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Adverse Childhood Experiences and Subsequent Substance Abuse

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DOI: 10.1080/15564886.2014.971478

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Adverse Childhood Experiences and Subsequent Substance Abuse in a Sample of Sexual Offenders: Implications for Treatment and Prevention Jill Levensona a School of Social Work, Barry University, Miami Shores, Florida, USA Published online: 09 Jan 2015.

To cite this article: Jill Levenson (2015): Adverse Childhood Experiences and Subsequent Substance Abuse in a Sample of Sexual Offenders: Implications for Treatment and Prevention, Victims & Offenders: An International Journal of Evidence-based Research, Policy, and Practice, DOI: 10.1080/15564886.2014.971478

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Victims & Offenders, 00:1–26, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 1556-4886 print/1556-4991 online DOI: 10.1080/15564886.2014.971478

Adverse Childhood Experiences and Subsequent Substance Abuse in a Sample of Sexual Offenders: Implications for Treatment and Prevention

Jill Levenson

School of Social Work, Barry University, Miami Shores, Florida, USA

Abstract: The purpose of this study was to explore the prevalence of substance abuse indicators in a sample of male sexual offenders (N = 679) and to examine the influence of adverse childhood experiences (ACE) on the likelihood of substance abuse outcomes. Half of these sex offenders reported a history of drug or alcohol abuse, and nearly one in five reported a substance-related arrest. Higher ACE scores were associated with endorsement of a greater number of substance-abuse-related problems, suggesting that accumulation of early trauma may increase the likelihood for substance misuse. By enhancing our understanding of the frequency and antecedents of dynamic risk fac- tors such as substance abuse, we can better devise clinical interventions that respond to the comprehensive needs of sexually abusive individuals and reduce risk for sexual reoffense. As well, early interventions for at-risk families and maltreated youth may interrupt their trajectory toward adulthood substance abuse and criminal behavior, including sex offending.

Keywords: addiction, sex offenders, treatment, trauma

Substance abuse is associated with childhood trauma, and individuals who grew up in homes where child maltreatment and household dysfunction were common are at increased risk for substance-related disorders in adulthood (Dube et al., 2001; Dube, Anda, Felitti, Edwards, & Croft, 2002; Dube et al.,

Address correspondence to Jill Levenson, School of Social Work, Barry University, 11300 NE 2nd Avenue, Miami Shores, FL 33161. E-mail: [email protected]

Color versions of one or more figures in the article can be found online at www. tandfonline.com/uvao.

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2003). Sex offenders have higher rates of adverse childhood experiences (ACE) than males in the general population (Jespersen, Lalumière, & Seto, 2009; Levenson, Willis, & Prescott, 2014; Reavis, Looman, Franco, & Rojas, 2013), which can contribute to increased risks for drug and alcohol abuse. The current study investigated the prevalence of substance abuse indicators in a sample of male sexual offenders, and examined the influence of early adverse expe- riences on the likelihood of substance abuse outcomes. It is expected that the study can inform treatment protocols designed to reduce the risk of reoffending for identified sexual abusers by better understanding the variables contribut- ing to this empirically derived dynamic risk factor (Abracen & Looman, 2004; Hanson & Harris, 1998; Långström, Sjöstedt, & Grann, 2004). As well, the link between early adversity and substance abuse has implications for early interventions that can reduce the risk of future criminality for child victims of maltreatment.

ACE SCORES AND SUBSTANCE ABUSE

In one of the largest surveys examining childhood trauma in the general pop- ulation, the Centers for Disease Control (CDC) studied 17,337 patients of a health insurance program in the United States who completed the 10-item Adverse Childhood Experiences (ACE) scale (Felitti et al., 1998). Among males, the ACE study found substantial prevalence rates of child maltreatment, defined as abuse (emotional = 8%, physical = 30%, and sexual = 16%) or neglect (emotional = 12%, physical = 11%). The scale also measured rates of household dysfunction (domestic violence = 12%, parents not married = 22%, or the presence of substance abuse [24%], mental illness [15%], or an incarcerated member of the household [4%]). The ACE study provided com- pelling evidence that child maltreatment and family dysfunction in American households are common.

One’s ACE score reflects the number of different types of adverse child- hood experiences experienced by the individual, and a higher score signifies the accumulation of trauma. Multiple forms of child abuse and household dysfunction often co-occur, and having experienced one adverse event sig- nificantly increases the odds of reporting additional adverse events (Dong et al., 2004). Numerous studies have consistently demonstrated the negative impact of cumulative childhood trauma on behavioral, medical, and psychoso- cial well-being in adulthood (Anda, Butchart, Felitti, & Brown, 2010; Briere & Elliot, 2003; Felitti et al., 1998; Maschi, Baer, Morrissey, & Moreno, 2013). As ACE scores increase, so does the risk for myriad adult troubles, includ- ing chemical dependency, injection drug use, suicide attempts, depression, smoking, heart and pulmonary diseases, fetal death, obesity, liver disease, and intimate partner violence (Felitti et al., 1998). As well, ACE scores are related to risky sexual behavior, including early initiation of sexual

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Adverse Childhood Experiences 3

activity, promiscuity, sexually transmitted diseases, and unintended preg- nancies (Centers for Disease Control and Prevention, 2013a; Felitti et al., 1998).

