(‘hlld Ahm’ & Meg/m. Vol. 16, pp. 475-483, Pnnted in the U.S.A. All rights reserved.
PARENTAL
0145-2134/92 $5.00 + .oO Copyright 0 1992 Pergamon Press Ltd.
1992
SUBSTANCE ABUSE AND THE NATURE OF CHILD MALTREATMENT RICHARD FAMULARO
Boston Juvenile Court; Massachusetts Department of Mental Health; Department of Pediatrics, Franciscan Children’s Hospital; Department of Psychiatry, The Children’s Hospital; Harvard Medical School. Boston, MA
ROBERT
KJNSCHERFF
Boston Juvenile Court; ~pa~ment of Psychology, Judge Baker Children’s Center; Special Research Fellow, Department of Pediatrics, Franciscan Children’s Hospital; Department of Psychiatry, Harvard Medical School, Boston, MA
TERENCE FENTON Department of Biostatistics, Harvard School of Public Health, Boston, MA
Abstract-The authors reviewed 190 randomly selected records from the case load of a large juvenile court. These records involved cases in which the state took legal custody of the children following a finding of significant child maltreatment, based on a “clear and convincing” standard of evidence. Sixty-seven percent (127/190) of these cases involved parents who were classified as substance abusers. The results of this study revealed specific associations between (a) alcohol abuse and physical maltreatment and (b) cocaine abuse and sexual maltreatment. Logistic analyses, testing for the effects of polysubstance abuse, revealed that additional forms of substance abuse failed to add signifi~ntly to the effects of alcohol in predicting physical maltreatment or cocaine in predicting sexual maltreatment. Key Words-Cocaine,
Alcohol, Substance abuse, Child maltreatment,
Child abuse.
INTRODUCTION IN THE PAST decade, child maltreatment and substance abuse have both emerged as critical issues for public policy and clinical practice. In the state in which the present study was conducted, as well as in most other states, children alleged to have suffered physical and/or sexual maltreatment are subject to particular care and protection by the state. The purpose is to guarantee that children “are protected against the harmful effects resulting from the absence, inability, inadequacy, or destructive behavior of parents or parent substitutes, and to insure good substitute parental care in the absence, temporary or permanent, inability or
This research was funded by the National Center on Child Abuse and Neglect (NCCAN), Department of Health and Human Services, Grant #go-CA- 1408. Received for publication November 2, 1990; final revision received January 22, 199 1; accepted January 22, 199 1. Requests for reprints may be sent to Richard Famularo, M.D., Boston Juvenile Court Clinic, New Court House, Room 2 10, 17 Somerset Street, Boston, MA 02 108.
476
R. Famularo, R. Kinscheti,
and T. Fenton
unfitness of parents to provide care and protection for their children” (Massachusetts General Law, 1988). It is increasingly clear that parental substance abuse often contributes to severe family dysfunction and elevates the risks of child maltreatment. For example, parental alcoholism has been associated with child maltreatment (Behling, 1979; Famularo, Stone, Barnum, & Wharton, 1986; Kaplan, Pelcovitz, & Salzinger, 1983), marital conflict (Reich, Earls, & Powell, 1988), domestic violence (Fitch & Papantonio, 1983), and increased risk of long-term psychiatric and social dysfunction among children raised in alcoholic homes (Black, Bucky, & Wilder-Padilla, 1986). Not surprisingly, particularly high rates of family violence have been documented when the alcoholic parent also presents with antisocial personality disorder and/or recurrent depressions (Bland & Orn, 1986). Much less is known and documented about the risks of child maltreatment associated with parental cocaine use. This is true despite the prevalence of cocaine use and evidence that cocaine dependency can substantially incapacitate the user (Castellani, Petrie, & Ellinwood, 1985; Weiss & Mirin, 1986). A May 1990 United States Senate Judiciary Committee study yielded an “extremely conservative” estimate that some 2.2 million Americans are “hard core” cocaine addicts (Committee on the Judiciary, United States Senate, 1990). Such users are reportedly over represented among the homeless and persons arrested for crimes (Committee on the Judiciary, United States Senate, 1990). The report went on to note: The addicts who break into our homes, turn our neighborhoods into war zones, and spread disease by selling their bodies are not casual, once-a-month users of illicit drugs-they are America’s hard core addicts. The children of the hard core addict suffer even more severely, often from physical abuse, and always from neglect. (Committee on the Judiciary. United States Senate, 1990, p. 22)
