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Caregiver Substance Use and Child Outcomes: A Systematic Review Michele Staton-Tindall PhD a , Ginny Sprang PhD b , James Clark PhD c , Robert Walker MSW LCSW d & Carlton D. Craig PhD a a Associate Professor, College of Social Work, University of Kentucky, Lexington, Kentucky, USA b Professor, College of Medicine, University of Kentucky, Lexington, Kentucky, USA c Professor, School of Social Work, University of Cincinnati, Cincinnati, Ohio, USA d Assistant Professor, College of Social Work, University of Kentucky, Lexington, Kentucky, USA Version of record first published: 19 Feb 2013.
To cite this article: Michele Staton-Tindall PhD , Ginny Sprang PhD , James Clark PhD , Robert Walker MSW LCSW & Carlton D. Craig PhD (2013): Caregiver Substance Use and Child Outcomes: A Systematic Review, Journal of Social Work Practice in the Addictions, 13:1, 6-31
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Journal of Social Work Practice in the Addictions, 13:6–31, 2013 Copyright © Taylor & Francis Group, LLC ISSN: 1533-256X print/1533-2578 online DOI: 10.1080/1533256X.2013.752272
ARTICLES
Caregiver Substance Use and Child Outcomes: A Systematic Review
MICHELE STATON-TINDALL, PHD Associate Professor, College of Social Work, University of Kentucky, Lexington,
Kentucky, USA
GINNY SPRANG, PHD Professor, College of Medicine, University of Kentucky, Lexington, Kentucky, USA
JAMES CLARK, PHD Professor, School of Social Work, University of Cincinnati, Cincinnati, Ohio, USA
ROBERT WALKER, MSW, LCSW Assistant Professor, College of Social Work, University of Kentucky, Lexington, Kentucky, USA
CARLTON D. CRAIG, PHD Associate Professor, College of Social Work, University of Kentucky, Lexington, Kentucky, USA
In spite of widespread concern that children living with sub- stance-misusing caregivers are experiencing greater risk for maltreatment, little research examines the direct effects of caregiver substance use on child outcomes. This systematic review inves- tigates the work done within and across disciplines of adult substance abuse, child welfare, and child mental health, includ- ing the measurement of key terms, conceptualization of primary variables, and suggested implications for translational science to practice. The findings of the review show considerable shortcomings for examining this complex problem. To move research forward, we suggest ways to improve measures and methods to provide more robust support for inferences about child maltreatment and mental health outcomes.
Received April 23, 2012; revised July 23, 2012; accepted October 4, 2012. Address correspondence to Michele Staton-Tindall, University of Kentucky, College of
Social Work, 659 Patterson Office Tower, Lexington, KY 40506-0027, USA. E-mail: mstindall@ uky.edu
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Abstract:
Caregiver Substance Use and Child Outcomes 7
KEYWORDS caregiver substance use, child maltreatment, child trauma, child welfare, systematic review
The National Center on Addiction and Substance Abuse (CASA) estimates that about 50% of U.S. children live with a caregiver who uses alcohol, illicit substances, or tobacco (CASA, 2005). Tobacco is the most common substance used in many of these homes (approximately 27 million), but an estimated 17 million children are exposed to caregivers engaging in binge drinking, and 9.2 children million have caregivers using illicit sub- stances (CASA, 2005). The Substance Abuse and Mental Health Services Administration (SAMHSA) recently reported that more than 8 million chil- dren between 2002 and 2007 lived with at least one caregiver who abused alcohol or used illicit substances during the past year or was dependent on those substances (National Survey on Drug Use and Health [NSDUH], 2009).
The relationship between caregiver substance misuse and child maltreatment has been the target of research in the clinical and empirical literature for many years (Dunn et al., 2002; Johnson & Leff, 1999; Magura & Laudet, 1996; Testa & Smith, 2009; Wells, 2009). A number of reasons have been offered for why substance misuse adversely affects children. The abuse of substances can diminish caregivers’ ability to respond to children’s cues for nurturing, and can impair judgment of priorities related to care, supervision, and guidance (Testa & Smith, 2009). Caregiver involvement with drug-using lifestyles often leads to unstable and chaotic home environments for chil- dren and can even involve exposure to crime or toxic substances. Caregiver substance misuse can also seriously affect caregiver expression of emotion, which can interfere with secure caregiver–child attachments. These prob- lems then can lead to negative consequences for children’s development of emotional regulation, confidence, social skills, and trustful relationships with others (Department of Health and Human Services [DHHS], 2009). Research indicates that these children disproportionately suffer from other mental health, behavioral, and academic problems (DHHS, 2009). Caregiver sub- stance misuse has also been documented as a powerful predictor of severity of maltreatment of children (Sprang, Clark, & Bass, 2005).
In addition, caregiver substance misuse is among the most powerful and robust predictors of children developing addiction disorders as adoles- cents (e.g., Widom, White, Czaja, & Marmorstein, 2007), and this suggests that substance use among adolescents is a coping strategy to deal with their chaotic and violent family lives (Kilpatrick, Acierno, Saunders, Resnick, & Best, 2000). Such adolescents are more likely to become involved with the criminal justice system (Huebner & Gustafson, 2007; Murray, Janson, & Farrington, 2007).
Given the findings about the effects of caregiver substance misuse on children, research that concurrently examines these effects from both the
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Introduction:
Problem description-
caregivers' substance use and children exposed to SU
Relationship between caregivers' SU and maltreatment
Problems' effects- caregivers' SU associated with other problems in children experiencing maltreatment
8 M. Staton-Tindall et al.
caregiver and child perspective is very limited. Typically, the research has either examined maltreatment among children with some consideration for caregiver substance misuse, or it has been focused on adult substance abuse, with peripheral examination of parenting behaviors. Thus, one body of literature has taken a child protective interest as it examines caregiver sub- stance misuse (Johnson & Leff, 1999; Kroll, 2004). Another very large body of research has looked at adult substance misuse patterns and the interests and needs of these individuals for treatment and rehabilitation (Magura & Laudet, 1996; Testa & Smith, 2009). The difference in perspectives between child protective interests and adult rehabilitation mirrors the tension in public policy between goals of child protection versus family reunification. These dual foci are often at odds in cases when both cannot be satisfied and one interest must predominate. Thus far, the literature has done little to bridge the gap between these two perspectives by examining how integrated treat- ment (for substance misuse and parenting) or other interventions might serve both goals. These distinct research perspectives have yielded important infor- mation for the substance misuse and child maltreatment fields, but they pose challenges to practitioners and policymakers when converting scien- tific information into either policy or practice. It is reasonable to speculate that the relationships among these phenomena are not simple and universal across all caregiver–child configurations, and that their effects will vary for different children living in various contexts.
The purpose of this article is to review relatively current literature that examined caregiver substance misuse as it impacts or influences child maltreatment with consideration for the specificity of substance use mea- sures, child maltreatment measures, and the degree to which studies could link caregiver substance use with child outcomes. Essentially, the question revolved around how well the emerging literature steps outside the two research silos of child maltreatment and substance abuse.
To explore this problem, a review was conducted to examine relevant, empirical work that has been accomplished within and across disciplines of adult substance misuse, child welfare, and child mental health. The objec- tives were to include literature that (a) examined measurement of caregiver substance use as an independent variable, (b) examined child maltreatment as a dependent variable, and (c) examined the implications of the existing research for addressing this problem.
METHOD
Systematic Literature Review and Analysis
This review was based on literature searches of peer-reviewed articles in scholarly databases. One primary search engine was Academic Search Premier (ASP), which enabled searches in Medline, PsychINFO, and Social
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Discussing how these problems and issues have been dealt in the literature to find gaps to propose research question.
Purpose of the study
Objectives of the systematic review
search database and search criteria
Caregiver Substance Use and Child Outcomes 9
Work Abstracts. Given the medical implications of substance misuse and child maltreatment, PubMed (PM) was also utilized. Primary search terms with the initial number of displayed articles for those terms in parenthe- ses were caregiver substance use and child maltreatment (7 articles ASP, 9 articles PM), caregiver substance use and child neglect (3 articles ASP, 31 articles PM), caregiver substance use and child abuse (10 articles ASP, 30 articles PM), parental substance use and child neglect (22 articles ASP, 332 articles PM), and parental substance use and child abuse (60 articles ASP, 331 articles PM). Given the large body of research on child trauma in relation to caregiver behavior, we also included “caregiver substance use and child trauma” in the search terms, but curiously, this only yielded four articles across both search engines (ASP and PM). One of the articles was repeated under the other search terms, and the other three articles did not meet search criteria for the study. Therefore, for consistency and clarity of operationalization, the primary dependent variable search term focused on issues related to child maltreatment rather than child trauma.
From the initial display of articles for each of these terms, final articles were selected for systematic review based on meeting the targeted criteria for this review based on the following decision rules:
1. Articles had to be empirical, data-driven studies (no literature reviews or meta-analyses).
2. Parental or caregiver substance use must have been used as an inde- pendent variable. For example, articles that included substance use as a covariant or mediating variable were not included in this analysis.