The ACE study had some important limitations, including the retro- spective data collection and the inclusion of a relatively small domain of maltreatment and family dysfunction variables. The ACE study may actu- ally underestimate the prevalence of childhood trauma, since the sample was highly educated and had health insurance—so impoverished and minority pop- ulations were underrepresented. A nationally representative sample of over 4,000 children and their parents, conducted via a randomized household tele- phone survey, revealed even higher rates of cumulative childhood trauma: two-thirds of the children had been exposed to more than one type of vic- timization and 30% experienced five or more (Finkelhor, Turner, Hamby, & Ormrod, 2011). The deleterious consequences of polyvictimization were evident in higher endorsements of trauma symptoms. Finkelhor, Shattuck, Turner, and Hamby (2013) made attempts to improve the ACE scale by modifying some items and adding additional domains of adversity (e.g., peer victimiza- tion, community violence, illnesses and injuries, socioeconomic status) utilizing nationally representative samples. They found that these modifications led to more robust effects when measuring distress by trauma scores, but confirmed that the child maltreatment items in the original ACE scale remained impor- tant contributors to the cumulative stress of childhood adversity (Finkelhor et al., 2013).

Chief among the sequelae of childhood trauma are substance abuse disor- ders. ACE scores showed a strong graded relationship to younger initiation of illicit drug use, any lifetime drug use, and drug addiction (Dube et al., 2003). Moreover, having a parent who abused alcohol is highly associated with other ACEs (Dube et al., 2001) and in turn heightens the risk for having problematic drinking behaviors oneself in adulthood (Dube et al., 2002). Alcohol and drug abuse is a significant problem in the United States and is exacerbated by a history of trauma. In 2012, over 9% of individ- uals over the age of 12 reported using an illicit drug at least once in the past month, and 6.5% reporting heavy drinking at least five times in the past month—with 23% revealing binge drinking (Substance Abuse and Mental Health Services Administration, 2012b). According to the National Epidemiologic Survey on Alcohol and Related Conditions, about 8.5% of American adults meet criteria for an alcohol disorder, and 2% meet criteria for a drug abuse disorder (National Institute on Alcohol Abuse and Alcoholism, 2006). Post-traumatic stress disorder (PTSD), which can result from child maltreatment experiences, has been found to be associated with having a co- occurring substance abuse diagnosis (Pietrzak, Goldstein, Southwick, & Grant, 2011).

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ACE, Substance Abuse, and Criminal Offenders Childhood trauma is frequently found in the histories of criminal offend-

ers. In a national study of inmates and probationers in the United States, 12% of males and 25% of females reported child physical abuse, while 5% of males and 26% of females reported sexual molestation (Harlow, 1999). Prisoners frequently report witnessing violence in their families of origin and many experienced the death of a family member, parental separation or aban- donment, foster care placement, or parental substance abuse (Courtney & Maschi, 2013; Haugebrook, Zgoba, Maschi, Morgen, & Brown, 2010; Maschi, Gibson, Zgoba, & Morgen, 2011). Prospectively collected data from the Chicago Longitudinal Study (N = 1,539 low-income minority children) highlighted child maltreatment as a predictor of criminal behavior for both boys and girls (Mersky, Topitzes, & Reynolds, 2012). A study of over 64,000 youth involved with the juvenile justice system in Florida revealed significantly higher preva- lence of all ACEs compared to the general population (Baglivio et al., 2014). These juveniles had significantly greater cumulative exposure (higher ACE scores) which were correlated with increased risk of reoffending (Baglivio et al., 2014). Childhood adversity is clearly associated with delinquency and criminality, and greater exposure to adverse events significantly increases the likelihood of mental health problems and serious involvement with drugs and crime (Harlow, 1999; Messina, Grella, Burdon, & Prendergast, 2007).

Substance misuse is among the most pervasive of mental health disor- ders for criminal offenders (Substance Abuse and Mental Health Services Administration, 2012a). According to the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA), in 2012 about 4 million men were on probation or parole, many of whom had a variety of behavioral health problems. Among offenders under community supervision, substance misuse is widespread; in 2012, about 30% of male probationers aged 18 to 49 had an alcohol use disorder, 19% had an illicit drug use disorder, and 40% had either an alcohol or illicit drug use disorder (Substance Abuse and Mental Health Services Administration, 2012a). In any given year, almost half of male offenders on probation or parole need substance abuse treatment; how- ever, only about a quarter receive intervention (Substance Abuse and Mental Health Services Administration, 2012a). Male and female drug-dependent prisoners with greater exposure to childhood adversity entered the criminal justice system and initiated substance use at earlier ages (Messina et al., 2007). In particular, early physical abuse, domestic violence, and traumatic neglect have been associated with increased substance abuse for delinquent youth (Ford, Hartman, Hawke, & Chapman, 2008).

It is unsurprising that early adversity is associated with both criminal behavior and addictive disorders. Chronic exposure to harsh or threatening conditions as a child produces anxiety, anger, and depression, along with a sense of helplessness which can lead to neurobiological changes such as

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hyperarousal (Beech & Mitchell, 2005; Creeden, 2009; Felitti, 2002; Felitti et al., 1998; Whitfield, 1998). High-risk behaviors such as smoking, drug and alcohol abuse, sexual behaviors, and aggression can become self-medication mechanisms because they provide pharmacological and psychological relief from emotional distress. Nicotine and other drugs, as well as sexual or aggres- sive activity, can provide an antidote to anxiety and thus potentiate the addictive nature of these substances and high-risk behaviors (Anda et al., 2006; Felitti et al., 1998; Ford, Fraleigh, Albert, & Connor, 2010; Whitfield, 1998). On the other hand, individuals vary in their responses to trauma and many people demonstrate resilience following adverse circumstances.

