotional needs, such parents may lash out at their children in hostile, rejecting, and punitive ways. Or, they may withdraw from them emotionally and physically with the aid of mood-altering drugs. Either way, maltreatment of the child results. Further, the poverty that often characterizes families where resources are disproportionally used to support parents’ chemical dependence is associated with other factors that independently correlate with child abuse and neglect (Trickett, Aber, Carlson, & Cicchetti, 1991). These include higher rates of partner-on-partner violence and parent mental illness, particularly clinical levels of maternal depression. Interpersonal violence characterizes the environments where drug and alcohol abuse occurs (Kilpatrick, Acierno, Resnick, Saunders, & Best, 1997; Ladwig & Anderson, 1989; Miller, Downs, & Testa, 1993; Zahnd, Klein, & Needell, 1995). Further, an association between substance abuse and spousal or partner battering is frequently documented. One study found alcohol abuse present in well over half of a sample of 88 families in which battering of the mother by the father had occurred (Spaccarelli, Sandler, & Roosa, 1994). Similarly, high rates of marital conflict and violence have been found in families where substance abuse is the identified problem (Reich, Earls, & Powell, 1988). An association between spousal or partner battering and child abuse has also been established (Jouriles, Barling, & O’Leary, 1987; McCloskey, Figueredo, & Koss, 1995). Children in homes where marital violence is occurring are at high risk for physical abuse themselves (O’Keefe, 1994). Even when violence is not directed at them, children who witness violence between parents or other care-takers in the home demonstrate a range of negative developmental outcomes, including conduct disorders, anxiety, depression, and aggression against parents and peers (Carlson, 1990; Fantuzzo et al., 1991; Kashani, Daniel, Dandoy, & Holcomb, 1992; O’Keefe, 1994). In addition to the relationship between poverty, substance abuse, and family violence, there is also an association between poverty and mental illness, particularly depression in women (Belle, 1990; Hall, Williams, & Greenberg, 1985; Kaplan, Roberts, Camacho, & Coyne, 1987). There is evidence that substance abuse is frequently an effort at self-medication for depression and other forms of mental illness, particularly in poor, oppressed inner-city populations who have little or no access to regular mental health care (Khantzian, 1997, 1985; Weiss, Griffin, & Mirin, 1992). Depression in mothers may be linked to child neglect through affective withdrawal and lack of

attention to caregiving tasks, and to child abuse because of the irritability and aggression that are often symptomatic of clinical levels of depression. Studies of depressed mothers’ parenting abound (Cohn, Campbell, Matias, & Hopkins, 1990; Field, Healy, Goldstein, & Guthertz, 1990; Gordon, Burge, Hammen, Adrian, Jaenicke, & Hiroto, 1989; Hops, Biglan, & Sherman, 1987; Leadbeater, Bishop, & Raver, 1996). Particular attention has been paid to depressed mothers’ interactions with their young children which have been found to be negative, critical, hostile, and rejecting when compared to nondepressed mothers (Gordon et al., 1989; Radke-Yarrow, Nottelmann, Belmont, & Welsh, 1993; Susman, Trickett, Iannotti, Hollenbeck, & Zahn-Waxler, 1985). With their infants, depressed mothers show more negative affect, are less responsive and provide less stimulation in face-to-face interactions (Cohn et al., 1990; Lyons-Ruth, Zoll, Connell, & Grunebaum, 1986). There is concern that the maternal behaviors that help to insure secure early attachment in infants are not present in depressed mothers, resulting in insecure attachments that carry into toddlerhood and beyond (Lyons-Ruth et al., 1986; Radke-Yarrow, Cummings, Kucyznski, & Chapman, 1985; Teti, Gelfand, Messinger, & Isabella, 1995). As previously mentioned, research has shown that infants of depressed mothers begin to mirror the depressed affect in the earliest months of life, leading to inhibition in social interaction and exploratory behavior by 12 months of age (Field et al., 1990). Such children are more likely to develop behavior problems, anxiety disorders, and affective disorders than children of nondepressed parents (Cummings & Davies, 1994; Lyons-Ruth, Alpern, & Repacholi, 1993). While those studying the effects of parental depression have researched various factors, including marital conflict, stressful environments, and harsh disciplinary practices, which contribute to the demonstrated negative outcomes for children in such families, no studies could be located which specifically examined the interaction of depression, substance abuse, and child maltreatment. Given the established associations between physical and sexual abuse in childhood, adult psychopathology, including depression, and substance abuse, as well as between substance abuse and child maltreatment, this would seem a logical combination of factors for investigation. The following section will examine how a parent’s early life experiences may contribute both to dependence on mind- and mood-altering drugs and to the perpetration of child abuse and neglect. Parents’ early life experiences, substance abuse, and child maltreatment

