Over the past few decades, researchers have focused their efforts along the causes of childhood and adolescent maltreatment and the consequences of experiencing abuse for emotional, psychological and behavioral development (e.g., Gelles 1997, National Research Council 1993).

Contemporary research on the causes and consequences of abuse as it pertains to alcohol problems, alcohol dependency and illicit drug use suggests links between substance abuse and maltreatment. However, the successful resolution of substance abuse and maltreatment in a family often requires a coordinated effort between social service providers not typically aligned with one another — the chemical dependency service providers and the child welfare service providers (USDHSS 1999a).

Before exploring the possible link between substance abuse and child maltreatment, terminology should be defined.

There is often some confusion surrounding what constitutes maltreatment.

Multiple definitions of what constitutes maltreatment can be found in the literature, but maltreatment encompasses sexual abuse, physical abuse, neglect, emotional abuse and psychological abuse (National Research Council 1993). The definition of each subcategory of maltreatment varies depending on its source — criminal statutes, family or child protection statutes, or clinical assessment. Variations in definition are to be expected given the different orientations of the agencies handling cases of maltreatment. Criminal statutes focus on the behavior of the offender, and the goal is punishment. Family and child protection statutes "protect children from injury or mistreatment and help to safeguard their physical, mental and emotional well-being" (NYS Family Court Act, §1011). Clinical definitions focus not only on protection, but also recovery. Therefore, clinical definitions of maltreatment may be broader in scope than statutorily constructed definitions of maltreatment (Faller 1993).

One of the most commonly used definitions of maltreatment comes from federal legislation. The Child Abuse Prevention and Treatment Act (CAPTA, 42 U.S.C.A. §5106g) defines child abuse and neglect as "any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse, or exploitation, or an act or failure to act which presents an imminent risk of serious harm" (Factsheet 2000). This definition applies to victims who are less than 18 years old at the time of the offense. While CAPTA provides a general framework for defining maltreatment, definitions of each of the subcategories of maltreatment exist.

Physical abuse results in physical injury to the child, but also includes high-risk acts regardless of the actual injury. For example, " . . . any punishment that involves hitting with a closed fist or an instrument, kicking, inflicting burns or throwing the child is considered abuse regardless of the severity of the injury sustained" (DePanfilis and Salus 1992:3). Yet, this definition does not fully clarify the relationship between corporal punishment and physical abuse. At what point does corporal punishment become physical abuse? Currently, there is no consensus on this issue.

Indicators of physical abuse include skin injuries like bruising, burning, and lesions; bone injuries; and abdominal injuries (Devlin and Reynolds, 1994). Bruises at various stages of healing suggest physical abuse, and the location of the bruises should also be considered. For example, bruises found on two or more planes (e.g., back and stomach) of a child's body may indicate physical abuse. And, the focus should not be just on young children, but adolescents as well (Tower 1992).

Sexual abuse includes a range of contact and non-contact acts. Non-contact acts include comments of a sexual nature, exhibitionism/masturbation, voyeurism and exposure to pornographic material. Contact acts include sexual contact, digital or object penetration and intercourse. Harm to the victim is not a required component of sexual abuse — rather the act itself (whether contact or non-contact) is sufficient for sexual abuse to occur.

Sexual abuse is particularly difficult to identify, but Devlin and Reynolds (1994) argue that children rarely make up stories about sexual activity. Indicators of sexual abuse may be anxiety, depression, or inappropriate sexual conduct by the child (Tower 1992, Devlin and Reynolds 1994), and it may become more difficult to identify the presence of sexual abuse as the victim moves into adolescence.

Child neglect "is the presence of certain deficiencies in caretaker obligations (usually the parent, although neglect can occur in residential centers or foster care homes) that harm the child's psychological and/or physical health" (National Research Council 1993:59-60). However, because of cultural variation in care and because neglect is often confounded with poverty, it can be hard to establish.

To further clarify neglect, the Study of National Incidence and Prevalence of Child Abuse and Neglect (Factsheet 2000) identified four different dimensions of neglect: physical neglect, inadequate supervision, emotional neglect and educational neglect. Failure to allow for or provide adequate healthcare, abandonment, expulsion, or inadequate nutrition and hygiene constitute physical neglect. Inattention to a child's emotional needs, domestic violence, or permitted alcohol or drug use reflects emotional neglect. Educational neglect includes chronic, unexplained absences from school, permitted truancy, failure to enroll a child in school and ignoring special educational needs.