ACE, Substance Abuse, and Sex Offenders Sexual offenders have significantly higher ACE scores than males in the

general population (Levenson, Willis, & Prescott, 2014; Reavis et al., 2013). A study of male sexual offenders (N = 679) compared ACE scores to those of males in the CDC sample, finding that sex offenders had more than three times the odds of child sexual abuse, nearly twice the odds of physical abuse, thirteen times the odds of verbal abuse, and more than four times the odds of emotional neglect or coming from a broken home (Levenson, Willis, & Prescott, 2014). Less than 16% of the sex offenders reported no adverse experiences and almost half endorsed four or more. Various maltreatments often coexisted with other types of household dysfunction, suggesting that many sex offend- ers were raised in a disordered social environment by caretakers who were ill-equipped to protect their children from harm. In another study, 9% of inter- personal violence offenders (male child abusers, domestic violence assaulters, sex offenders, and stalkers) reported no adverse events in childhood (com- pared to 38% of males in the original ACE study) and 48% reported four or more adverse experiences (compared to 9% of the males in the ACE study) (Reavis et al., 2013). Weeks and Widom (1998) also found higher rates of early maltreatment for sex offenders, with 26% reporting sexual abuse in childhood, 18% reporting neglect, and two-thirds revealing childhood physical abuse.

Child abuse and neglect occur in a pathogenic environment that can impede healthy functioning across the life span (Cicchetti & Banny, 2014; Rutter, Kim-Cohen, & Maughan, 2006). Developmental psychopathology theo- rists postulate that relational and behavioral patterns result from a dynamic interaction of affective and cognitive processing by which individuals attach meaning to their experiences (Rutter & Sroufe, 2000). Abusive or neglect- ful parenting is characterized by betrayal and invalidation, which contribute to distorted expectations of oneself, others, and relationships, cultivating the formation of maladaptive schema, disorganized attachment styles, and poor affect regulation (Beech & Mitchell, 2005; Chakhssi, Ruiter, & Bernstein, 2013; Loper, Mahmoodzadegan, & Warren, 2008; Young, Klosko, & Weishaar, 2003).

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Developmental theories of antisocial behavior further suggest that incom- petent parenting, harsh punishment, poor supervision, and limited positive family involvement pave the way for conduct problems and delinquent activ- ities (Cicchetti & Banny, 2014; Ford, Chapman, Connor, & Cruise, 2012; Kohlberg, Lacrosse, Ricks, & Wolman, 1972; Patterson, DeBaryshe, & Ramsey, 1990; Rutter et al., 2006). The detrimental effects of complex trauma on biopsychosocial development and attachment increase risk for a range of self- regulation problems including aggression and substance abuse (Ford et al., 2012). Early maltreatment and family dysfunction can lead to mistrust and hostility, which can elicit social rejection and lead to loneliness, negative peer associations, and delinquent behavior. This intricate trajectory is further impacted by cumulating cascade effects, by which an early disadvantage in one domain subsequently impairs functioning and mastery in other developing areas (Masten & Cicchetti, 2010; Rutter et al., 2006).

Insecure attachments can contribute to problematic and coercive interper- sonal styles, which play a role in sexual abuse (Beech & Mitchell, 2005; Grady, Swett, & Shields, 2014; Smallbone, 2006). Such intimacy deficits are related to reoffense risk for convicted sex offenders (Hanson & Morton-Bourgon, 2005; Smallbone, 2006). Molestation in childhood can make a unique contribution to sexually abusive behavior through a number of avenues: compensation for feelings of powerlessness, social learning by which individuals model their own abuser’s behavior and distorted thinking, or through the association of sex- ual arousal with adult-child sexual situations (Seto, 2008). A lack of healthy emotional intimacy in a childhood environment can contribute to subsequent impersonal, selfish, or adversarial relational patterns, and tolerant attitudes toward nonconsensual sex can develop through an individual’s attempt to rec- oncile their own experiences or by adopting the mind-set of abusers in one’s life (Hanson & Morton-Bourgon, 2005). A link found between sex offenders’ ACE scores and risk factors for sexual recidivism suggests that the role of early adversity in the development of sexual aggression is a relevant consideration in treatment (Levenson, Willis, & Prescott, 2014).

As Seto (2008) described, some men who abuse children may have the dis- order of pedophilia while others do not. Ward (2014) described the need for “integrative pluralism” (p. 3) as a way to amalgamate multiple theories of sex- ual offending in a way that recognizes the multidimensionality of the problem. For instance, four distinct but related constructs seem to contribute to sexual offending to a greater or lesser extent for each individual: emotional regu- lation problems, deviant sexual attractions, intimacy and social deficiencies, and offense-tolerant belief systems (Ward, 2014). A challenge for researchers and clinicians is to conceptualize offending patterns according to the complex and interacting biopsychosocial factors that help explain behavior, includ- ing the ways that developmental adversity contributes to the neurobiology of attachment and intimacy (Beech & Mitchell, 2005).