3. The primary dependent variable for the study must have focused on the child—including any form of child maltreatment such as neglect or abuse, accidental injury, or behavioral or psychological outcome.
4. The analytic approach was intended to examine the relationship between caregiver substance use and child outcomes.
5. Articles with a publication date since 2000 were included to garner the most recent approaches in measurement and the most current thinking in implications for practice and research.
Twenty-three articles met the inclusion requirement for this study. A content analysis approach was used to address each of the primary objec- tives of the article. For Objective 1, the articles were organized to define measurement of key constructs, including substance misuse, child outcomes, and potential covariants used in the analysis. Other key elements of the sam- ple were also outlined for descriptive purposes. For Objective 2, the articles were organized by their outcome relative to child maltreatment, including (a) acts of maltreatment (physical abuse, sexual abuse, neglect, and frequency and severity of harm) or (b) other child outcomes (any and all emotional, cognitive, or behavioral response, typically to either a maltreatment event
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inclusion criteria, how search was conducted, and results
Results and how analysis for each objectives can be performed.
10 M. Staton-Tindall et al.
or response to caregiver substance misuse), and primary findings were described. The table was then reorganized so that child maltreatment out- comes were grouped together and other child outcomes were together to easily compare study findings. For Objective 3, discussion sections of each article were carefully examined and organized into tabular format and com- pared for their implications for particular types of professions. To show the practice relevance for findings, we identified potential user groups broadly into child welfare, child mental health, or adult caregiver substance misuse professions.
RESULTS
Complexity of Measurement
CAREGIVER SUBSTANCE MISUSE
As shown in Table 1, some articles used standardized and widely used sub- stance use assessment tools such as the Addiction Severity Index (Connors- Burrow, Johnson, & Whiteside-Mansell, 2009; Van de Mark et al., 2005), Composite International Diagnostic Interview Short Form (Barth, Gibbons, & Guo, 2006), Michigan Alcohol Screening Test (Jester, Jacobson, Sokol, Tuttle, & Jacobson, 2000; Ondersma, 2002), and the Timeline FollowBack Method (Jester et al., 2000). These tools allowed for assessment of a number of vari- ables to determine indicators of problem severity associated with alcohol or illicit substance use. Using either these or other tools, a few articles examined their primary measure of substance use in terms of frequency of drug and alcohol use (Bailey, Hill, Oesterle, & Hawkins, 2009; Berger, 2005). Although these articles reflect consistency with the overall substance use literature in assessment of problem severity and frequency of use, they were limited in comparison to the larger body of literature on adult substance misuse inde- pendent of relationship to child care or maltreatment. The majority of articles in this review included only a single item indictor of “any substance use,” and the primary method of data collection included secondary analysis from child protective service (CPS) records. Other measures to note included per- ceptions of caregiver substance misuse by the child or adolescent or the CPS worker. Thus across these studies, validated and extensive self-reports, brief self-reports, investigation records, and provider and professional opinions were used, making across-study comparisons impossible.
CHILD MALTREATMENT
Measures of child maltreatment were more clearly defined. Standardized tools such as the Child Behavior Checklist (CBCL; Achenbach, 1991) were commonly used to measure parent’s report of child internalizing behavior and child externalizing behavior (Bailey et al., 2009; McNichol & Tash, 2001;
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T A
B L E
1 M
e as
u re
m e n t Su
m m
ar y
o f Su
b st
an ce
U se
an d
C h il d
O u tc
o m
e V ar
ia b le
s
A u th
o r
C h il d
Sa m
p le
C ar
e g iv
e r
Sa m
p le
Su b st
an ce
U se
M e as
u re
m e n t
C h il d
O u tc
o m
e M
e as
u re
m e n t
B ai
le y
e t al
. (2
0 0 9 )
8 0 8
st u d e n ts
, ag
e s
1 0 – 1 6
P ar
e n ts
o f e le
m e n ta
ry sc
h o o l ch
il d re
n F re
q u e n cy
o f al
co h o l,
m ar
iju an
a, an
d ci
g ar
e tt e
u se
C B
C L
(p ar
e n t e x te
rn al
iz in
g b e h av
io r,
ch il d
e x te
rn al
iz in
g b e h av
io r)
, p ar
e n ta
l m
o n it o ri n g ,
h ar
sh d is
ci p li n e , IP
V B
ar th
e t al
. (2
0 0 6 )
1 ,1
0 1
ch il d re
n in
th e
N SC
A W
d at
a se
t F e m
al e
ca re
g iv
e rs
w it h
at le
as t o n e
in d ic
at o r
o f
su b st
an ce
ab u se
tr e at
m e n t n e e d
A ct
iv e
al co
h o l o r
d ru
g p ro
b le
m ,
n e e d
fo r
su b st
an ce
ab u se
tr e at
m e n t,
p o si
ti v e
sc re
e n
o n
C ID
I- SF
B as
e d
o n
C P S
re p o rt , w
as a
re re
p o rt
o f ab
u se
o r
n e g le
ct fi le
d w
it h in
1 8
m o n th
s o f o ri g in
al ca
se
B e rg
e r
(2 0 0 5 )
2 ,7
6 0
fa m
il ie
s P o p u la
ti o n -b
as e d
te le
p h o n e
su rv
e y
re sp
o n d e n ts
N u m
b e r
o f ti m
e s
u si
n g
d ru
g s
o r
b e in
g d ru
n k
in th
e p as
t y e ar
V io
le n ce
ag ai
n st
ch il d re
n : C o n fl ic
t T ac
ti c
Sc al
e , o th
e r
p h y si
ca l ab
u se
C o n n o rs
-B u rr
o w
e t al
. (2
0 0 9 )
7 0
ch il d re
n e n ro
ll e d
in su
b st
an ce
ab u se
tr e at
m e n t w
it h
m o th
e r
5 5
m o th
e rs
in su
b st
an ce
ab u se
tr e at
m e n t
A d d ic
ti o n
Se v e ri ty
In d e x
F re
q u e n cy
o f e x p o su
re to
v io
le n ce
(T SH
sc al
e )
C ra
n d al
l e t al
. (2
0 0 6 )
3 ,8
0 8
m o th
e r–
ch il d
d y ad
s B
io lo
g ic
al m
o th
e rs
1 y e ar
p o st
p ar
tu m
Se lf -r
e p o rt e d
u se
o f an
y al
co h o l
o r
il li ci
t d ru
g s
Su st
ai n e d
an in
ju ry
re q u ir in
g m
e d ic
al at
te n ti o n
d u ri n g
th e
fi rs
t y e ar
o f li fe
D iL
au ro
(2 0 0 4 )
2 6 1
ch il d re
n , ag
e s
1 m
o n th
to 1 7
y e ar
s A
n y
p ar
e n t o r
ca re
g iv
e r
B as
e d
o n
C P S
re co
rd s,
an y
u se
o f al
co h o l an
d o th
e r
d ru
g s
B as
e d
o n
C P S
re co
rd s,
ty p e
o f
p e rp
e tr at
o r
m al
tr e at
m e n t in
fl ic
te d
(n e g le
ct , ab
u se
) F o rr
e st
e r
(2 0 0 0 )
9 5
ch il d re
n in
C P R
(C P S)
P ri m
ar y
ca re
g iv
e r
o f ch
il d
o n
th e
C P R
in th
e ta
rg e t d is
tr ic
t in
Lo n d o n
B as
e d
o n
C P R , ca
se w
o rk
e r
p e rc
e p ti o n
o f p ar
e n t su
b st
an ce
u se
an d
ar e as
o f “c
o n ce
rn ”
C at
e g o ry
o f C P R
re p o rt : n e g le
ct ,
p h y si
ca l ab
u se
, se
x u al
ab u se
, e m