Cocaine exposure in pregnant women, adolescent mothers, and newborns is common enough to prompt medical investigation (Chasnoff et al., 1985; Kozel & Adams, 1986; Osterloh & Lee, 1989; Shannon, Lacouture, Roa, & Woolf, 1989) and policy debates on the problem of “crack babies” and intraute~ne cocaine exposure. A recent study (Amaro, Zuckerman, & Cabral, 1989) found that a majority of a sample of pregnant adolescents had used substances during pregnancy. One in six specifically acknowledged using cocaine during pregnancy. Comparisons between pregnant drug users and nonusers found that the former were more likely to report factors that have also been associated with increased risks for child maltreatment‘ These include drug use itself (Regan, Erlich, & Finnegan, 1987), financial stresses, and a history of criminal activity or legal involvement. Drug-abusing pregnant adolescents were also twice as likely to have a history of venereal disease (suggesting multiple sexual partners), and an almost three times greater risk of having a male partner who uses marijuana or cocaine. They demonstrated a trend toward increased risk of exposure to abuse themselves, and relative isolation from their own families. In short, these adolescents present with many of the features noted in clinical and empirical literature as high-risk factors for child maltreatment, directly or by failure to establish and maintain stable protective environments. The psychopharmacological effects of cocaine and alcohol among adults must be understood to appreciate the potential cont~bution of these drugs to risk for child maltreatment. Typically, alcohol intoxication is characterized by maladaptive behavior (particularly aggressive and assaultive behavior) and includes central nervous system depression, emotional lability, decreased attentional parameters, irritability, impaired judgement and social or occupational dysfunction. Physiological signs include gait and coordination disturbances, flushing, slurred speech, and nystagmus. Alcohol withdrawal presents in varied manners following cessation or reduction of heavy, continual alcohol ingestion. The presentation includes increased blood pressure and pulse,
Substance abuse and child maltreatment
477
sweating, anxiety, depression, insomnia, headache, weakness, nausea or vomiting, and potentially hallucinosis, illusions, and delirium. Cocaine intoxication, like alcohol intoxication results in impaired and maladaptive behaviors, although cocaine is a central nervous system stimulant. Typical cocaine intoxication includes euphoria, grandiosity, impaired judgement, hypervigilance, agitation, reduced social inhibitions and increased sexual interest. These effects are generally consistent with reports of stimulant use at low-to-moderate doses (Lasagna, von Felsinger, & Beecher, 1955; Nathanson. 1937; Van Dyke, Ungerer, Jatlow, Parash, & Byck, 1982). The rush, secondary to ingestion, may progress to headaches, p~pitations, EKG alterations, visual and/or tactile hallu~inations, and even seizures. Bizarre behavior, stereotypic movements, and paranoid ideation can develop. Following discontinuation, especially after high dose ingestion, a “crash” develops characterized by anxiety, irritability, fatigue, insomnia, depression, psychomotor agitation, further cocaine craving, and even delirium. In cocaine-dependent individuals, withdrawal effects can persist for weeks. Cocaine~ependent users report ihat the risk of moving from controlled to compulsive use escalates with greater access to the drug, or when the cocaine is injected intravenously or smoked (Gawin & Kleber, 1985; Siegel, 1985). A major problem posed by smoked forms of cocaine (“freebase” and “crack”) is that they are now, in some urban areas, widely available cheaply, and are associated with epidemics of smoking and a high level of compulsive use. Such use is characterized by a pattern of binge use of multiple high-dose administrations in which the drug may be ingested many times each day, often with only a few days respite between binges. The absence of daily use may represent a pattern of heavy binge use, rather than moderate controlled use, although this clinical marker is reportedly often misinterpreted (Gawin & Ellinwood, 1988; Gawin & Kleber, 1985). One review of the literature concluded that during binges “nou~shment, sleep, safety, survival, money, morality, loved ones, and responsibility become immaterial” (Gawin & Ellinwood, 1988). Binge ingestion results in the well-known signs of high dose stimulant use, including disinhibition, impulsivity, hypersexuality, poor judgement, extreme hyperactivity, and irritability. Over 80% of regular cocaine users have reported these drug effects (Gold, Washton, & Drakis, 1985). Users also commonly report that continued binge administration results in a euphoria increasingly inte~pted by episodes of intense anxiety, irritability, and panic. Paranoid states and severe transient panics with a fear of impending death can occur. Cocaine abusers report that these states are not uncommon (Gold, Washton, & Dackis, 1985). Children exposed to parents or other adults in their environment impaired by the direct psychopharmacological effects of cocaine ingestion may be at significant risk for lapses in parental care or protection, or may become the direct targets of maltreatment. Additional risk of child maltreatment may be generated by parental cocaine use in the presence of other psychiatric