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Sexually abusive behavior and substance misuse may be among the mal- adaptive coping responses that emerge from early traumatic experiences. It is not unusual for sexual offenders to have substance abuse problems; in fact, a recent meta-analysis estimated that about half of sex offenders had a his- tory of substance abuse (Kraanen & Emmelkamp, 2011). Because intoxication can be a significant disinhibitor, several scholars have described substance abuse as an important dynamic (fluctuating and changeable) risk factor for sex offense recidivism (Hanson & Harris, 1998, 2001; Hanson, Morton, & Harris, 2003) and therefore as a relevant treatment target (Andrews & Bonta, 2007, 2010). Drug and alcohol problems are thought to be broadly related to inti- macy deficits and general self-regulation problems for sex offenders (Abracen & Looman, 2004), and substance disorders are a common co-morbid condition with paraphilias and hypersexuality (Kafka & Hennen, 2002). A meta-analysis of 42 studies assessing drug and alcohol misuse among sex offenders found that about half were diagnosed with some sort of substance abuse problem in their lifetime, with alcohol abuse more prominent than drug abuse (Kraanen & Emmelkamp, 2011). Though a history of substance abuse was unrelated to recidivism in an early meta-analysis (Hanson & Bussiere, 1998), other stud- ies have found alcohol and drug abuse to be dynamic predictors of recidivism (Abracen & Looman, 2004; Hanson & Harris, 1998, 2000; Långström et al., 2004). Moreover, measures of alcohol abuse added to the prediction of violent and sexual recidivism as measured by an actuarial instrument (Looman & Abracen, 2011). Thus, substance abuse and its relationship to early adversity is a topic relevant to sex offender treatment and preventing the intergenerational cycle of maltreatment.

Investigations of the effectiveness of sex offender treatment continue to produce mixed results (Hanson, Bourgon, Helmus, & Hodgson, 2009; Hanson et al., 2002; Marques, Wiederanders, Day, Nelson, & van Ommeren, 2005), and meta-analytic researchers have highlighted central weaknesses in research designs that preclude drawing conclusions about the effectiveness of treatment (Långström et al., 2013). While researchers strive to better identify the vari- ables that contribute to reduced recidivism, clinicians are challenged to imple- ment evidence-based methods aimed at preventing victimization and helping offenders build more functional and satisfying lives (Hanson et al., 2009; Ward, Yates, & Willis, 2012; Yates, Prescott, & Ward, 2010). Several scholars have emphasized a need for the field to move toward tailoring treatment plans to individualized risks and needs (Hanson et al., 2009), recognizing the impor- tance of therapeutic engagement and therapist characteristics (Levenson & Macgowan, 2004; Levenson, Macgowan, Morin, & Cotter, 2009; Marshall, 2005; Marshall et al., 2002; Prescott, 2009) and incorporating trauma-informed and relational interventions (Gannon & Ward, 2014; Levenson, 2014; Reavis et al., 2013; Singer, 2013). Thus, therapy outcomes might be improved by treatment models that consider the role of early adversity in the development of coping behaviors such as sexual and substance abuse (Levenson & Prescott, 2014).

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PURPOSE OF THE CURRENT STUDY

The purpose of this study was to explore the prevalence of substance abuse indicators in a sample of male sexual offenders, and to examine the influ- ence of adverse childhood experiences on the likelihood of substance abuse outcomes. By enhancing our understanding of the frequency and antecedents of dynamic risk factors such as substance abuse, we can better devise clinical interventions that respond to the comprehensive needs of sex offender clients and reduce the risk of sexual reoffending.

METHOD

Participants A nonrandom convenience sample of participants was surveyed in civil

commitment (28%) and outpatient (72%) sex offender treatment programs across the United States. A solicitation on the professional list-serv of the Association for the Treatment of Sexual Abusers was posted to recruit program participation. Practitioners who agreed to become data collection sites then invited their clients to participate in the survey. Outpatient sex offender treatment programs typically serve clients who have been mandated to treatment by the court as part of their parole requirements following a criminal conviction, or as part of a family court case plan related to a child pro- tective services investigation. Participants included sex offenders from New Jersey, Illinois, Texas, Florida, Georgia, Maryland, Montana, Washington, and Maine. All clients attending treatment at the outpatient or inpatient programs (approximately 970) were invited to participate, and a total of 709 sex offenders (response rate = approximately 73%) voluntarily agreed to complete the survey.

The sample for the current study was comprised of 679 male adult sex offenders. Females did complete the survey in some sites, but they were excluded from the current analyses and those data have been published else- where. Sample demographics can be found in Table 1. Most participants were white (67%) and a majority (71%) were between 30 and 60 years of age, with 20% under age 30 (7% were 18–25) and 9.6% over age 60. Nearly two- thirds (62%) of the sample had completed high school or obtained a Graduate Equivalency Diploma (GED), and about one in five identified themselves as college graduates. More than half earned less than $30,000 per year in the last year they earned income. Almost half of the sex offenders had never been married, with 16% currently married and 34% divorced or separated.

Table 2 describes the characteristics of the participants, their offenses, and their victims. The offenders had been arrested for a variety of sexual crimes; two-thirds reported that their index offense involved sexual contact

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Table 1: Sample demographics.

Demographic Categories Percent (N = 679) Race

White 67 Minority 32

Age (Years) 18–30 20 31–40 21 41–50 30 51–60 20 Over 60 9

Marital Status Never married 47 Married 16 Divorced/Separated 34 Widowed 3

Education Not high school graduate 18 High school graduate or GED 63 College graduate or higher 19

Income Under $20,000 42 $20,000–$29,999 17 $30,000–$49,999 20 $50,000+ 21

with a minor, and 9% reported sexual assault of an adult. About 9% said they had been arrested for a child pornography offense, 7% for Internet solicita- tion, 3% for exposure of genitals, and less than 1% for voyeurism. Participants answered a series of questions about victim characteristics, taking into account their index offense, any prior arrests, and any undetected offending. Most participants revealed that they had offended against female victims, about one-third said that they had victimized strangers, and more than half reported they offended against prepubescent children (percentages do not add up to 100% because some endorsed multiple categories). It should be noted that although most sex offenses involve perpetrators and victims who are known to each other (Bureau of Justice Statistics, 1997, 2010), this sample was more likely to have a stranger victim, as 28% of the participants were civilly com- mitted; when asked if they had ever had a stranger victim, 62% of the civilly committed offenders endorsed “yes” compared to 25% of the outpatients. Most participants (69%) reported that they had been arrested once for a sex crime, 19% twice, and approximately 12% reported three or more sex crime arrests. Consistent with statutory criteria used to determine whether a person is eli- gible for civil confinement, civilly committed sex offenders had a higher mean number of sex crime arrests (2.3, SD = 1.5) than outpatients (1.2, SD = .79). The median length of time in treatment was 30 months (mode = 24, M = 50, SD = 53).