o ti o n al
ab u se
G ib
b s
e t al
. (2
0 0 8 )
N / A
3 ,9
5 9
ca re
g iv
e r/
so ld
ie r
w it h
a d o cu
m e n te
d ch
il d
m al
tr e at
m e n t
in ci
d e n t
B as
e d
o n
A rm
y C e n tr al
R e g is
tr y
re co
rd s,
an y
al co
h o l o r
d ru
g u se
b y
th e
ch il d
m al
tr e at
m e n t
o ff e n d e r
E ac
h ab
u se
/ n e g le
ct ty
p e
(p h y si
ca l,
e m
o ti o n al
, o r
se x u al
) co
d e d
as m
il d , m
o d e ra
te , o r
se v e re
(C o n
ti n
u ed
)
11
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T A
B L E
1 (C
o n ti n u e d )
A u th
o r
C h il d
Sa m
p le
C ar
e g iv
e r
Sa m
p le
Su b st
an ce
U se
M e as
u re
m e n t
C h il d
O u tc
o m
e M
e as
u re
m e n t
H an
so n
e t al
. (2
0 0 6 )
4 ,0
2 3
ad o le
sc e n ts
, ag
e s
1 2 – 1 7
4 ,8
3 6
p ar
e n t o r
g u ar
d ia
n in
th e
h o u se
h o ld
P ar
e n t- p e rc
e iv
e d
p ro
b le
m w
it h
d ru
g s
o r
al co
h o l b y
th e
ad o le
sc e n t
V io
le n ce
e x p o su
re : se
x u al
as sa
u lt ,
p h y si
ca l as
sa u lt , w
it n e ss
e d
v io
le n ce
M e n ta
l h e al
th o u tc
o m
e s:
P T SD
, m
aj o r
d e p re
ss iv
e e p is
o d e , SA
D Je
st e r
e t al
. (2
0 0 0 )
3 4 0
m o th
e r–
ch il d
d y ad
s 3 4 0
A fr
ic an
A m
e ri ca
n b io
lo g ic
al m
o th
e rs
Se lf -r
e p o rt
al co
h o l:
T im
e li n e
F o ll o w
B ac
k M
e th
o d , M
A ST
; fr
e q u e n cy
o f o th
e r
d ru
g u se
F am
il y
E n v ir o n m
e n t Sc
al e ,
in te
ll e ct
u al
st im
u la
ti o n
an d
e m
o ti o n al
su p p o rt ; C o n fl ic
t T ac
ti cs
Sc al
e M
cG la
d e
e t al
. (2
0 0 9 )
1 1 9
in fa
n ts
o f
su b st
an ce
-u si
n g
m o th
e rs
, 2 3 8
m at
ch e d
co n tr o ls
3 5 7
b ir th
m o th
e rs
A n y
m at
e rn
al d is
cl o su
re o f u se
o r
e v id
e n ce
o f u se
am o n g
in fa
n t
Su b st
an ti at
e d
h ar
m : p h y si
ca l ab
u se
, n e g le
ct , se
x u al
ab u se
, e m
o ti o n al
ab u se
F o st
e r
ca re
p la
ce m
e n t
M cN
ic h o l &
T as
h (2
0 0 1 )
2 6 8
fo st
e r
ca re
ch il d re
n B
io lo
g ic
al p ar
e n ts
B as
e d
o n
C P S
re co
rd s,
ca re
g iv
e rs
g ro
u p e d
b y
p re
n at
al e x p o su
re ,
ac ti v e
d ru
g ab
u se
, n o
d ru
g u se
C B
C L,
co g n it iv
e fu
n ct
io n in
g / IQ
, fo
st e r
ca re
o u tc
o m
e s:
ag e
an d
le n g th
o f st
ay , g e n d e r
d if fe
re n ce
s O
n d e rs
m a
(2 0 0 2 )
C P S
n e g le
ct re
fe rr
e d
ca se
s 2 0 3
fe m
al e
p ri m
ar y
ca re
g iv
e rs
C ar
e g iv
e r
se lf -r
e p o rt
b as
e d
o n
li fe
ti m
e ab
u se
, p ro
b le
m in
p as
t 1 – 5
y e ar
s, an
y tr e at
m e n t o r
se lf -h
e lp
in v o lv
e m
e n t
C P S
co d e s
fo r
n e g le
ct ; C W
B S;
B e av
e rs
fa m
il y
co m
p e te
n ce
sc al
e
O n d e rs
m a
e t al
. (2
0 0 6 )
6 6 5
m o th
e r–
ch il d
d y ad
s B
io lo
g ic
al m
o th
e rs
M A
ST ; ch
il d
re p o rt
(T h in
g s
I H
av e
Se e n
an d
H e ar
d )
C B
C L
e x te
rn al
iz in
g su
b sc
al e ;
e x p o su
re to
v io
le n ce
(T h in
g s
I H
av e
Se e n
an d
H e ar
d T SH
sc al
e )
O st
le r
e t al
. (2
0 0 7 )
2 3
ch il d re
n , ag
e s
7 – 1 4
1 5
b io
lo g ic
al m
o th
e rs
, 1 3
b io
lo g ic
al fa
th e rs
, 2
m o th
e r’ s
p ar
tn e rs
C ar
e g iv
e r
m e th
u se
d o cu
m e n te
d in
C P S
fi le
M e n ta
l h e al
th fu
n ct
io n in
g : C B
C L;
C h il d re
n ’s
D is
so ci
at iv
e C h e ck
li st
; T SC
C Sc
an n ap
ie co
& C o n n e ll -C
ar ri ck
(2 0 0 7 )
9 5
fa m
il ie
s, ch
il d re
n ag
e s
0 – 4 8
m o n th
s 7 7
m o th
e rs
, 8
fa th
e rs
A n y
ca re
g iv
e r
d ru
g u se
as n o te
d in
th e
C P S
fi le
Su b st
an ti at
e d
v s.
n o n su
b st
an ti at
e d
m al
tr e at
m e n t b as
e d
o n
ca se
w o rk
e r
re p o rt
12
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Sp ra
n g
e t al
. (2
0 0 8 )
1 ,1
2 7
ch il d re
n (a
v e ra
g e
ag e
= 5 .1
) 1 ,1
2 7
ca re
g iv
e rs
: b io
lo g ic
al , ad
o p ti v e ,
an d
fo st
e r
A n y
ca re
g iv
e r
d ru
g u se
as n o te
d in
th e
C P S
fi le
T ra
u m
a e x p o su
re : co
d in
g tr au
m a
e v e n ts
u si
n g
T ra
u m
a D
e ta
il F o rm
T ra
u m
a re
sp o n se
: P T SD
A 1
an d
A 2
re sp
o n se
Su n
e t al
. (2
0 0 1 )
2 ,7
5 6
fa m
il ie
s C ar
e g iv
e rs
o f ch
il d re
n re
fe rr
e d
to C P S
B as
e d
o n
C P S
re co
rd s,
in d ic
at io
n o f al
co h o l ab
u se
, d ru
g ab
u se
, b o th
, o r
n e it h e r
R e as
o n
fo r
re fe
rr al
to C P S:
p h y si
ca l
ab u se
, n e g le
ct , e m
o ti o n al
ab u se
, se
x u al
ab u se
, m
e d ic
al n e g le
ct V an
d e
M ar
k e t al
. (2
0 0 5 )
C h il d re
n , ag
e s
5 – 1 0
2 5 3
m o th
e rs
in a
la rg
e r
re se
ar ch
tr ia
l o n
m e n ta
l h e al
th an
d v io
le n ce
A SI
D ru
g C o m
p o si
te C B
C L,
B E R S;
li fe
ti m
e e x p o su
re to
p h y si
ca l o r
se x u al
ab u se
W al
sh e t al
. (2
0 0 3 )
9 ,9
5 3
h o u se
h o ld
s P ar
e n ts
, m
o th
e r,
an d
fa th
e r
A d u lt s’
re tr o sp
e ct
iv e
ac co
u n ts
o f
p ar
e n ta
l su
b st
an ce
u se
w h e n
th e y
w e re
g ro
w in
g u p ;
se lf -r
e p o rt e d
“p ro
b le
m ”
A d u lt s’
re tr o sp
e ct
iv e
ac co
u n ts
o f
p as
t ch
il d
ab u se
o r
m al
tr e at
m e n t,
in cl
u d in
g p h y si
ca l ab
u se
an d
se x u al
ab u se
W o lo
ck e t al
. (2
0 0 1 )
2 3 8
fa m
il ie
s A
n y
ca re
g iv
e r
B as
e d
o n
C P S
re co
rd s,
an y
u se
, o r
se lf -r
e p o rt e d
at su
b se
q u e n t
in te
rv ie
w s
B as
e d
o n
C P S
re p o rt s,
ab u se
an d
n e g le
ct ; ra
te s
o f su
b st
an ti at
e d
ca se
s Y am
p o ls
k ay
a &
B an
k s
(2 0 0 6 )
3 ,6
4 6 ,4
5 0
ch il d re
n fr
o m
b ir th
to 1 8
in F lo
ri d a
D o cu
m e n te
d ca
re g iv
e r
in C P S
ca se
fi le
s B
as e d
o n
C P S
re co
rd s,
an y
d ru
g o r
al co
h o l u se
b y
m al
tr e at
m e n t
p e rp
e tr at
o r
(i n
co m
b in
at io
n o r
al o n e )
B as
e d
o n
C P S
re co
rd s,
ty p e
o f
m al
tr e at
m e n t (a
b u se
, n e g le
ct ,
th re
at ),
co -o
cc u rr
in g
m al
tr e at
m e n t,
re cu
rr e n ce
o f
m al
tr e at
m e n t,
se v e ri ty
o f ty
p e ,
se v e ri ty
o f in
ci d e n t
N o te
s. C B
C L
= C h il d
B e h av
io r
C h e ck
li st
; IP
V =
in ti m
at e
p ar
tn e r
v io
le n ce
; N
SC A W
= N
at io
n al
Su rv
e y
o f
C h il d
an d
A d o le
sc e n t
W e ll -B
e in
g ;
C ID
I- SF
= C o m
p o si
te In
te rn
at io
n al
D ia
g n o st
ic In
te rv
ie w
Sh o rt
F o rm
; C P S
= ch
il d
p ro
te ct
iv e
se rv
ic e s;
D SM
– IV
= D
ia gn
o st
ic a
n d
St a
ti st
ic a
l M
a n
u a
l o f
M en
ta l D
is o rd
er s
(4 th
e d .;
A m
e ri ca
n P sy
ch ia
tr ic
A ss
o ci
at io
n , 2 0 0 0 );
C P R
= C h il d
P ro
te ct
io n
R e g is
te r;
P T SD
= p o st
tr au
m at
ic st
re ss
d is
o rd
e r;
SA D
= su
b st
an ce
ab u se
d is
o rd
e r;
M A ST
= M
ic h ig
an A lc
o h o l
Sc re
e n in
g T e st
; C W
B S
= C h il d
W e ll -B
e in
g Sc
al e ; T SC
C =
T ra
u m
a Sy
m p to
m C h e ck
li st
fo r C h il d re
n ; A
SI =
A d d ic
ti o n
Se v e ri ty
In d e x ; B
E R S
= B e h av
io ra
l an
d E m
o ti o n al
R at
in g
Sc al
e .