Severely unsanitary conditions at home and inappropriate clothing can further indicate child neglect. While physical abuse may be targeted at one child in the family, neglect is usually all inclusive — all offspring are typically subjected to similar neglect (Tower 1992). Gaudin (1993) provides a comprehensive discussion of indicators and strategies to assess the presence of child neglect in the family. Included in his discussion is an overview of assessment tools designed to identify neglect and the risk of neglect.

Emotional abuse and psychological abuse are often thought of as synonymous, but O'Hagan (1995) argues to conceptually separate these two forms of abuse. Accordingly, emotional abuse "is the sustained, repetitive, inappropriate emotional response to the child's experience of emotion and its accompanying expressive behavior. Emotional abuse repeatedly inflicts emotional pain on the child . . . it impairs emotional development" (O'Hagan 1995:456). However, "in some cases . . . parental acts alone, without any harm evident in the child's behavior or condition, are sufficient to warrant CPS (Child Protective Services) intervention" (DePanfilis and Salus 1992:4). According to DePanfilis and Salus (1992), emotional abuse is often very difficult to recognize and may often be confounded or confused with emotional disturbances.

However, some basic guidelines exist to help clinicians to discriminate between emotionally disturbed and abused children. For example, parents of the emotionally disturbed typically recognize the problem and seek out professional help to lessen or resolve the problem. On the other hand, parents of the emotionally abused often present as unconcerned and punitive, placing blame upon the child (DePanfilis and Salus 1992).

Psychological abuse is "sustained, repetitive, inappropriate behavior which damages or substantially reduces the creative and developmental potential of crucially important mental faculties and mental processes of a child. These faculties and processes include intelligence, memory, recognition, perception, attention, imagination and moral development" (O'Hagan 1995:458).

Viewing domestic violence, desertion, deception and exploitation may be psychologically abusive. Also, much physical and sexual abuse and neglect may involve emotional or psychological abuse.

The National Incidence Study of Child Abuse and Neglect (NIS) is the "single most comprehensive source of information about the current incidence of child abuse and neglect in the United States" (Sedlak and Broadhurst 1996:2). NIS-3 is the third and most recent National Study and results are based on a nationally representative sample of over 5,600 professionals in 842 agencies serving 42 counties (Sedlak and Broadhurst 1996:2).

Therefore, NIS does not rely only upon child protective services (CPS), but also collects data from community professionals such as police agencies and public schools on children not seen by CPS. To ascertain the level of child maltreatment NIS uses a harm standard and an endangerment standard. The harm standard requires that " . . . an act or omission result in demonstrable harm in order to be classified as abuse or neglect" (Sedlak and Broadhurst 1996:5).

The endangerment standard — somewhat less stringent — allows abuse and neglect to be counted in the absence of clear harm. Using the harm standard, an estimated 1.55 million children were abused or neglected in 1993, a 67 percent increase since the NIS-2 estimate in 1986. The endangerment standard indicates even greater increases in maltreatment — a 98 percent increase from 1986 with an estimated 2.82 million maltreatment incidents in 1993.

Overall, whether using the harm or endangerment standard, sexual abuse is the least common form of maltreatment while neglect (emotional, physical, educational or combined) represents the most common form of maltreatment. Children at lowest risk for any maltreatment were between the ages of 0-2 and 15-17, and girls are at greater risk for sexual abuse than boys. Boys are at greater risk for serious injury, and more likely to be emotionally neglected (Sedlak and Broadhurst 1996). Finally, NIS-3 found that more maltreated children are identified by schools in 1993 (54 percent) than by all other community agencies and institutions combined, and about one-third of all cases of maltreatment known to community agencies and institutions are investigated by child protective services (OJJDP 2000).

The National Child Abuse and Neglect Data System (NCANDS) provides a national picture of child maltreatment. NCANDS collects and analyzes child abuse and neglect data from child protective services agencies — every state submitted data for 1998 (USDHSS 1999b). According to NCANDS, in 1998, approximately 90,300 children were victims of maltreatment (substantiated by CPS), and the child victimization rate for 1998 was about 12.9 per 1,000 children in the population — a decrease from 1997.