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Table 2: Offender, offense, and victim characteristics.

Valid N Mean/%

Female victim 681 77% Male victim 676 28% Family victim 677 40% Unrelated victim 677 48% Stranger victim 681 35% Victim under 12 683 52% Teen victim 675 56% Adult victim 673 29% Total sex crime arrests 684 1.58 Total victims 636 20.32+ Ever used force 682 23% Ever used weapon 689 9% Ever caused injury 687 9% Total nonsex arrests 685 1.50 Months in treatment 645 50.09 On probation now 666 61% Months on probation 400 45.21 Lifetime months in prison 670 85.25 Lifetime months on probation 637 47.31

Note: Percentages may not add up to 100% because some categories were not mutually exclusive. +The average number of victims was skewed due to a few high-value outliers. Median number of victims = 2 and mode = 1.

Participants reported a median number of two total victims, including those they had not been arrested for (mode = 1, M = 20, SD = 172). Three participants disclosed that they had over 1,000 victims, while 82% reported 10 victims or less and 67% reported 3 victims or less. Outliers can skew mea- sures of central tendency, and therefore the 5% trimmed mean (excluding the 5% highest and lowest values) was calculated, and the mean number of vic- tims was then found to be 6. It should be noted that noncontact offenders were included in the sample, perhaps explaining some of the outlying cases; for instance, exhibitionism is known to be a highly compulsive and repeti- tive disorder and some men have engaged in the behavior thousands of times (McGrath, 1991; Morin & Levenson, 2008).

Instrumentation A survey was developed for the purpose of collecting data about the

prevalence of early trauma and adult outcomes. The first section of the sur- vey consisted of the Adverse Childhood Experiences (ACE) scale (Centers for Disease Control and Prevention, 2013b), a 10-item dichotomous (yes/no) scale in which participants endorse whether or not they had experiences prior to 18 years of age that included abuse (emotional, physical, and sex- ual), neglect (emotional and physical), and household dysfunction (domestic

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Table 3: ACE item endorsements.

While you were growing up, during your first 18 years of life . . . % “Yes”

Verbal abuse 53.3% Physical abuse 42.2% Child sexual abuse 38% Emotional neglect 37.6% Physical neglect 15.9% Parents not married 54.3% DV in home 24% Substance abuse in home 46.7% Mental illness in home 25.9% Incarceration family member 22.6%

Distribution of ACE Scores (range = 0−10) Mean ACE score = 3.54 0 15.6% 1 13.7% 2 12.8% 3 12.3% 4+ 45.7%

violence, unmarried parents, and the presence of a substance-abusing, men- tally ill, or incarcerated member of the household). One’s total ACE score is a tabulation of the number of items endorsed by that individual (range = 0–10). The ACE categories were originally developed by adapted items from earlier studies: the Conflict Tactics Scale (Straus, Gelles, & Smith, 1990), the Child Trauma Questionnaire (Bernstein et al., 1994) and questions from a survey about sexual abuse (Wyatt, 1985). The ACE items can be seen in Table 3.

The second section of the survey collected information about 40 different adult health, mental health, and behavioral outcomes. Participants were asked to endorse dichotomous (yes/no) items. Findings reported here include only the substance abuse questions, which can be seen in Table 4.

The third section of the survey asked questions about offense history using forced-choice categorical responses in order to ensure anonymity. Questions about the nature of the sex offenses committed were asked, such as victim age, gender, and relationship, as well as the number of prior arrests. No information that could potentially identify offenders or victims was sought.

Data Collection Federal guidelines for human subject protection were followed and the

project was approved by an institutional review board. Clients were invited to complete the anonymous survey during regularly scheduled group therapy ses- sions at participating data collection sites. Clients were instructed not to write their names on the survey, and to place the completed survey in a sealed box with a slot opening. Informed consent was provided in writing and explained

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Table 4: Substance abuse scale items.

As an adult, since you’ve turned 18, which of the following have you ever experienced at any time? % “Yes”

Alcohol abuse (excessive or problematic alcohol use) 44% Illicit drug abuse (excessive or problematic illegal drug use) 33% Prescription drug abuse (excessive or problematic Rx drug use) 12% Marijuana abuse 40% Smoked cigarettes 64% Sought treatment voluntarily for drug or alcohol abuse 24% Been mandated to treatment for drug or alcohol abuse 29% Been told I have developed a medical problem related to smoking

cigarettes 7%

Been told I have developed a medical problem related to drug or alcohol abuse

8%

I’ve been arrested for DUI 17% I’ve been arrested for a drug-related crime 20%

Distribution of Substance Abuse Scores (range = 0–11) Mean = 2.9 0 21.7% 1 17% 2 11.6% 3 11.8% 4+ 37.9%

verbally; however, in order to protect anonymity participants were not required to sign a consent document. Completion of the survey was considered to imply informed consent to participate in the project.