13
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14 M. Staton-Tindall et al.
Ondersma, Delaney-Black, Covington, Nordstrom, & Sokol, 2006; Ostler et al., 2007; Van de Mark et al., 2005). Other well-validated tools such as the Conflict Tactics Scale (Straus & Gelles, 1990) were used to examine exposure to specific violent acts between adult caregivers from which infer- ences of traumatic child witnessing could be made (Berger, 2005; Jester et al., 2000). In addition, other scales such as the Things I Have Seen and Heard Scale (Richters & Martinez, 1992) were used to assess exposure to violent activities among children, again allowing for inferences about child trauma or maltreatment (Connors-Burrow et al., 2009; Ondersma et al., 2006). However, the most consistent and widely used dependent variable was the investigator opinion about the presence of suspected or substantiated abuse and neglect charges. As earlier, the primary method of data collection for these variables was extraction from CPS records. This review also found more articles that focused on child welfare and safety issues than issues specific to psychosocial or behavioral outcomes such as trauma or specific developmental consequences.
Child Outcomes
As noted and shown in more detail in Table 2, much of the focus in the literature on the impact of caregiver substance misuse has focused on child maltreatment outcomes. For this analysis, the articles were organized by their outcome relative to child maltreatment, including (a) acts of maltreatment (physical abuse, sexual abuse, neglect, and frequency and severity of harm) or (b) psychosocial and behavioral outcomes (any and all emotional, cog- nitive, or behavioral response typically to either a maltreatment event or response to caregiver substance misuse).
CHILD MALTREATMENT
Consistent with the search terms used for this review, the majority of the 23 articles (65%, n = 15) identified had dependent variables specific to child maltreatment. Caregiver substance misuse was strongly related to findings at the systems level with a number of studies focusing on the number of referrals and rereferrals to CPS for families with a substance-using caregiver compared to other families (Barth et al., 2006; McGlade, Ware, & Crawford, 2009; Yampolskaya & Banks, 2006). Consistently, having a substance-using caregiver was associated with a higher rate of referral to CPS, having a higher rate of rereferrals to CPS, and having a higher rate of substantiated cases within the system. With the estimated current lifetime average cost per vic- tim of child maltreatment at more than $210,000 (Fang, Brown, Florence, & Mercy, 2012), it is imperative that child abuse prevention efforts begin to collaborate with treatment initiatives for substance-misusing caregivers as a way to enhance services to these at-risk families.
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T A
B L E
2 Su
m m
ar y
o f St
u d y
F in
d in
g s
fo r
C h il d
O u tc
o m
e s
A u th
o r
P re
v al
e n ce
o f Su
b st
an ce
U se
P ri m
ar y
F in
d in
g s
fo r
C h il d
M al
tr e at
m e n t
P ri m
ar y
F in
d in
g s
fo r
C h il d
P sy
ch o so
ci al
o r
B e h av
io ra
l O
u tc
o m
e s
H an
so n
e t al
. (2
0 0 6 )
1 8 .4
% o v e ra
ll fo
r an
y fa
m il y
m e m
b e r
(5 0 .6
% al
co h o l
u se
, 1 9 .1
% d ru
g u se
)
P ar
e n ta
l su
b st
an ce
u se
w as
si g n ifi
ca n tl y
as so
ci at
e d
w it h
a h ig
h e r
p ro
p o rt io
n o f
ad o le
sc e n ts
w h o
re p o rt e d
se x u al
as sa
u lt ,
p h y si
ca l as
sa u lt , o r
w it n e ss
e d
v io
le n ce
.
P ar
e n ta
l al
co h o l u se
— b u t n o t d ru
g u se
— in
cr e as
e d
th e
li k e li h o o d
o f p o o r
ad o le
sc e n t m
e n ta
l h e al
th o u tc
o m
e s,
in cl
u d in
g P T SD
, d e p re
ss io
n , an
d su
b st
an ce
ab u se
d is
o rd
e rs
. F in
al ly
, th
o se
w h o
b o th
w it n e ss
e d
v io
le n ce
an d
h ad
an al
co h o l u si
n g
p ar
e n t w
e re
m o st
at ri sk
fo r
M D
E .
Sp ra
n g
e t al
. (2
0 0 8 )
6 8 .1
% su
b st
an ce
u se
(n o t
in cl
u d in
g al
co h o l)
P ar
e n ta
l su
b st
an ce
u se
w as
si g n ifi
ca n tl y
as so
ci at
e d
w it h
in cr
e as
e d
li k e li h o o d
o f
p h y si
ca l ab
u se
, ch
il d
e n d an
g e rm
e n t,
w it n e ss
in g
d o m
e st
ic v io
le n ce
, ch
e m
ic al
e x p o su
re , an
d e x p o su
re to
m u lt ip
le tr au
m as
.
Su b st
an ce
u se
b y
ca re
g iv
e r
in cr
e as
e d
th e
li k e li h o o d
o f e x p o su
re to
ch il d
tr au
m at
ic e v e n ts
. E v e n
th o u g h
5 2 %
o f
th o se
in th
e n o n -s
u b st
an ce
-u se
g ro
u p
w e re
e x p o se
d to
a tr au
m at
ic e v e n t,
ap p ro
x im
at e ly
h al
f h ad
d o cu
m e n te
d re
sp o n se
s th
at m
e t P T SD
C ri te
ri o n
A 2 ,
as o p p o se
d to
al m
o st
tw o
th ir d s
o f th
e su
b st
an ce
-u si
n g
ca re
g iv
e r
g ro
u p .
Je st
e r
e t al
. (2
0 0 0 )
1 3 %
h e av
y d ri n k e rs
at 7 -y
e ar
fo ll o w
-u p ; o n ly
3 0 %
re p o rt e d
ab st
ai n in
g fr
o m
an y
al co
h o l u se
F re
q u e n t h e av
y al
co h o l u se
w as
h ig
h ly
co rr
e la
te d
w it h
in cr
e as
e d
w it n e ss
in g
o f
d o m
e st
ic v io
le n ce
.
F re
q u e n t h e av
y al
co h o l u se
w as
h ig
h ly
co rr
e la
te d
w it h
p o o r
fa m
il y
fu n ct
io n in
g an
d d e cr
e as
e d
in te
ll e ct
u al
st im
u la
ti o n
fo r
ch il d re
n .
O st
le r
e t al
. (2
0 0 7 )
1 0 0 %
m e th
am p h e ta
m in
e u se
N o t d is
cu ss
e d
F in
d in
g s
in d ic
at e d
th at
m o re
th an
h al
f o f
th is
sm al
l sa
m p le
o f ch
il d re
n sc
o re
d in
th e
cl in
ic al
ly o r
b o rd
e rl in
e si
g n ifi
ca n t
ra n g e
o n
th e
C B
C L
an d
m o re
th an
a th
ir d
sc o re
d in
th e
cl in
ic al
ly o r
b o rd
e rl in
e si
g n ifi
ca n t ra
n g e
o f th
e T SC
C .