impairments, other sources of family dysfunction, or the demands of parenting in the stressful environmental conditions that prevail in the inner cities or other economically depressed areas. Studies of psychiatric comorbidity among persons undergoing treatment for cocaine abuse indicate that mood disorders (particularly cyclical mood disorders) and residual attention deficit disorder are ove~epresented among cocaine abusers (Gawin & Kleber, 1985, 1984; Weiss, Mirin, Michael, & Sollogub, 1986). The mood disorders exist independently from the dysphoria, anxiety, agitation, and irritability of the “crash” of cocaine withdrawal, and such disorders have been shown to be correlated in complex ways with increased risk of child maltreatment (Famularo, Barnum, & Stone, 1986). The present study focused upon alcohol and illegal drug abuse among families involved with court actions arising from significant maltreatment of their children. The aim of the
478
R. Famuiaro, R. K.insche&, and T. Fenton
study was to examine whether, within such a sample, there were relationships between specific forms of child maltreatment and specific types of substance abuse. The study focused upon cases of severe maltreatment of children, involving either gross neglect or physical and/or sexual maltreatment. It examined whether unique patterns of substance abuse could specifically predict the probability of physical or sexual maltreatment.
METHOD The sample was comprised of 190 previously unreported cases from a large urban juvenile court, involving physical or sexual maltreatment of children, gross neglect, or combinations of the above. Permission was obtained from the chiefjustice and the chief probation oflicer to perform a random review of the records of child “care and protection” cases completed between 1985- 1988. The cases were all selected from actions in which the court had granted a petition to transfer legal custody from the parents due to severe maltreatment of the children. Completed cases were chosen in preference to active cases, since they were more fully documented, and their examination was less intrusive to the court and families. All data were recorded with reference to a confidential identification number. No record of any individual’s name was obtained by the researchers. Each chart was read fully by one or more ofthe authors and reviewed by the principal author. These court proceedings generally represented cases of relatively severe child maltreatment. While there were more than 4,000 cases of alleged child maltreatment in the county where the study was done, only 300-600 new cases per year during the study period were brought before the court to seek transfer of parental custody to the state. Given the legal procedures in place, false positive cases of child maltreatment in this setting were rare. Dichotomous variables representing physical and sexual maltreatment served as dependent variables in this study. Sexual maltreatment was defined as substantiated evidence of physical contact of a sexual nature between the child and parent including genital fondling (either child, adult, or both), attempted intercourse or completed intercourse {anal, oral, or vaginal). Physical maltreatment was defined as substantiated evidence of a form of assault that included closed fist punching, bruising or marking, broken bones, bleeding, or concussion. Independent variables consisted of dichotomous markers indicating whether or not the following substances had been abused: (a) Alcohol, (b) cocaine, (c) opiates, and (d) other. “Substance abuse” for the purposes of this study was established by: (a)substantitzted allegations by two or more separate professionals (social service or mental health) of alcohol and/or drug misuse, or (b) parental self-reports of substance abuse of sufficient severity to meet Research Diagnostic Criteria (Spitzer, Endicott, & Robbins, 1978). Recreational or occasional use alone was not considered “substance abuse.” The scope of the study was limited to cases in which the perpetrator of the maltreatment was one of the child’s parents. Cases in which the perpetrator was not a parent or stepparent living in the home and cases revealing both parents as ~~trators were eliminated from the study. Cases in which relatives or older siblings abused the child were also removed from this study. Data on each identified perpetrator and his/her substance use pattern were recorded on standardized questionnaires during review of the case charts.
RESULTS A preliminary examination of the data indicated that 36 of the 190 cases involved both physical and sexual maltreatment, 66 involved only physical maltreatment, 18 involved only
479
Substance abuse and child maltreatment Table 1. The Relationship Between Parentat Substance Abuse and the Type of Maltreatment Experienced by the Child Type of Child Maltreatment
Substance Abused Physical
Sexual
96 of Parents committing This Form of Maltreatment
% of Parents Committing This Form of Maltreatment
N
%
X2
P
%
X2
73 117
70% 44%
12.48
PARENTAL
0145-2134/92 $5.00 + .oO Copyright 0 1992 Pergamon Press Ltd.