Analyses Descriptive statistics are reported for each of the survey items. Group

comparisons and bivariate correlations were used to examine relationships between variables. Logistic regression was used to explore the influence of ACE score on substance abuse outcomes.

RESULTS

Table 3 displays the proportion of participants endorsing “yes” to each ACE item1. Child maltreatment and household dysfunction were common, with more than half of the participants reporting verbal abuse and parental separa- tion or divorce (53% and 54%, respectively), nearly half reporting household substance abuse (47%), and greater than one-third of participants endors- ing childhood physical abuse (42%), sexual abuse (38%), or emotional neglect (38%). The distribution of ACE scores revealed that fewer than 16% said that they experienced zero adverse childhood experiences, and nearly half endorsed four or more. The mean ACE score was 3.5 (median = 3, SD = 2.74).

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0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

0 1 2 3 4

Susbstance Abuse Score

0-4+

ACE SCORE 0-4+

Figure 1: Average substance abuse scale score by ACE score.

Pearson Correlation = .37, p < .01. Note: scores above 4 on both scales were collapsed into a score of 4+.

Table 4 shows the proportion of sex offenders who endorsed indicators of problematic substance use. Nearly half of the participants reported that they had had a problem with alcohol, and one-third stated that they had engaged in illicit drug abuse. Marijuana use was common as well, and a majority of the offenders said that they had smoked cigarettes. About one-quarter had sought treatment for substance abuse at some time, with a slightly higher proportion indicating that treatment services were mandated in some way. About one in five had been arrested for a drug-related crime, with almost as many reporting a DUI arrest. When the items were tallied into a scale (Cronbach’s alpha = .78), 38% had endorsed 4 or more of the 11 items, and the mean score was 2.9.

ACE scores were significantly correlated with substance abuse scores (r = .37, p < .01). There was a consistent incremental increase in the mean substance abuse score as more ACE items were reported (see Figure 1). In other words, as ACE scores increased, so did the number of substance abuse items endorsed. Those with an ACE score of four or more endorsed more than twice the number of substance abuse items as those with a score of zero. The only single ACE item that was significantly correlated with an elevated substance abuse score was the presence of a substance abuser in the home while growing up.

The substance abuse score was significantly associated with a higher num- ber of nonsex arrests (r = .47, p < .01), lifetime months in prison (r = .28, p <

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14 J. Levenson

.01), and lifetime months on probation (r = .28, p < .01), but not with a higher number of sex crime arrests or total victims. Those who used force, weapons, or caused an injury in the commission of a sex offense had significantly higher substance abuse scores (4.2, 4.5, 4.8, respectively) than those who did not (2.6, 2.8, 2.8, respectively; p < .001). Civilly committed offenders had higher ACE scores (4.5 versus 3.2, respectively; p < .001) and substance abuse scores (3.6 versus 2.7, respectively, p < .001). Those with adult victims had signifi- cantly higher (p < .001) mean ACE scores (4.4 versus 3.2) and substance scores (3.8 versus 2.6) than those with child victims.

Child molesters are more likely to specialize in sex offending, while rapists of adults tend to be more versatile across their criminal careers (Harris, Knight, Smallbone, & Dennison, 2011; Harris, Smallbone, Dennison, & Knight, 2009; Lussier, LeBlanc, & Proulx, 2005). Versatile sex offenders are more likely than specialists to possess traits of general antisociality rather than sexual deviance (Harris et al., 2009). Since civilly committed offenders and those with adult victims may be different from their outpatient and minor-abusing counterparts, ACE items were entered into a hierarchical multiple regression analysis to predict the substance abuse score while controlling for civil commit- ment status (yes/no) and adult victim (yes/no). Civil commitment and adult victim variables were entered in step 1, and explained about 4% of the vari- ance in the substance abuse score, with adult victim contributing significantly to the model (p < .001) and civil commitment showing a p value of .058. ACE items were entered in step 2, improving the model and explaining 16% of the variance in the dependent variable. This change was significant, F (10, 577) = 9.515, p < .001.Within the final model, substance abuse in the childhood home and having adult victims were the significant predictors of a higher substance score.

Logistic regression is used to examine the influence of an independent variable on a dichotomous dependent variable, and in this case was used to explore the influence of the total ACE score on each substance abuse outcome. The Wald statistic is calculated for each independent variable to determine the statistical significance of the value of β, the correlation coefficient which measures the strength of the relationship (Pampel, 2000). The square of the ratio of β to the standard error (S.E.) equals the Wald statistic. The Wald statistic indicates whether the variable is a significant (p < .05) predictor and contributes to the model more than would be expected by chance. Exp(B) is the proportional change in the odds of the outcome occurring for each unit increase in the independent variable (ACE score). When the odds ratio is greater than 1, increasing values of the independent variable increase the odds of the dependent variable’s occurrence.

Table 5 illustrates that as ACE scores increased by one point, the likelihood of alcohol abuse in adulthood increased by 29%, illegal drug abuse by 24%, marijuana abuse by 22%, and smoking cigarettes by 14%. A one-point increase

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Table 5: Logistic regression: ACE score predicts substance abuse.