(C o n
ti n
u ed
)
15
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T A
B L E
2 (C
o n ti n u e d )
A u th
o r
P re
v al
e n ce
o f Su
b st
an ce
U se
P ri m
ar y
F in
d in
g s
fo r
C h il d
M al
tr e at
m e n t
P ri m
ar y
F in
d in
g s
fo r
C h il d
P sy
ch o so
ci al
o r
B e h av
io ra
l O
u tc
o m
e s
M cN
ic h o l &
T as
h (2
0 0 1 )
1 4 %
p ar
e n ta
l su
b st
an ce
u se
N o t d is
cu ss
e d
2 9 .9
% o f fo
st e r
ca re
ch il d re
n sc
o re
d in
h ig
h ra
n g e
o f C B
C L
co m
p ar
e d
to n o rm
at iv
e sa
m p le
s, an
d th
o se
w it h
su b st
an ce
-u si
n g
ca re
g iv
e rs
w e re
m o re
li k e ly
to b e
ra te
d b y
te ac
h e rs
as h av
in g
m o re
b e h av
io ra
l an
d so
ci al
p ro
b le
m s.
B ai
le y
e t al
. (2
0 0 9 )
N o t p ro
v id
e d
N o t d is
cu ss
e d
P ar
e n t su
b st
an ce
u se
w as
re la
te d
to in
cr e as
e d
ch il d
e x te
rn al
iz in
g b e h av
io r
(C B
C L)
in ac
ro ss
-g e n e ra
ti o n
p ai
rs .
G ra
n d p ar
e n t su
b st
an ce
u se
w as
re la
te d
to p ar
e n t e x te
rn al
iz in
g b e h av
io r
as ad
o le
sc e n ts
, w
h ic
h w
as , in
tu rn
, re
la te
d to
th e ir
ad u lt
su b st
an ce
u se
. P ar
e n ta
l ad
u lt
su b st
an ce
u se
w as
as so
ci at
e d
w it h
h ig
h e r
le v e ls
o f
ad o le
sc e n t e x te
rn al
iz in
g b e h av
io r.
V an
d e
M ar
k e t al
. (2
0 0 5 )
9 8 %
o f p ar
e n ts
tr e at
e d
fo r
su b st
an ce
ab u se
p ro
b le
m N
o t d is
cu ss
e d
H ig
h e r
m at
e rn
al sc
o re
s o n
A SI
-D ru
g co
m p o si
te re
la te
d to
h ig
h e r
ch il d
re si
li e n t so
re s
o n
C B
C L
an d
B E R S.
E ig
h ty
-s ix
p e rc
e n t o f ch
il d re
n h ad
sc o re
s in
th e
av e ra
g e
ra n g e
o n
B E R S.
M cG
la d e
e t al
. (2
0 0 9 )
1 0 0 %
se lf -r
e p o rt e d
m o th
e rs
A h ig
h e r
n u m
b e r
o f C P S
re fe
rr al
s w
e re
m ad
e fo
r in
fa n ts
o f su
b st
an ce
-u si
n g
m o th
e rs
(5 1 %
) co
m p ar
e d
to a
m at
ch e d
co n tr o l (6
% )
o f n o n -s
u b st
an ce
-u si
n g
m o th
e rs
. A
ft e r
a n u m
b e r
o f ad
ju st
m e n ts
fo r
co n tr o l v ar
ia b le
s, su
b st
an ce
-u si
n g
m o th
e rs
w e re
m o re
li k e ly
to h av
e su
b st
an ti at
e d
cl ai
m s
o f h ar
m (h
ig h e st
fo r
p h y si
ca l h ar
m an
d n e g le
ct ).
A h ig
h e r
p e rc
e n ta
g e
o f su
b st
an ce
-u si
n g
m o th
e rs
lo st
cu st
o d y
o f th
e ir
in fa
n ts
to fo
st e r
ca re
(2 4 %
) d u ri n g
th e
fo ll o w
-u p , co
m p ar
e d
to co
n tr o l (2
% )
m o th
e rs
.
N o t d is
cu ss
e d
16
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Sc an
n ap
ie co
& C o n n e ll -C
ar ri ck
(2 0 0 7 )
1 0 0 %
fa m
il ie
s A
m o n g
su b st
an ce
-u si
n g
ca re
g iv
e rs
, 5 2 %
h ad
a su
b st
an ti at
e d
m al
tr e at
m e n t ca
se w
it h
C P S.
St u d y
fi n d in
g s
in d ic
at e d
th at
ch il d re
n o f d ru
g - an
d al
co h o l- u si
n g
p ar
e n ts
w e re
m o re
v u ln
e ra
b le
, m
o re
fr ag
il e , an
d le
ss p ro
te ct
e d . T h e y
al so
h ad
le ss
p ar
e n ti n g
ca p ab
il it y , le
ss re
so u rc
e s,
m o re
p ar
e n ti n g
st re
ss , an
d m
o re
st re
ss fu
l h o m
e e n v ir o n m
e n ts
. P ar
e n ts
w h o
u se
d d ru
g s
w e re
al so
fo u n d
to h av
e m
o re
se ri o u s
p at
te rn
s o f m
al tr e at
m e n t an
d m
o re
ch ro
n ic
p at
te rn
s o f m
al tr e at
m e n t
b as
e d
o n
th e
h is
to ry
o f C P S
re p o rt s.
N o t d is
cu ss
e d
Su n
e t al
. (2
0 0 1 )
1 1 %
ca re
g iv
e rs
A n y
ty p e
o f ca
re g iv
e r
al co
h o l o r
d ru
g u se
w as
m o re
li k e ly
to b e
as so
ci at
e d
w it h
su b st
an ti at
e d
ca se
s o v e ra
ll in
C P S
re co
rd s,
b u t p ar
ti cu
la rl y
as so
ci at
e d
w it h
p h y si
ca l ab
u se
an d
n e g le
ct ca
se s.
N o t d is
cu ss
e d
C o n n o rs
-B u rr
o w
e t al
. (2
0 0 9 )
1 0 0 %
m o th
e rs
R e ce
n t su
b st
an ce
ab u se
se v e ri ty
w as
as so
ci at
e d
w it h
ch il d re
n ’s
v io
le n ce
e x p o su
re , w
it h
e x p o su
re to
v io
le n ce
b e in
g h ig
h e r
am o n g
ch il d re
n w
h o se
m o th
e rs
re p o rt e d
h av
in g
m o re
d ay
s w
h e re
th e y
e x p e ri e n ce
d p ro
b le
m s
re la
te d
to th
e ir
d ru
g u se
. In
ad d it io
n , ch
il d re
n ’s
v io
le n ce
e x p o su
re w
as al
so g re
at e r
am o n g
ch il d re
n w
h o se
m o th
e rs
e n d o rs
e d
m o re
b e li e fs
as so
ci at
e d
w it h
ab u si
v e
an d
n e g le
ct fu
l p ar
e n ti n g
o n
th e
A A
P I-
2 .
N o t d is
cu ss
e d
O n d e rs
m a
(2 0 0 2 )
3 1 %
su b st
an ce
ab u se
in fa
m il y
F am
il y
su b st
an ce
ab u se
w as
a si
g n ifi
ca n t
p re
d ic
to r
o f n e g le
ct , e v e n
h ig
h e r
w h e n
co u p le
d w
it h
o th
e r
n e g at
iv e
li fe
e v e n ts
.
N o t d is
cu ss
e d
O n d e rs
m a
e t al
. (2
0 0 6 )
2 5 .6
% A
fr ic
an A
m e ri ca
n m
o th
e rs
M A
ST se
lf -r
e p o rt ,
4 8 .6
% ch
il d
re p o rt
M at
e rn
al su
b st
an ce
u se
v ar
ia b le
e x p la
in e d
n e ar
ly 3 0 %
o f o v e ra
ll v ar
ia n ce
in ch
il d
re p o rt
o f v io
le n ce
e x p o su
re ; st
ro n g e st
p re
d ic
to rs
w e re
w it n e ss
in g
d ru
g d e al
s an
d se
e in
g d ru
g s
in th
e h o m
e .
N o t d is
cu ss
e d
(C o n
ti n
u ed
)
17
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6] a
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3
T A
B L E
2 (C
o n ti n u e d )
A u th
o r
P re
v al
e n ce
o f Su
b st
an ce
U se
P ri m
ar y
F in
d in
g s
fo r
C h il d
M al
tr e at
m e n t
P ri m
ar y
F in
d in
g s
fo r
C h il d
P sy
ch o so
ci al
o r
B e h av
io ra
l O
u tc
o m
e s
C ra
n d al
l e t al
. (2
0 0 6 )
2 %
il li ci
t d ru
g u se
b y
m o th
e rs
T w
o ri sk
fa ct
o rs
w e re
fo u n d
to b e
si g n ifi
ca n t in
p re
d ic
ti n g
in ju
ry re
q u ir in
g m
e d ic
al at
te n ti o n
d u ri n g
th e
fi rs
t y e ar
o f
li fe
: (a
) m
o th
e r
sp an
k in
g ch
il d
d u ri n g
th e
p re
v io
u s
m o n th
an d
(b )
al co
h o l u se
b y
m o th
e r
d u ri n g
th e
p re
v io
u s
m o n th
.