1992
SUBSTANCE ABUSE AND THE NATURE OF CHILD MALTREATMENT RICHARD FAMULARO
Boston Juvenile Court; Massachusetts Department of Mental Health; Department of Pediatrics, Franciscan Children’s Hospital; Department of Psychiatry, The Children’s Hospital; Harvard Medical School. Boston, MA
ROBERT
KJNSCHERFF
Boston Juvenile Court; ~pa~ment of Psychology, Judge Baker Children’s Center; Special Research Fellow, Department of Pediatrics, Franciscan Children’s Hospital; Department of Psychiatry, Harvard Medical School, Boston, MA
TERENCE FENTON Department of Biostatistics, Harvard School of Public Health, Boston, MA
Abstract-The authors reviewed 190 randomly selected records from the case load of a large juvenile court. These records involved cases in which the state took legal custody of the children following a finding of significant child maltreatment, based on a “clear and convincing” standard of evidence. Sixty-seven percent (127/190) of these cases involved parents who were classified as substance abusers. The results of this study revealed specific associations between (a) alcohol abuse and physical maltreatment and (b) cocaine abuse and sexual maltreatment. Logistic analyses, testing for the effects of polysubstance abuse, revealed that additional forms of substance abuse failed to add signifi~ntly to the effects of alcohol in predicting physical maltreatment or cocaine in predicting sexual maltreatment. Key Words-Cocaine,
Alcohol, Substance abuse, Child maltreatment,
Child abuse.
INTRODUCTION IN THE PAST decade, child maltreatment and substance abuse have both emerged as critical issues for public policy and clinical practice. In the state in which the present study was conducted, as well as in most other states, children alleged to have suffered physical and/or sexual maltreatment are subject to particular care and protection by the state. The purpose is to guarantee that children “are protected against the harmful effects resulting from the absence, inability, inadequacy, or destructive behavior of parents or parent substitutes, and to insure good substitute parental care in the absence, temporary or permanent, inability or
This research was funded by the National Center on Child Abuse and Neglect (NCCAN), Department of Health and Human Services, Grant #go-CA- 1408. Received for publication November 2, 1990; final revision received January 22, 199 1; accepted January 22, 199 1. Requests for reprints may be sent to Richard Famularo, M.D., Boston Juvenile Court Clinic, New Court House, Room 2 10, 17 Somerset Street, Boston, MA 02 108.
476
R. Famularo, R. Kinscheti,
and T. Fenton
unfitness of parents to provide care and protection for their children” (Massachusetts General Law, 1988). It is increasingly clear that parental substance abuse often contributes to severe family dysfunction and elevates the risks of child maltreatment. For example, parental alcoholism has been associated with child maltreatment (Behling, 1979; Famularo, Stone, Barnum, & Wharton, 1986; Kaplan, Pelcovitz, & Salzinger, 1983), marital conflict (Reich, Earls, & Powell, 1988), domestic violence (Fitch & Papantonio, 1983), and increased risk of long-term psychiatric and social dysfunction among children raised in alcoholic homes (Black, Bucky, & Wilder-Padilla, 1986). Not surprisingly, particularly high rates of family violence have been documented when the alcoholic parent also presents with antisocial personality disorder and/or recurrent depressions (Bland & Orn, 1986). Much less is known and documented about the risks of child maltreatment associated with parental cocaine use. This is true despite the prevalence of cocaine use and evidence that cocaine dependency can substantially incapacitate the user (Castellani, Petrie, & Ellinwood, 1985; Weiss & Mirin, 1986). A May 1990 United States Senate Judiciary Committee study yielded an “extremely conservative” estimate that some 2.2 million Americans are “hard core” cocaine addicts (Committee on the Judiciary, United States Senate, 1990). Such users are reportedly over represented among the homeless and persons arrested for crimes (Committee on the Judiciary, United States Senate, 1990). The report went on to note: The addicts who break into our homes, turn our neighborhoods into war zones, and spread disease by selling their bodies are not casual, once-a-month users of illicit drugs-they are America’s hard core addicts. The children of the hard core addict suffer even more severely, often from physical abuse, and always from neglect. (Committee on the Judiciary. United States Senate, 1990, p. 22)