There is a growing research literature on the association between physical and/or sexual abuse in childhood and substance abuse, often beginning in early adolescence (Cohen & Densen-Gerber, 1982; Caviola & Schiff, 1988; Harrison, Fulkerson, & Beebe, 1997; Roesler & Dafler, 1993; Rohsenow, Corbett, & Devine, 1988). This relationship has been found in both clinic and community samples. Findings of childhood sexual abuse among substance abusers range from just over 30% to 75% in various samples (Bollerud, 1990; Cohen & Densen-Gerber, 1982; Grice, Brady, Dunstan, Malcolm, & Kilpatrick, 1995; Harrison, 1989; Yandow, 1989). Boyd (1993) found a strong relationship between early sexual abuse, subsequent onset of depression, and crack cocaine use in a sample of 105 predominately African American urban women. She noted the consistency of these findings with other studies which have found a similar association to alcoholism in Anglo-American women (Pribor & Dinwiddie, 1992). More recently, researchers have attempted to identify the pathway by which early sexual abuse leads to substance abuse in women (Brady, Killeen, Saladin, Dansky, & Becker, 1994; Swett & Halpert, 1994). One such study noted the frequency of symptoms of Post Traumatic Stress Disorder (PTSD) in individuals who were sexually traumatized in childhood and posited that substance abuse represents an effort to manage the symptoms of this disorder (Epstein, Saunders, Kilpatrick, & Resnick, 1998). Symptoms of PTSD relate to feelings of intense anxiety and include hyperarousal, avoidant behaviors, emotional numbing, and flashbacks to the traumatic event. Epstein and his colleagues found in interviewing over three thousand women that those who reported a childhood experience of sexual abuse had twice as many PTSD symptoms as women who reported no such experience. Further, sexual abuse victims had double the number of alcohol abuse symptoms as women who had not been abused in this way. And, finally, those abuse victims who reported experiencing PTSD symptoms had twice as many alcohol abuse symptoms as abuse victims who had no symptoms of PTSD. From this, Epstein concluded that PTSD is the connecting pathway between early sexual abuse and later chemical dependence. Recent studies have also linked early life trauma such as sexual abuse, physical abuse, or witnessing domestic violence, to the development of symptoms of Borderline Personality Disorder (BPD) (Herman, Perry, & van der Kolk, 1989; Weaver & Clum, 1993), a form of personality disorder which is more often diagnosed in women than men and which has been linked theoretically (Prodgers, 1984) and