N o t d is
cu ss
e d
W al
sh e t al
. (2
0 0 3 )
1 7 .2
% an
y su
b st
an ce
u se
e it h e r
p ar
e n t
P ar
e n ta
l su
b st
an ce
ab u se
w as
st ro
n g ly
co rr
e la
te d
w it h
ri sk
o f e x p o su
re to
b o th
ch il d
p h y si
ca l an
d se
x u al
ab u se
in a
C an
ad ia
n h o u se
h o ld
su rv
e y .
N o t d is
cu ss
e d
B ar
th e t al
. (2
0 0 6 )
N o t p ro
v id
e d
Su b st
an ce
-u si
n g
ca re
g iv
e rs
w e re
m o re
li k e ly
to h av
e a
re p o rt
an d
a re
o cc
u rr
e n ce
o f ch
il d
ab u se
o r
n e g le
ct w
it h
C P S,
an d
th e
ri sk
s d id
n o t d e cr
e as
e am
o n g
a sa
m p le
w h o
e n ro
ll e d
in su
b st
an ce
ab u se
se rv
ic e s.
N o t d is
cu ss
e d
F o rr
e st
e r
(2 0 0 0 )
6 8 %
fa m
il ie
s In
a re
v ie
w o f C P R
re co
rd s
in a
Lo n d o n
d is
tr ic
t, su
b st
an ce
-u si
n g
fa m
il ie
s w
e re
si g n ifi
ca n tl y
o v e rr
e p re
se n te
d in
n e g le
ct ca
se s
(6 5 .2
% ).
Su b st
an ce
u se
w as
al so
p re
se n t in
al l th
e ca
se s
o f p h y si
ca l
(1 0 0 %
) an
d th
e m
aj o ri ty
o f e m
o ti o n al
(6 6 .7
% )
ab u se
ca se
s.
N o t d is
cu ss
e d
D iL
au ro
(2 0 0 4 )
2 1 .4
% an
y su
b st
an ce
D ru
g -u
si n g
ca re
g iv
e rs
w e re
m o re
li k e ly
to n e g le
ct th
e ir
ch il d re
n (7
8 .3
% )
th an
th e
n o n -d
ru g -u
si n g
ca re
g iv
e rs
(4 6 .8
% ),
b u t
th e y
w e re
le ss
li k e ly
to ca
u se
p h y si
ca l
h ar
m ab
u se
th an
th e
o th
e r
g ro
u p .
N o t d is
cu ss
e d
18
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Y am
p o ls
k ay
a &
B an
k s
(2 0 0 6 )
N o t p ro
v id
e d
In C P S
re co
rd s
re v ie
w o f a
la rg
e d at
ab as
e ,
ca se
s in
v o lv
in g
ca re
g iv
e r
al co
h o l o r
d ru
g u se
w e re
as so
ci at
e d
w it h
su b st
an ti at
e d
ch il d
n e g le
ct an
d th
re at
e n e d
h ar
m .
N o t d is
cu ss
e d
B e rg
e r
(2 0 0 5 )
N o t p ro
v id
e d
M at
e rn
al al
co h o l ab
u se
, n o t d ru
g ab
u se
an d
n o t p at
e rn
al d ru
g o r
al co
h o l ab
u se
, w
as a
st ro
n g
p re
d ic
to r
o f in
cr e as
e d
p h y si
ca l ab
u se
.
N o t d is
cu ss
e d
W o lo
ck e t al
. (2
0 0 1 )
5 5 %
o f fa
m il ie
s F o u n d
th at
p ar
e n ta
l su
b st
an ce
u se
is a
u n iq
u e
co n tr ib
u to
r in
a m
u lt iv
ar ia
te ri sk
m o d e l to
su b se
q u e n t re
p o rt s
to C P S
an d
to su
b st
an ti at
io n
st at
u s,
e v e n
w h e n
o th
e r
fa ct
o rs
as so
ci at
e d
w it h
th e
fa m
il y
e n v ir o n m
e n t ar
e co
n tr o ll e d .
N o t d is
cu ss
e d
G ib
b s
e t al
. (2
0 0 8 )
1 3 %
o f ch
il d
m al
tr e at
m e n t
o ff e n d e rs
O ff e n d e rs
w h o se
fi rs
t ch
il d
m al
tr e at
m e n t
e x p e ri e n ce
in v o lv
e d
su b st
an ce
u se
w e re
m o re
li k e ly
to h av
e p re
v io
u sl
y re
ce iv
e d
a re
fe rr
al to
su b st
an ce
ab u se
se rv
ic e s.
Le v e ls
o f v io
le n ce
al so
v ar
ie d , w
it h
th o se
w h o
co m
m it te
d b o th
ch il d
an d
sp o u se
ab u se
o n
th e
sa m
e d ay
b e in
g m
o re
li k e ly
to h av
e ab
u se
d al
co h o l o r
d ru
g s
th an
th o se
w h o
o n ly
co m
m it te
d ch
il d
m al
tr e at
m e n t.
Su b st
an ce
-u si
n g
ca re
g iv
e rs
al so
w e re
m o re
li k e ly
to co
m m
it se
v e re
n e g le
ct an
d e m
o ti o n al
ab u se
co m
p ar
e d
to n o n -s
u b st
an ce
-u si
n g
ca re
g iv
e rs
.
N o t d is
cu ss
e d
N o te
s. P T SD
= p o st
tr au
m at
ic st
re ss
d is
o rd
e r;
M D
E =
m aj
o r
d e p re
ss iv
e d is
o rd
e r;
D SM
= D
ia gn
o st
ic a
n d
St a
ti st
ic a
l M
a n
u a
l o f
M en
ta l
D is
o rd
er s;
C B
C L
= C h il d
B e h av
io r
C h e ck
li st
; T SC
C =
T ra
u m
a Sy
m p to
m C h e ck
li st
fo r
C h il d re
n ; B
E R S
= B e h av
io ra
l an
d E m
o ti o n al
R at
in g
Sc al
e ; C P S
= ch
il d
p ro
te ct
iv e
se rv
ic e s;
A A P I- 2
= A
d u lt -A
d o le
sc e n t P ar
e n ti n g
In v e n to
ry -2
; M
A ST
= M
ic h ig
an A
lc o h o l Sc
re e n in
g T e st
; C P R
= C h il d
P ro
te ct
io n
R e g is
te r.
19
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20 M. Staton-Tindall et al.
In addition to outcomes at the systems level, there are a number of important observations to make about consistent findings at the client level as well. Consistently, caregiver substance use was strongly and positively associated with an increased likelihood of children being exposed to vio- lence, thus incurring risk of child trauma outcomes as well (Connors-Burrow et al., 2009; Hanson et al., 2006; Jester et al., 2000; Ondersma et al., 2006; Sprang, Staton-Tindall, & Clark, 2008). Some of these violent acts were asso- ciated with increased activities around the drug-using lifestyle as noted by Connors-Burrow et al. (2009), who used the Things I Have Seen and Heard Scale with robust predictors being events like witnessing types of drug deals go down in the home and seeing drugs in the home. Other violent acts were noted as domestic violence (Sprang et al., 2008), marital conflict or spouse abuse (Gibbs et al., 2008), and these events suggest a very different at-risk situation for children.
In addition to increased violence exposure, types of child maltreatment were also consistently identified among substance-misusing caregivers in these articles. Physical abuse and neglect were the most commonly reported types of child maltreatment associated with caregiver substance misuse in the articles reviewed for this analysis. The most prevalent form of study design for the reviewed articles was a secondary data analysis from CPS records, but the findings were consistent in showing association between increased child risk for physical abuse or neglect if there was at least one caregiver with substance misuse. Few of these studies, however, examined the other relevant family risk variables in expanded regression models to understand the unique contribution of the caregiver substance misuse. One exception is Wolock, Sherman, Feldman, and Metzger (2001), who found that substance use remains a significant and unique contributor to variance in substantia- tion risk even when other family risk variables are controlled. In addition, other studies have found that not only is the presence of alcohol or drug use in the home a major risk factor, but intensity and frequency of use can be associated with severity of maltreatment (Gibbs et al., 2008). However, given the wealth of other research findings about co-occurring risk factors in homes where caregivers are active substance misusers, the number of studies examining specific substance misuse effects was astonishingly low.
PSYCHOSOCIAL AND BEHAVIORAL CHILD OUTCOMES
Although the primary search term used in this analysis was child maltreatment, a number of articles met inclusion criteria for the study that did not focus on the presence or nature of child maltreatment. These articles investigated the emotional, behavioral, or psychosocial response to either a maltreatment experience or the child’s experience of living with a substance- using caregiver. In general, caregiver substance use had a negative impact on child’s outcomes, but there was little consistency in the measurement
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Caregiver Substance Use and Child Outcomes 21
of symptoms with the exception of the CBCL’s internalizing and externaliz- ing symptoms. Caregiver substance use was consistently related to higher, and even clinically significant, scores on CBCL measures in this analysis. A number of the studies in this analysis (Bailey et al., 2009) focused specifi- cally on externalizing behavior. Although the CBCL was the most commonly instrument used, a few other studies also examined mental health symptoms, including posttraumatic stress disorder (PTSD), depression, adolescent sub- stance use disorders, and overall family functioning. Consistently, caregiver substance use had a negative and consistent relationship with these disorders among children, and in some cases there was a cumulative effect where chil- dren who experienced witnessing violence and living with a substance-using caregiver were at greatest risk for developing a major depressive disorder (Hanson et al., 2006).