Cocaine exposure in pregnant women, adolescent mothers, and newborns is common enough to prompt medical investigation (Chasnoff et al., 1985; Kozel & Adams, 1986; Osterloh & Lee, 1989; Shannon, Lacouture, Roa, & Woolf, 1989) and policy debates on the problem of “crack babies” and intraute~ne cocaine exposure. A recent study (Amaro, Zuckerman, & Cabral, 1989) found that a majority of a sample of pregnant adolescents had used substances during pregnancy. One in six specifically acknowledged using cocaine during pregnancy. Comparisons between pregnant drug users and nonusers found that the former were more likely to report factors that have also been associated with increased risks for child maltreatment‘ These include drug use itself (Regan, Erlich, & Finnegan, 1987), financial stresses, and a history of criminal activity or legal involvement. Drug-abusing pregnant adolescents were also twice as likely to have a history of venereal disease (suggesting multiple sexual partners), and an almost three times greater risk of having a male partner who uses marijuana or cocaine. They demonstrated a trend toward increased risk of exposure to abuse themselves, and relative isolation from their own families. In short, these adolescents present with many of the features noted in clinical and empirical literature as high-risk factors for child maltreatment, directly or by failure to establish and maintain stable protective environments. The psychopharmacological effects of cocaine and alcohol among adults must be understood to appreciate the potential cont~bution of these drugs to risk for child maltreatment. Typically, alcohol intoxication is characterized by maladaptive behavior (particularly aggressive and assaultive behavior) and includes central nervous system depression, emotional lability, decreased attentional parameters, irritability, impaired judgement and social or occupational dysfunction. Physiological signs include gait and coordination disturbances, flushing, slurred speech, and nystagmus. Alcohol withdrawal presents in varied manners following cessation or reduction of heavy, continual alcohol ingestion. The presentation includes increased blood pressure and pulse,
Substance abuse and child maltreatment
477
sweating, anxiety, depression, insomnia, headache, weakness, nausea or vomiting, and potentially hallucinosis, illusions, and delirium. Cocaine intoxication, like alcohol intoxication results in impaired and maladaptive behaviors, although cocaine is a central nervous system stimulant. Typical cocaine intoxication includes euphoria, grandiosity, impaired judgement, hypervigilance, agitation, reduced social inhibitions and increased sexual interest. These effects are generally consistent with reports of stimulant use at low-to-moderate doses (Lasagna, von Felsinger, & Beecher, 1955; Nathanson. 1937; Van Dyke, Ungerer, Jatlow, Parash, & Byck, 1982). The rush, secondary to ingestion, may progress to headaches, p~pitations, EKG alterations, visual and/or tactile hallu~inations, and even seizures. Bizarre behavior, stereotypic movements, and paranoid ideation can develop. Following discontinuation, especially after high dose ingestion, a “crash” develops characterized by anxiety, irritability, fatigue, insomnia, depression, psychomotor agitation, further cocaine craving, and even delirium. In cocaine-dependent individuals, withdrawal effects can persist for weeks. Cocaine~ependent users report ihat the risk of moving from controlled to compulsive use escalates with greater access to the drug, or when the cocaine is injected intravenously or smoked (Gawin & Kleber, 1985; Siegel, 1985). A major problem posed by smoked forms of cocaine (“freebase” and “crack”) is that they are now, in some urban areas, widely available cheaply, and are associated with epidemics of smoking and a high level of compulsive use. Such use is characterized by a pattern of binge use of multiple high-dose administrations in which the drug may be ingested many times each day, often with only a few days respite between binges. The absence of daily use may represent a pattern of heavy binge use, rather than moderate controlled use, although this clinical marker is reportedly often misinterpreted (Gawin & Ellinwood, 1988; Gawin & Kleber, 1985). One review of the literature concluded that during binges “nou~shment, sleep, safety, survival, money, morality, loved ones, and responsibility become immaterial” (Gawin & Ellinwood, 1988). Binge ingestion results in the well-known signs of high dose stimulant use, including disinhibition, impulsivity, hypersexuality, poor judgement, extreme hyperactivity, and irritability. Over 80% of regular cocaine users have reported these drug effects (Gold, Washton, & Drakis, 1985). Users also commonly report that continued binge administration results in a euphoria increasingly inte~pted by episodes of intense anxiety, irritability, and panic. Paranoid states and severe transient panics with a fear of impending death can occur. Cocaine abusers report that these states are not uncommon (Gold, Washton, & Dackis, 1985). Children exposed to parents or other adults in their environment impaired by the direct psychopharmacological effects of cocaine ingestion may be at significant risk for lapses in parental care or protection, or may become the direct targets of maltreatment. Additional risk of child maltreatment may be generated by parental cocaine use in the presence of other psychiatric