β Wald Sig. Exp(B)

Alcohol abuse .257 61.529 .000 1.292 Illegal drug abuse .219 44.691 .000 1.244 Rx drug abuse −1.951 260.068 .000 .142 Marijuana abuse .200 40.400 .000 1.221 Smoking cigarettes .134 17.575 .000 1.143 Sought treatment for drug or alcohol abuse .201 33.309 .000 1.223 Mandated treatment for drug or alcohol

abuse .187 32.224 .000 1.206

Developed medical problem related to smoking cigarettes

.214 14.955 .000 1.239

Developed medical problem related to drug or alcohol abuse

.117 6.913 .009 1.124

Arrested for DUI .033 .736 .391 1.034 Arrested for drug related crime .097 7.174 .007 1.101

in the ACE score increased the likelihood of seeking voluntary or mandatory treatment for substance abuse by 22% and 21%, respectively. As ACE scores increased, sex offenders were 23% more likely to develop medical problems related to cigarettes and 12% more likely to develop health consequences of drug or alcohol abuse. Increased ACE scores increased the likelihood of being arrested for a drug-related crime by about 10%.

DISCUSSION

The results indicate that childhood adversity may increase the risk for sub- stance abuse problems in adulthood for male sex offenders. Consistent with past research (Kraanen & Emmelkamp, 2011), about half of these sex offenders reported a history of drug or alcohol abuse, and many reported substance- related arrests. Higher ACE scores were associated with endorsement of a greater number of substance abuse items, suggesting that an accumulation of early trauma increased the likelihood of adult substance abuse. Substance abuse behaviors were reported by a substantial portion of the sample, and 38% endorsed four or more items. Related medical and legal consequences were reported with moderate frequency. About one-quarter sought treatment for alcohol or drug abuse at some point in their lives. Substance abuse scores were higher for those sex offenders who used force, weapons, or physical violence during a sex offense, and for those with adult victims. Having a substance- abusing household member as a child was a significant predictor of a higher substance score, suggesting a possible modeling effect. However, parental sub- stance abuse can also lead to inept parenting, lack of supervision, and chaotic household dynamics, which increase risk for other child maltreatments and subsequent delinquency and addiction. These findings have implications for

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sex offender treatment as well as for interrupting the cycle of interpersonal violence for maltreated children.

Implications for Practice First, the results underscore the need for sex offender clinicians to assess

substance abuse behaviors and to incorporate pertinent treatment plans. Drug and alcohol abuse is identified as a dynamic risk factor for sexual recidivism because it impairs judgment, interferes with impulse control, and lowers inhi- bitions. Sex offenders with a history of substance misuse should be assessed on an ongoing basis and indicators of current use should be addressed in the treat- ment setting. Substance abuse relapse should raise a red flag for the possibility of sexual and nonsexual criminal recidivism. Interventions that help to pre- vent substance relapse can occur within sex offender treatment settings and in other related venues such as 12-step program meetings, and are relevant to protecting the community from repeat offending.

In addition, the potential role of cumulative trauma in the development of high-risk behaviors should be recognized by sex offender clinicians, with assessment for trauma history an essential part of every clinical evaluation. In a study of male survivors of child sex abuse, post-traumatic growth was enhanced when the individual developed a better understanding of the per- sonal meaning he attached to his abuse and the impact on his life (Easton, Coohey, Rhodes, & Moorthy, 2013). Because male survivors often have psy- chological and behavior problems including substance abuse, opportunities to explore the possible connections between sexual trauma and adult func- tioning can promote emotional growth and behavioral change (Easton et al., 2013). Sex offenders’ perception of the maltreatment events early in their lives have been shown to affect their ways of coping with childhood violence and the associated emotions (Abbiati et al., 2014) . Thus, discussion with clients about the impact of traumatic childhood environments on adult behavior might lead to improved therapeutic outcomes for sex offenders (Abbiati et al., 2014), including reduction of anxious and insecure attachment styles (Grady et al., 2014).

To this end, trauma-informed care (TIC) recognizes the prevalence of early trauma and the impact of violence and victimization on psychosocial develop- ment and coping strategies (Elliott, Bjelajac, Fallot, Markoff, & Reed, 2005; M. E. Harris & Fallot, 2001). TIC is now becoming more common in chemi- cal dependency programs (M. E. Harris & Fallot, 2001; Substance Abuse and Mental Health Services Administration, 2013) and in correctional settings for females (Covington, 2007; Covington & Bloom, 2007). An adverse family atmosphere can create a fertile breeding ground for maladaptive interpersonal patterns, including sexually abusive tendencies. Sex offenders may be among those most in need of TIC, and some researchers have specifically called for

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the implementation of trauma-informed and relational models of sex offender treatment that attend to early maladaptive schema and attachment issues (Abbiati et al., 2014; Chakhssi et al., 2013; Grady et al., 2014; Levenson, 2014; Levenson et al., 2014; Reavis et al., 2013; Singer, 2013).

Practitioners who establish a trauma-informed therapy environment understand that validating the subjective nature of trauma is a central com- ponent of the healing process. TIC emphasizes strengths over pathology and skills-building over symptom reduction, delivering services in a manner that is relevant to the needs of trauma survivors, including those who have per- petrated interpersonal violence. Above all, TIC ensures that the dynamics of disempowering early relationships are not unwittingly replicated in the ther- apeutic encounter (Elliott et al., 2005; M. E. Harris & Fallot, 2001). Some scholars have already begun to emphasize the importance of providing treat- ment to offenders which models compassion and respect while maintaining an atmosphere of accountability without overt confrontation (Marshall, 2005; Marshall, Burton, & Marshall, 2013; Yates et al., 2010).