Findings Related to Targeted Practice Areas
Table 3 summarizes implications for practice as noted in each of the articles focused on caregiver substance use and child maltreatment. Across jour- nals, the most commonly noted area for targeting implications of study findings was to adult substance users—these implications were typically focused on enhancing assessment and treatment practices for women and families. In addition to enhancing substance abuse treatment programming, a number of articles also included a specific focus on the inclusion of effec- tive parenting as a critical element of treatment (Bailey et al., 2009; Berger, 2005; Connors-Burrow et al., 2009; DiLauro, 2004). In addition, other studies talked about other important co-occurring enhancements to treatment includ- ing mental health programming (Barth et al., 2006) and victimization/PTSD content (Connors-Burrow et al., 2009). Not surprising with the number of articles that focused on child maltreatment outcomes, a large number of articles also focused on implications for child welfare professionals. These findings highlight the need to increase access to evidence-based interven- tions (Berger, 2005), increase collaboration with other systems such as the military, which has had extensive experience with substance-using caregivers who have been child maltreatment perpetrators (Gibbs et al., 2008), and gain a better understanding of substance use within the context of the other risk factors of the home environment (Scannapieco & Connell-Carrick, 2007).
These articles provided some recommendations for practice specific to assessment that pertained to mental health professionals. However, implications for practice specific to children’s mental health were lacking. Few articles made the connection between children’s exposure to vio- lence, chaotic lifestyles, and at-risk situations often associated with drug use to potential mental health consequences such as PTSD for children. As shown in Table 3, implications for child mental health professionals are rare—despite the obvious potential impairments associated with children’s
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T A
B L E
3 Su
m m
ar y
o f P ra
ct ic
e Im
p li ca
ti o n s
Im p li ca
ti o n s
fo r
P ra
ct ic
e
A u th
o r
Jo u rn
al
C h il d
W e lf ar
e P ro
fe ss
io n al
s
C h il d
M e n ta
l H
e al
th P ro
fe ss
io n al
s
C ar
e g iv
e r
Su b st
an ce
U se
P ro
fe ss
io n al
s Sy
st e m
s/ P o li cy
Sy st
e m
s In
te g ra
ti o n
A ss
e ss
m e n t
P re
v e n ti o n
B ai
le y
e t al
. (2
0 0 9 )
D ev
el o p m
en ta
l P
sy ch
o lo
gy X
B ar
th e t al
. (2
0 0 6 )
Jo u
rn a
l o f
Su b st
a n
ce A
b u
se T re
a tm
en t
X X
B e rg
e r
(2 0 0 5 )
C h
il d
A b u
se a
n d
N eg
le ct
X X
C o n n o rs
-B u rr
o w
e t al
. (2
0 0 9 )
Jo u
rn a
l o f
P ed
ia tr
ic N
u rs
in g
X
C ra
n d al
l e t al
. (2
0 0 6 )
Jo u
rn a
l o f
Su rg
ic a
l R
es ea
rc h
X D
iL au
ro (2
0 0 4 )
C h
il d
W el
fa re
Le a
gu e
o f
A m
er ic
a X
F o rr
e st
e r
(2 0 0 0 )
C h
il d
A b u
se R
ev ie
w X
X G
ib b s
e t al
. (2
0 0 8 )
C h
il d
M a
lt re
a tm
en t
X X
X H
an so
n e t al
. (2
0 0 6 )
A d
d ic
ti ve
B eh
a vi
o rs
X X
Je st
e r
e t al
. (2
0 0 0 )
A lc
o h
o li
sm :
C li
n ic
a l a
n d
E x p er
im en
ta l
R es
ea rc
h X
X
M cG
la d e
e t al
. (2
0 0 9 )
P ed
ia tr
ic s
X X
M cN
ic h o l &
T as
h (2
0 0 1 )
C h
il d
W el
fa re
Le a
gu e
o f
A m
er ic
a X
X O
n d e rs
m a
(2 0 0 2 )
A m
er ic
a n
Jo u
rn a
l o f
O rt
h o p sy
ch ia
tr y
X X
O n d e rs
m a
e t al
. (2
0 0 6 )
Jo u
rn a
l o f
T ra
u m
a ti
c St
re ss
X X
X X
O st
le r
e t al
. (2
0 0 7 )
Jo u
rn a
l o f
th e
A m
er ic
a n
A ca
d em
y o f
C h
il d
& A
d o le
sc en
t P
sy ch
ia tr
y X
X X
Sc an
n ap
ie co
& C o n n e ll -C
ar ri ck
(2 0 0 7 )
Su b st
a n
ce U
se a
n d
M is
u se
X X
X
Sp ra
n g
e t al
. (2
0 0 8 )
Jo u
rn a
l o f
T ra
u m
a ti
c St
re ss
X X
X Su
n e t al
. (2
0 0 1 )
C h
il d
W el
fa re
Le a
gu e
o f
A m
er ic
a X
X X
X V an
d e
M ar
k (2
0 0 5 )
Jo u
rn a
l o f
C o m
m u
n it
y P
sy ch
o lo
gy X
X W
al sh
e t al
. (2
0 0 3 )
C h
il d
A b u
se a
n d
N eg
le ct
X W
o lo
ck e t al
. (2
0 0 1 )
C h
il d
re n
a n
d Y
o u
th Se
rv ic
es R
ev ie
w X
X Y am
p o ls
k ay
a &
B an
k s
(2 0 0 6 )
A ss
es sm
en t
X X
22
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Caregiver Substance Use and Child Outcomes 23
experiences. In addition, few articles speak to the need to integrate resources across child welfare, children’s mental health, and adult treatment services to enhance services for these at-risk families.
DISCUSSION
Although a number of literature reviews and meta-analyses have investigated the relationship between caregiver substance use and child maltreatment using preexisting frameworks derived from the larger fields of addiction or child welfare, this review enhances our understanding of these phenomenon by exploring the state of knowledge regarding the measurement of specific variables of interest, the range of child outcomes targeted for study, and how these studies might inform practice. To this end, this review highlights major challenges to researchers investigating the impact of caregiver substance mis- use on child maltreatment in the area of measurement of key variables, and points to the need for more sophisticated, nuanced conceptual frameworks to understand the translational implications of the work.
Any understanding of the relationship between caregiver substance mis- use and child maltreatment is advanced by efforts to improve the sensitivity and precision of measurement of key constructs. In the adult substance abuse treatment literature, dichotomous measures of substance use (any use: yes–no) have been supplanted by complex measures that lead to infer- ences about addiction severity. Research on neurodevelopment throughout childhood has likewise used complex measures of the behavioral outcomes of child maltreatment (Perry, 2009). However, when it comes to stud- ies specifically examining combined caregiver substance misuse and child maltreatment, the reliance is on very weak and largely dichotomous mea- sures. In addition, most of the findings are derived from unreliable secondary data sources that are dependent on “the presence of any substance use” in the file record. Although these studies make some contributions, our review strongly supports the claims made by Testa and Smith (2009) that the current state of measurement and assessment of substance use does very little to help us understand the mechanisms of action and risk for children within substance-using families unless used in concert with equally sophis- ticated child maltreatment and family environment measures. What makes this even more disturbing is that there are a wealth of sophisticated mea- sures of adult substance misuse that can be readily employed in studying this problem. The reliance on child welfare data at this stage of the inves- tigative process is equally disturbing. Entry of data by child welfare workers lacks validity or reliability as well as specificity. Thus, even sophisticated analysis of secondary data is likely working from poor data sources that will not allow exploration of complex associations, let alone cause–effect inferences.
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We suggest that the future direction for examining the relationship between caregiver substance misuse must move beyond just conceptualizing substance use as an isolated factor. For example, many of the studies reviewed did not consider possible co-occurring conditions that could com- promise the substance use and child maltreatment trajectories for these families. Substance use is likely to co-occur with high rates of poverty (Smyth, 1998) and other extreme living conditions, which might impact the life of children living in the home independent of the caregiver substance misuse (Sprang et al., 2008). Substance use is also likely to exist comor- bidly with other mental conditions that can impact the caregiver’s ability to successfully parent, such as depression, anxiety, and other disorders (Testa & Smith, 2009; Wells, 2009). Also, because some forms of substance use are illegal, it is likely to co-occur with high rates of criminal activity (CASA, 1998) and potentially high-risk behaviors in the home, which could create risk of harm for children living in the environment (Wells, 2009).