impairments, other sources of family dysfunction, or the demands of parenting in the stressful environmental conditions that prevail in the inner cities or other economically depressed areas. Studies of psychiatric comorbidity among persons undergoing treatment for cocaine abuse indicate that mood disorders (particularly cyclical mood disorders) and residual attention deficit disorder are ove~epresented among cocaine abusers (Gawin & Kleber, 1985, 1984; Weiss, Mirin, Michael, & Sollogub, 1986). The mood disorders exist independently from the dysphoria, anxiety, agitation, and irritability of the “crash” of cocaine withdrawal, and such disorders have been shown to be correlated in complex ways with increased risk of child maltreatment (Famularo, Barnum, & Stone, 1986). The present study focused upon alcohol and illegal drug abuse among families involved with court actions arising from significant maltreatment of their children. The aim of the
478
R. Famuiaro, R. K.insche&, and T. Fenton
study was to examine whether, within such a sample, there were relationships between specific forms of child maltreatment and specific types of substance abuse. The study focused upon cases of severe maltreatment of children, involving either gross neglect or physical and/or sexual maltreatment. It examined whether unique patterns of substance abuse could specifically predict the probability of physical or sexual maltreatment.
METHOD The sample was comprised of 190 previously unreported cases from a large urban juvenile court, involving physical or sexual maltreatment of children, gross neglect, or combinations of the above. Permission was obtained from the chiefjustice and the chief probation oflicer to perform a random review of the records of child “care and protection” cases completed between 1985- 1988. The cases were all selected from actions in which the court had granted a petition to transfer legal custody from the parents due to severe maltreatment of the children. Completed cases were chosen in preference to active cases, since they were more fully documented, and their examination was less intrusive to the court and families. All data were recorded with reference to a confidential identification number. No record of any individual’s name was obtained by the researchers. Each chart was read fully by one or more ofthe authors and reviewed by the principal author. These court proceedings generally represented cases of relatively severe child maltreatment. While there were more than 4,000 cases of alleged child maltreatment in the county where the study was done, only 300-600 new cases per year during the study period were brought before the court to seek transfer of parental custody to the state. Given the legal procedures in place, false positive cases of child maltreatment in this setting were rare. Dichotomous variables representing physical and sexual maltreatment served as dependent variables in this study. Sexual maltreatment was defined as substantiated evidence of physical contact of a sexual nature between the child and parent including genital fondling (either child, adult, or both), attempted intercourse or completed intercourse {anal, oral, or vaginal). Physical maltreatment was defined as substantiated evidence of a form of assault that included closed fist punching, bruising or marking, broken bones, bleeding, or concussion. Independent variables consisted of dichotomous markers indicating whether or not the following substances had been abused: (a) Alcohol, (b) cocaine, (c) opiates, and (d) other. “Substance abuse” for the purposes of this study was established by: (a)substantitzted allegations by two or more separate professionals (social service or mental health) of alcohol and/or drug misuse, or (b) parental self-reports of substance abuse of sufficient severity to meet Research Diagnostic Criteria (Spitzer, Endicott, & Robbins, 1978). Recreational or occasional use alone was not considered “substance abuse.” The scope of the study was limited to cases in which the perpetrator of the maltreatment was one of the child’s parents. Cases in which the perpetrator was not a parent or stepparent living in the home and cases revealing both parents as ~~trators were eliminated from the study. Cases in which relatives or older siblings abused the child were also removed from this study. Data on each identified perpetrator and his/her substance use pattern were recorded on standardized questionnaires during review of the case charts.
RESULTS A preliminary examination of the data indicated that 36 of the 190 cases involved both physical and sexual maltreatment, 66 involved only physical maltreatment, 18 involved only
479
Substance abuse and child maltreatment Table 1. The Relationship Between Parentat Substance Abuse and the Type of Maltreatment Experienced by the Child Type of Child Maltreatment
Substance Abused Physical
Sexual
96 of Parents committing This Form of Maltreatment
% of Parents Committing This Form of Maltreatment
N
%
X2
P
%
X2
73 117
70% 44%
12.48