Implications for Policy In terms of policy, the more we learn about early adversity, the more we rec-

ognize that early intervention with at-risk families is crucial. The cumulative stress of childhood trauma leads to social, emotional, and cognitive impair- ment, facilitates the adoption of high-risk behaviors as coping strategies, and culminates in the development of psychosocial problems and premature mor- tality at rates higher than in the general population (Felitti et al., 1998). Adverse childhood experiences have been referred to as a public health cri- sis (Anda et al., 2010; Felitti, 2002) and prioritizing preventive interventions would benefit youngsters growing up in disadvantaged environments as well as society over the long term.

American social policies have been largely reactive to problems of child maltreatment, strongly emphasizing the role of offender punishment and child placement in lieu of primary prevention. There is a compelling research literature indicating that children who experience early adversity are at increased risk for polyvictimization and subsequently for more pervasive trauma symptoms (Finkelhor et al., 2011). As well, children who experience chronic maltreatment and family dysfunction are more likely than nonabused youngsters to become the addicts and criminal offenders of the future (DeHart, 2009; DeHart, Lynch, Belknap, Dass-Brailsford, & Green, in press; Harlow, 1999; Mersky et al., 2012; Topitzes, Mersky, & Reynolds, 2012; Widom & Maxfield, 2001). There is little resistance to funding criminal justice initia- tives, while prevention programs and social services are typically among the first to be cut from legislative budgets. However, it is critical for victims of child abuse to receive therapy and counseling, for abusive parents to receive

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intervention services, and for the criminal justice community to recognize that self-regulation difficulties may be symptomatic of ACEs (Baglivio et al., 2014). Investing in a comprehensive array of prevention and early intervention ser- vices for abused children and at-risk families is an important step in halting the cycles of interpersonal violence and addiction in our communities (Anda et al., 2010; Baglivio et al., 2014).

A final policy consideration is the availability and accessibility of reentry support services for convicted sex offenders. Following release from prison, sex offender registration creates social and pragmatic barriers to reintegration, including employment obstacles, housing instability, and estrangement from family and support systems (Jeglic, Mercado, & Levenson, 2011; Levenson & Cotter, 2005; Tewksbury, 2005). Few reentry services exist in many com- munities to help offenders rebuild a productive and meaningful life, leading many of them to encounter profound disempowerment, hopelessness, shame, and stigmatization (Jeglic et al., 2011; Levenson & Cotter, 2005; Levenson, D’Amora, & Hern, 2007; Mercado, Alvarez, & Levenson, 2008; Tewksbury & Mustaine, 2009). Facing obstacles to community reentry, many sex offenders describe a sense of despondence that challenges their already limited coping skills. At times of crisis, people are more likely to resort to the familiar (albeit dysfunctional) coping strategies that served them in the past, including self- medication with drugs or alcohol. The stigma of sex offender registration may create psychosocial stressors that reactivate feelings of childhood trauma (iso- lation, shame, rejection) and contribute to the possibility of substance relapse for some offenders. Employment, housing, substance abuse, and mental health services should be readily available in our communities to help sex offenders achieve reintegration in productive and fruitful ways, thus minimizing the risk to children and other potential victims.

Limitations There were some limitations to this study. First, all information was pro-

vided by offender self-report, so responses may be biased by impression man- agement or by a desire to hide embarrassing behaviors or experiences. As well, some offenders may not readily recognize adverse childhood experiences as pertaining to themselves, perhaps underreporting early child maltreatment. It is also possible that some offenders embellish early trauma or substance use reports in order to gain sympathy from therapists or to obfuscate personal responsibility.

The collection of substance abuse outcomes in this study simply con- sisted of asking a series of yes/no questions. In retrospect, a screening instrument measuring substance disorder symptoms (e.g., a Diagnostic and Statistical Manual of Mental Disorders V criteria checklist or an assessment

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tool such as the MAST or DAST) might have added informative elements to the self-reported data. The new dimensional approach to the diagnosis of substance disorders in the DSM-V (American Psychiatric Association, 2013) assesses drug and alcohol use on an incremental scale by adding up the num- ber of substance disorder symptom criteria reported by an individual in order to determine the existence of a mild, moderate, or severe disorder. In a similar vein, our admittedly less sophisticated substance abuse scale simply tallied the number of items that applied to each participant as an indication of the severity of the problem. We did not ask about substances used at the time of the commission of a sex offense, which might have revealed valuable infor- mation. The information obtained, therefore, is limited to relatively simplistic measures of self-reported substance use behaviors over the life span.

Given the retrospective and cross-sectional design, and the dichotomous nature of measurement, statements of causal influence cannot definitively be made. Substance abuse does not cause sexual assault but can facilitate abuse by lowering inhibitions, and may play a larger role in situational or opportunis- tic sexual assaults rather than those committed by offenders who are more paraphilic (Seto, 2008). These exploratory analyses do support other research, however, that a relationship exists between early adversity and adult drug or alcohol abuse.

Conclusions Nearly half of these sex offenders reported a history of substance misuse

problems, resulting, for many of them, in arrests, health problems, and man- dated interventions. Sex offender treatment providers should recognize the prevalence of substance misuse and its relationship to early family dysfunction in the lives of clients. While substance abuse does not cause sexually abusive behavior, it can facilitate sexual abuse by reducing inhibitions and impair- ing judgment and impulse control. Because substance abuse is a dynamic risk factor for reoffending, sex offender treatment models should integrate trauma- informed interventions that respond to the needs of clients who tend to turn to substances to manage emotional dysphoria. As well, early interventions for at-risk families and maltreated youth may interrupt their trajectory toward adulthood criminal behavior, including sex offending and substance abuse.

NOTE

1. These data have been published elsewhere (Levenson, Willis, & Prescott, 2014), but for the convenience of the reader are provided here.

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