The majority of studies in the field have examined outcomes relative to acts of child maltreatment or the responsiveness of the child wel- fare system. Despite the inevitable consequences of those acts, very few articles illuminated the experiences of children living in the drug-using environment—referred to as “the elephant in the living room” by Kroll (2004). Only one third of the identified articles examined the other types of outcome such as mental health consequences of caregiver substance use for children or behavioral or emotional responsiveness. These studies used a wide range of standardized measures of child distress, but approached children in the sample as a homogenous target population. That is, differ- ential findings by developmental stage were largely nonexistent, providing little direction for practitioners who work with children. These findings high- light the limitations of knowledge in this area, and explain the paucity of empirically validated practice standards for this population.
It is notable that we found that the majority of reviewed papers focused their attention on adult problems, such as the assessment and treatment of caregivers, and that so few considered the implications of substance mis- use on the children in their samples. Adult caregivers certainly merited the attention of researchers and practitioners, but so did the children, especially because the putative goal of most studies was to understand the relationships of substance misuse to violence, child maltreatment, or both. Because the phenomenology of addiction-related maltreatment points to children as the “target,” their systematic exclusion from these investigations and implications is striking and puzzling.
One possible explanation is that such exclusions are the product of “silo” effects that flow from the formal organization of research and prac- tice domains. Often discipline driven, these orientations, in turn, affect researchers’ fields of observation, the selected problems for investigation, and even the “samples” and “data” available for research studies. Indeed, real
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Caregiver Substance Use and Child Outcomes 25
differences in training and orientations exist among those affiliated with the child welfare, child mental health, family studies, intimate partner violence, and addiction treatment sectors. Each field or subfield holds a long tradi- tion of distinct research and practice emphases, which in turn, can direct the focus of theoretical and empirical attention (e.g., child–adult, males–females, individual–family, addict–enabler). Although there has been some progress toward seeing the broader systemic and ecological realities facing clients, arguably, many professionals continue to be directed into lesser and greater emphases that have more to do with their educational and training roots, than with real-world configurations—which, as shown by these findings, could limit the translational science of important cross-disciplinary work.
Even when the emphasis is primarily on children, the silo problem persists. Social work education, for example, has often bifurcated training between child mental health (for those pursuing clinical social work in com- munity mental health) and child welfare training (for those heading for child protection, foster care, and adoption agencies), which might contribute to the divergence we see in the research findings presented here with researchers focusing on primarily one or the other in terms of dependent measures. The profession, in effect, has frequently advanced the idea that a distinct set of skills are necessary, to the point that the “child” population served by the profession requires two very different knowledge bases and skill sets, depending into which system the child presents.
Similarly, many community agencies are oriented to primarily serve either children or adults, and historically recruit professionals with those areas of distinct specialty training. Many financing mechanisms continue to consider the child as the “target” of care, and the caregiver as a “collat- eral,” rather than the reality that both child and caregiver are targets needing intensive interventions, or that the “family” should be considered the target for change, and services reimbursed in ways that recognize this need. These differences go beyond just professional training. As mentioned earlier, the policy differences between child protection and family reunification play out throughout the practice and research environments. Researchers and practi- tioners “take sides” and fail to grasp the important interactional dimensions of caregiver–child problems and solutions. Instead, this review suggests that siloing continues to diminish the advance of science and practice.
Next Steps: Emphasis on the Role of Trauma
Although the search term child trauma did not yield a workable number of articles to be included in the final search for this article, four articles meeting study criteria under the child maltreatment search terms included PTSD, trauma exposure, or subthreshold traumatic stress symptoms as study variables. A trauma framework, however, might have significant conceptual, empirical, and translational utility for consideration for future research in this
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important area of study. Over the years, a number of studies have demon- strated a biopsychosocial interaction between traumatic stress and substance use, describing the relationship between the two conditions as reciprocal and complex (Grella, Stein, & Greenwell, 2005; Janikowski & Glover, 1994; Sprang et al., 2008). Studies have documented trauma exposure ranging from 30% to 90% in substance-using, treatment-seeking samples (Moncrieff, Drummond, Candy, Checinski, & Farmer, 1996; Najavits, Weiss, Shaw, & Muenz, 1998; Rice et al., 2001). The associations of caregiver substance mis- use with trauma and other mental health problems are particularly prevalent among victimized women—a large number of whom are in the child welfare system (Logan, Walker, Jordan, & Leukefeld, 2006). Additionally, substance misuse could increase vulnerability to trauma exposure (beyond physical and sexual abuse) in adults who engage in unsafe and disinhibited behav- iors while under the influence (Logan et al., 2006; Parks & Miller, 1997; Sprang et al., 2008), and in children, who are living with impaired caregivers who have high levels of parenting stress, poor impulse control, and who are inattentive to their needs (Sprang et al., 2008; Sprang et al., in press).
What is surprising from this review is the comparative absence of child trauma measures among the constellation of findings from studies of caregiver substance misuse and child maltreatment. The silo effect evident in this review is difficult to explain given the vast amount of attention that has been given to associations of child maltreatment with trauma condi- tions. Clearly, the advancement of meaningful translational research on this complex problem will require examination of caregiver substance misuse and related disorders, child maltreatment, and child mental health outcomes. Conveying useful information to practice or policy will depend on far more sophisticated research designs and methods in recognition of the advances in child development studies. Anchoring research and practice implications regarding caregiver substance misuse in a trauma framework provides an opportunity to direct assessment and treatment practices in an integrated way for the adult caregiver, the child, and the family in a manner that respects the physiological and psychological assault imposed by trauma exposure, and the intertwined challenges associated with recovery and treatment. In considering directions for future research and practice, for the trauma framework to add substantively to this field of work, two parallel missions must be achieved: (a) creation of a trauma-informed system of substance abuse care and (b) the development of evidence-based trauma treatment to treat comorbid traumatic stress and substance use disorders.
First, creating a system of care that is trauma informed mandates that services are grounded in the knowledge base of trauma, and consider the epidemiology, impact, relationship dynamics, and recovery process associ- ated with trauma recovery. The development and maintenance of caregiver substance use disorders might represent maladaptive attempts to self-regulate affect and reexperiencing past traumatic events (Finklestein et al., 2004).
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Caregiver Substance Use and Child Outcomes 27
Trauma-informed systems place a priority on client safety, empowerment, and control, recognizing the loss of autonomy and self-efficacy induced by victimization. This type of approach for the family would focus on heal- ing for the caregiver in an integrated model such as Seeking Safety (Najavits et al., 1998), as well as child or relationally focused treatments such as trauma focused-cognitive behavioral therapy (Cohen, Berliner, & Mannarino, 2010), Alternatives for Families, A Cognitive-Behavioral Therapy (AF–CBT; Kolko & Swenson, 2002), and child–parent psychotherapy (Lieberman & Van Horn, 2008).
Second, a trauma-informed system should provide evidence-based, trauma-specific services to address co-occurring traumatic stress conditions such as PTSD, acute stress disorder, and a range of substance use disorders. Although the fields of traumatic stress and substance misuse represent silos of knowledge regarding the etiology, assessment, and treatment of these condi- tions, the proposed approach requires integration of a family-focused trauma framework to reach caregiving parents and their children who are in need of trauma-focused services. As Finklestein et al. (2004) noted, “Both paral- lel and sequential approaches underestimate the realities of the close and often mutually reinforcing relationships between trauma and substance use” (p. 4). Thus, the synchronized delivery of services in an integrated model represents an opportunity to improve psychosocial and behavioral outcomes for caregivers and children.
Limitations
There are limits to any systematic literature search that could have impacted this review. Although considerable care was taken to identify and include all published peer-reviewed articles that would address the specified objectives of the review, it is possible that inaccurate or incomplete key wording in the editorial process could have prevented relevant studies from being detected. It is also conceivable that researchers from diverse disciplines utilize different nomenclatures to operationalize key concepts. This could have resulted in the omission of studies that could have shed some light on the impact of caregiver substance misuse on child outcomes from a unique perspective.
CONCLUSION
The current emphasis in the United States on translational science suggests that this important area of research focused on caregiver substance use and the impact on children must move beyond the simplistic measurement of both caregiver and child characteristics in cases of maltreatment. With agen- cies, practice providers, and researchers focused on either child maltreatment or on adult substance misuse patterns, there is a tendency to view study
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populations in disciplinary silos. What is needed for this version for transla- tional, desiloized research to go forward is a focus on traumagenic conditions rather than on individuals who initiate and perpetuate the problem or on the individuals who suffer at the hands of those perpetrators. In many regards, the articles point to a disturbing lack of sophistication in the current state of the science in this area. Given the great wealth of findings in other research areas about the complexity of child outcomes from maltreatment and the complexity of adult substance misuse characteristics, this body of reviewed research is disappointing. The cost of future trauma of children and the dashed hopes for parental recovery demand a science that is commensurate with the scope of seriousness of the problems to be studied.
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