Just over 50 percent of the victims suffered neglect, about 23 percent were physically abused, and about 12 percent were sexually abused — paralleling the general pattern of results from NIS-3. However, in contrast to NIS-3, NCANDS reports that the highest victimization rates were for the 0-3 age group, and the rates declined as the age of the victim increased. These nationally based estimates of maltreatment, however, probably represent only a proportion of all maltreatment that occurs. (Gelles 1997, Straus et al., 1980).

According to analysis conducted by Huang et al. (1998), using data from the 1996 National Household Survey on Drug Abuse " . . . an estimated 8.3 million children in the United States, 11 percent of all children in the U.S., live in households in which at least one parent is either alcoholic or in need of substance abuse treatment" (USDHHS 1999a:2). Slightly over half (about 4.2 million) of children who live with a substance abusing parent are age 2 - 9. Additionally, "parents with substance-abuse problems have somewhat less education, are somewhat less likely to be employed full time, and are much less likely to be married and much more likely to participate in welfare programs than are other parents" (USDHHS 1999b:7). Yet, the relationship between parental alcohol and drug use and child maltreatment is not well understood (Gaudin 1993, National Research Council 1993).

Early research (Famularo et al. 1986, Martin and Walters 1982) indicated that parental alcoholism co-varied with maltreatment of children in the home.

More recent, more sophisticated research tends to confirm that in families where there is parental drug or alcohol abuse, the risk for maltreatment is greater than in families where there is no parental drug or alcohol abuse.

Kelleher et al. (1994:1588-89), for example, use data from the Epidemiological Catchment Area Study (n=11,662) and find that " . . . adults with an alcohol or drug disorder (alcohol abuse, dependence; drug abuse, dependence) were 2.7 times more likely to have reported abusive behavior toward children, and 4.2 times more likely to have reported neglectful behavior toward children than were their matched control subjects.

Chaffin et al. (1996) extend Kelleher et al.'s (1994) study by examining the temporal relationship between parental drug or alcohol use and subsequent maltreatment and re-affirm the previous findings with longitudinal data. Ammermann et al., (1999), Jaudes et al., (1995), Wolock and Magura (1996), and Brown et al., (1998) find a relationship between substance abuse disorders and parental risk of child abuse.

However, the samples, measurement and methodologies vary greatly across the studies, but there is no clear tendency for the abuser to be either the mother or the father. In fact, some of the research indicates substance-abusing mothers are more likely to abuse than are substance-abusing fathers.

Nevertheless, getting some idea of the actual proportion of families with at least one parent with a substance abuse problem that maltreat offspring has proven to be quite difficult for a variety of reasons (USDHHS 1999a). According to the U.S Department of Health and Human Services somewhere between " . . . one-third and two-thirds of substantiated child abuse and neglect reports involve substance abuse. . . . In addition, substance abuse is much more likely to be a factor in child neglect than in child abuse" (USDHHS 1999a:10, also see Dore et al. 1995). Another USDHHS study (USDHHS 1993 cited by USDHHS 1999a) on a national probability sample of child with substantiated maltreatment indicated that about 42 percent of the victims of child abuse presented with a substance abuse problem in the family, and that among caretakers with substance abuse problems, alcohol was the primary problem (USDHHS 1999a:11). Overall, " . . . the extent to which abusive and neglectful families also have substance abuse problems, and vice versa, are complex and confusing.

While specific studies vary considerably for methodological and other reasons, the bottom line is that a significant proportion of the child welfare caseload involves families with substance-abuse disorders. . . . In addition, it is clear that alcohol as well as illicit drugs may place children at risk, and that parental substance abuse is a problem for children of all ages" (USDHHS 1999a:22).

Researchers have examined the possibility that substance use may be a response to maltreatment experienced as a child. Two strategies are used. One strategy asks adolescents or adults in clinical or institutional settings about childhood maltreatment experiences, and then compares their substance use/abuse to those in the same setting who report no maltreatment experiences (e.g., Downs et al. 1987, Miller et al. 1987, 1989, Singer et al. 1989, Harrison et al. 1989, Dembo et al. 1990, 1992, Kang et al. 1999).