empirically (Brennan, Andrews, Morris-Yates, & Pollock, 1990; Famularo, Kinscherff, & Fenton, 1992; Taylor et al., 1991) with perpetration of child maltreatment. Recent studies of children and adults with BPD diagnoses have reported finding rates of childhood physical and sexual abuse of 30% to 80% (Goldman, D’Angelo, DeMaso, & Mezzacappa, 1992; Herman et al., 1989). BPD symptoms include: (a) a pattern of intense but unstable interpersonal relationships which include alternately idealizing and devaluing others; (b) impulsiveness in at least two potentially self-destructive areas, including use of mind- and mood-altering chemicals; (c) instability of affect with marked shifts in mood; (d) inappropriate, intense anger; (e) recurring suicidal threats, gestures, or behaviors, including self-mutilation; (f) identity confusion or disturbance; (g) chronic feelings of emptiness or boredom; (h) preoccupation with real or imagined abandonment. It is not difficult to see how a parent with BPD might maltreat a child. Prodgers (1984) drew a comparison between BPD symptoms and findings of empirical studies regarding characteristics of physically abusive parents. He noted particularly the consistent finding that abusive parents have difficulty controlling their anger and that they often exhibit pervasive hostility and aggressiveness in interpersonal relationships. As noted earlier, studies have also called attention to the social and emotional isolation of maltreating parents, paralleling the difficulties persons with BPD have in sustaining meaningful interpersonal relationships. Prodgers (1984) noted other similarities as well, including emotional immaturity, poor self-image, and depression. In support of Prodger’s theoretical comparison, Brennan and his colleagues (1990) found that a court sample of abusive parents scored significantly higher than non-abusing controls on indicators of projection, displacement, isolation, denial, and splitting, all characteristics associated with BPD. Herman (1992) has called attention to the parallels between symptoms of BPD and PTSD, and hypothesized that BPD in some women is a manifestation of PTSD resulting from physical and sexual trauma in early life. Herman notes that, because of their socialization, women are likely to turn their rage inward and blame themselves when they are abused in childhood by a trusted caregiver. They may also engage in a form of dissociation or psychological numbing that results in the self-destructive risk-taking and self-injurious behaviors such as substance abuse and self-mutilation that are symptomatic of BPD. Given the demonstrable damaging effects of abuse and neglect on psychosocial functioning and

development, it is highly likely that an adult who was subjected to severe maltreatment at a young age will be affected in negative ways. In their review of the literature on the long-term effects of physical abuse, Malinosky-Rummell and Hansen (1993) found compelling evidence for its impact in a variety of functional domains. One of these findings is that adults who were abused as children are more likely to be aggressive and violent toward others and to engage in antisocial behavior. A high correlation has been found among abuse and neglect in early childhood, symptoms of antisocial personality disorder in adulthood, substance abuse, and aggression, particularly in males. In one study of men imprisoned for assault, it was found that men who had been sexually abused as children were more likely to commit sexual assaults, while those who had been physically abused committed more physical assaults (Dutton & Hart, 1992). As noted previously, it is well-established in the research literature that parents who themselves were abused as children are more likely to abuse their own children than those who were not (see Oliver, 1993 for a review of the literature on intergenerational transmission of child abuse). Further, the impact of PTSD and BPD symptoms on the parenting function cannot be underestimated. Burkett (1991) observed the parenting behaviors of 20 mothers who were sexually abused in childhood and compared them with 20 mothers who were not abused. She found the abused mothers to be more self-focused and to communicate with their children in blaming and belittling ways. One group of abused mothers was deeply depressed and appeared to have little emotional energy left for parenting. The members of this group were also more likely to be drug or alcohol involved. The other group of abused mothers was more positive and engaged with their children, almost to a fault. They seemed to seek affirmation and nurturing from their children, rather than the other way around. Indeed, Burkett noted that both groups of abused mothers sought more emotional support from their children than did the nonabused mothers. Herzog, Gara, and Rosenberg (1992) also explored the parenting behaviors of mothers abused as children, this time through a case design study. They found that mothers who detached themselves psychologically from their own childhood experiences of abuse, that is, they had failed to process feelings associated with this maltreatment, were more likely to hold unrealistically high expectations of their children’s developmental capacities. Unrealistic expectations of children are a common finding in studies of abusive parents. Such expectations are believed to contribute to abusive behavior in that when the