Generally, these studies support the argument that maltreatment increases the use of either or both drugs and alcohol. However, studies of this type suffer from a number of methodological problems including reliance on retrospective recall of maltreatment and highly specialized samples (Ireland and Widom 1994).

The alternative strategy uses longitudinal data collected over relatively long periods of time either from samples selected randomly from a population (Thornberry et al. 2000), or from matched case-control studies (Ireland and Widom 1994, Widom et al. 1995). Thornberry et al. (2000) using data collected on a random sample of high-risk urban youths found that any substantiated case of maltreatment prior to age 18 covaried with adolescent self-reported drug use and self-reported problems associated with alcohol use.

Widom et al. (1995) using self-reported data on alcohol abuse and dependency found that those in the abused sample (abused prior to age 12, court identified) were more likely to have both alcohol abuse and alcohol dependency problems in early adulthood compared to a matched control group.

However, when parental alcohol use along with other characteristics were controlled for statistically, the relationship between maltreatment and alcohol problems persisted only for females.

Overall, research consistently suggests that maltreatment experienced as a child increases the risk of drug and alcohol use in adolescence and early adulthood.

Research into substance abuse as a cause and a consequence of child maltreatment consistently indicates that parental substance abuse (alcohol and illicit drugs) increases the risk of child maltreatment in the family, although the actual risk varies in studies.

Additionally, victims of child maltreatment also appear to be at risk for substance abuse in adolescence and early adulthood (again both alcohol and illicit drug use), although there may be a gender effect that places maltreated girls at greater risk for alcohol and illicit drug use than maltreated boys.

Substance abuse treatment personnel should be cognizant of the risk of child maltreatment when working with parents and children/adolescents who abuse alcohol and/or drugs. Yet, given the definitional ambiguity of child maltreatment, recognizing it is often difficult. The medical profession continues to struggle with diagnosis of various forms of physical, sexual and emotional abuse, and physical and emotional neglect (National Research Council, 1993).

Presently, no universally accepted standardized assessment tools exist that aid in the identification of child maltreatment. Recognition is further complicated because treatment providers may often deal only with the parent, and therefore important physical or behavioral signs of child abuse are never observed. However, the " . . . demeanor of the child's parent or caretakers is sometimes revealing.

"For example, the mother's assessment of her pregnancy, labor, and delivery will often provide an insight into her attitude about her child" (OJJDP Portable Guide 1996:3). Additionally, if a parent blames or belittles the child, sees the child as very different, as bad or evil, or seems unconcerned about the child it is suggestive of abuse and/or neglect (Tower 1992).

Therefore, recognizing child abuse may be quite difficult for substance abuse counselors. Aware of the complexity involved in identification of maltreatment, every state has enacted legislation that protects against civil and criminal liability as long as the reporter is acting in good faith (American Humane Association 2000, NCCAN 2000a).

While confirming child maltreatment is not the responsibility of treatment providers, their responsibility is to recognize the possibility of maltreatment among their clientele, and report the suspected maltreatment to child welfare services or law enforcement.

According to the American Humane Association "reasonable suspicion based on objective evidence is all that is needed to report. That evidence might be your firsthand observation or statements made by a parent or a child" (2000:1). Additionally, some of the primary reasons for not reporting include unfamiliarity with state law, frustration with child welfare professionals and an unwillingness to get involved.

Each state has legislation that requires mandatory reporting of suspected child maltreatment by healthcare providers, mental-health personnel, social workers, education/child care employees and law enforcement personnel. Only 29 states require mandatory reporting by all persons who have reasonable grounds to believe the presence of maltreatment or require mandatory reporting by drug and alcohol treatment providers (NCCAN, 2000b).

Given the consistent research linking substance abuse and maltreatment it is somewhat surprising that drug and alcohol treatment providers are not required to report suspected maltreatment in 21 states.

An obvious starting point to begin to address the service provider response to families that experience both substance abuse and maltreatment is to inform both child welfare personnel and substance abuse personnel of the possibility of co-occurrence. Simply, information about the possibility of substance abuse and child maltreatment co-occurring should result in greater awareness and may lead to better coordination of services directed at these suffering families. 

Timothy Ireland, PhD, is assistant professor of criminal justice,
Niagara University, Niagara, New York. Ireland received an award
from the Journal of Studies on Alcohol for outstanding scholarship
on the long-term consequences of child victimization.

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