child is unable to conform, the parent interprets this inability as purposeful, and becomes enraged at what she sees as the child’s willful opposition (Larrance & Twentyman, 1983). Herzog and her colleagues interpreted these unrealistic parental expectations as the inability of the abused parent to identify with her child. Instead she projects onto the child an adultlike persona, removing from her vision of the child any sense of the vulnerability that characterized her own relationship with her childhood abuser. SUMMARY AND CONCLUSIONS It is clear from this brief and cursory review of the research literature on the interaction of substance abuse and child maltreatment that this is a complex dynamic that calls for thoughtful interventive approaches. First, there is the direct effect of mood- and mind-altering substances on a parent’s physical well-being, resulting in emotion and behavior that is likely altered in ways that are detrimental to parenting and to the positive development of children. Some of the ways in which various parenting functions are affected have been reviewed here. Second, there is the context in which parenting takes place that is also profoundly affected in negative ways by the parent’s substance abusing behavior. The poverty, interpersonal violence, social isolation, the presence of unrelated substance abusing adults in the home, and parental mental illness, particularly depression, that often co-occur with parental substance abuse are all associated with both child maltreatment and high risk to normative psychosocial development of children. Many of these factors, of course, exist independently of parental substance abuse. All parents who are poor or who live in violent circumstances do not abuse or neglect their children. However, according to the research on factors which place children at high risk of developmental psychopathology, the presence of multiple risk factors greatly increases the probability that children will suffer adverse consequences. Further, these kinds of high risk environments also place extraordinary stress on parents, even those who function well. For a parent whose functioning is already impaired by the use of drugs or alcohol, living in such a stressful environment increases the likelihood that he or she will lose control and become abusive, or, conversely, withdraw physically and emotionally from a child. Finally, there are the effects of a parent’s own childhood experiences of abuse on both the probability of becoming a substance abuser and the psychodynamic consequences manifested in behaviors associated with child abuse and neglect. There is evidence that a high proportion, estimated at one third,

of parents who are abused as children will go on to severely maltreat their own children (Oliver, 1993). Another third of such individuals are thought to be more vulnerable than the norm to effects of environmental stress. They can be easily pushed by stressful circumstances into engaging in maltreating behavior. Then, there is the final third of parents maltreated in childhood who are resilient in the face of this developmental threat. These parents are indistinguishable from other parents who were not abused or neglected as children. It is the first two groups that are thought to be at highest risk of developing problems with substance abuse, thereby compounding the likelihood that they will become perpetrators of child maltreatment themselves. How can we help these families to better parent their children? There are no simple solutions. Interventions must be directed toward each of the three substance abuse/child maltreatment pathways identified in this paper. Simply getting clean and sober is not enough. Nor will court-ordered parenting classes alone suffice. Interventions must take place at multiple levels: with the substance abusing parent, with her children, and with the context in which they exist. Substance abuse treatment programs must recognize the special problems faced by chemically dependent parents who cannot turn away from their other responsibilities to focus all their energies on getting clean and sober as the traditional substance abuse treatment model requires. These programs must begin to address the multiple factors in the lives of parents which make sobriety difficult to sustain, particularly their struggles with parenting their children and with their own childhood trauma. And, parenting programs must recognize that training in the skills of child management is not enough. They must pay attention to the substance abusing parent’s difficulties in interpersonal functioning, her lack of social skills, and her diminished social network, as well as her relationships with her children. Parenting programs aimed at enhancing attachment behaviors in parents of newborns show great promise for maltreating parents who lack sensitivity and responsiveness to their infants (van Ijzendoorn, Juffer, & Duyvensteyn, 1995). We must also discover how disrupted or tenuous attachments between newly sober parents and their children can be strengthened as well. Finally, if our goal is really to help protect children from the impact of parental substance abuse and child maltreatment, in addition to treating their parents, we must also intervene on the child level. Children who have been exposed to all of the detrimental factors associated with parental substance

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