Substance use within a child welfare-involved sample: The Maltreatment and Adolescent Pathways (MAP) Project

1. Substance use within a child welfare-Substance use within a child welfare-
involved sample:involved sample:
The Maltreatment and AdolescentThe Maltreatment and Adolescent
Pathways (MAP) ProjectPathways (MAP) Project
Christine Wekerle, Ph.D. (cwekerle@uwo.ca)Christine Wekerle, Ph.D. (cwekerle@uwo.ca)
The University of Western OntarioThe University of Western Ontario
MAP KT website (www2.oacas.org)MAP KT website (www2.oacas.org)
Presented at the Practice and Research TogetherPresented at the Practice and Research Together
(PART; www.partontario.org) training(PART; www.partontario.org) training
April 2009April 2009

2. MAP Co-investigatorsMAP Co-investigators
Chris Wekerle, Ph.D.Chris Wekerle, Ph.D. (PI – UWO)(PI – UWO)
Harriet MacMillan, M.D.Harriet MacMillan, M.D. (McMaster)(McMaster)
Michael Boyle, Ph.D.Michael Boyle, Ph.D. (McMaster)(McMaster)
Nico Trocmé, Ph.D.Nico Trocmé, Ph.D. (McGill)(McGill)
Eman Leung, Ph.D.Eman Leung, Ph.D. (UWO)(UWO)
Randall Waechter, Ph.D.Randall Waechter, Ph.D. (UWO)(UWO)
Deb Goodman, Ph.D.Deb Goodman, Ph.D. (Toronto CAS)(Toronto CAS)
Bruce Leslie, M.S.W.Bruce Leslie, M.S.W. (Catholic CAS)(Catholic CAS)
Brenda Moody, M.B.A.Brenda Moody, M.B.A. (Peel Region CAS)(Peel Region CAS)
MAP Advisory Board:MAP Advisory Board: Kong Chung, Lori Bell, NatashaKong Chung, Lori Bell, Natasha
Budzarov, Darlaine Mathews, David Firang, Dan Cadman, Susan GainesBudzarov, Darlaine Mathews, David Firang, Dan Cadman, Susan Gaines
Cherry Chan, Mario Giancola, Judith Wharton, Bervin Garraway, CarlaCherry Chan, Mario Giancola, Judith Wharton, Bervin Garraway, Carla
Da Fonte, Jacqueline BittencourtDa Fonte, Jacqueline Bittencourt

3. MAP Support & Funding AgenciesMAP Support & Funding Agencies
• Children’s Aid Society Agencies: Toronto, Toronto Catholic,Children’s Aid Society Agencies: Toronto, Toronto Catholic,
and Peel Region; Ontario Association of Children’s Aidand Peel Region; Ontario Association of Children’s Aid
SocietiesSocieties
• The Ontario Ministry of Children and Youth Services OntarioThe Ontario Ministry of Children and Youth Services Ontario
• The Public Health Agency of Canada; Health CanadaThe Public Health Agency of Canada; Health Canada
• The Centre for Excellence in Research in Child WelfareThe Centre for Excellence in Research in Child Welfare
• Centre for Addiction and Mental Health – The Ontario StudentCentre for Addiction and Mental Health – The Ontario Student
Drug and Health SurveyDrug and Health Survey
• The Canadian Institutes of Health Research (CIHR), InstituteThe Canadian Institutes of Health Research (CIHR), Institute
of Gender and Healthof Gender and Health
• The Ontario Mental Health FoundationThe Ontario Mental Health Foundation
• The Children’s Hospital of Eastern Ontario (CHEO) Centre ofThe Children’s Hospital of Eastern Ontario (CHEO) Centre of
Excellence in ChildExcellence in Child && YouthYouth Mental HealthMental Health
• CIHR/Ontario Women’s Health Council Mid-Career Award (toCIHR/Ontario Women’s Health Council Mid-Career Award (to
CChrishris Wekerle)Wekerle)

4. Nico Trocmé, Barbara Fallon, Bruce MacLaurin, Joanne Daciuk, Caroline Felstiner,Nico Trocmé, Barbara Fallon, Bruce MacLaurin, Joanne Daciuk, Caroline Felstiner,
Tara Black, Lil Tonmyr, Cindy Blackstock, Ken Barter, Daniel Turcotte, Richard Cloutier.Tara Black, Lil Tonmyr, Cindy Blackstock, Ken Barter, Daniel Turcotte, Richard Cloutier.
Canadian Incidence Study of Reported Child Abuse and Neglect – 2003: Major Findings.Canadian Incidence Study of Reported Child Abuse and Neglect – 2003: Major Findings.
Minister of Public Works and Government Services Canada, 2005.Minister of Public Works and Government Services Canada, 2005.

5. DevelopmentDevelopment Child Welfare IssuesChild Welfare Issues Child DysfunctionChild Dysfunction
Positive Self-Positive Self-
regardregard
Affect-regulationAffect-regulation
Emotional Abuse:Emotional Abuse:
(for example, Witnessing(for example, Witnessing
domestic violence,domestic violence, verbalverbal
abuse)abuse)
InternalizingInternalizing
SymptomatologySymptomatology
Substance use (coping,Substance use (coping,
self-medication)self-medication)
Private Self/Private Self/
Healthy SexualityHealthy Sexuality
Sexual Abuse:Sexual Abuse:
(For example, exposure to(For example, exposure to
pornography, sexual contact)pornography, sexual contact)
Risky Sexual PracticesRisky Sexual Practices
Dating ViolenceDating Violence
VictimizationVictimization
BehavioralBehavioral
controlcontrol
Physical Abuse:Physical Abuse:
(Arbitrary, coercive discipline)(Arbitrary, coercive discipline)
Antisociality (vs.Antisociality (vs.
Authority)Authority)
Dating ViolenceDating Violence
PerpetrationPerpetration
DelinquencyDelinquency
Substance abuseSubstance abuse
Physical IntegrityPhysical Integrity
NeglectNeglect
(Food, Shelter, Basics)(Food, Shelter, Basics)
HealthHealth
Self-care, HygieneSelf-care, Hygiene
Suicidal IdeationSuicidal Ideation
Child Development ModelChild Development Model

6. MAPS Goals & strategiesMAPS Goals & strategies
Collects data from youth (ages 14.0 to 17.0 years) who areCollects data from youth (ages 14.0 to 17.0 years) who are
active on the child welfare caseload from an urbanactive on the child welfare caseload from an urban
catchment area and are randomly selectedcatchment area and are randomly selected
 The MAP eThe MAP evaluates the health and well-being ofvaluates the health and well-being of adolescentsadolescents
involved in the CPS system in one urban catchment area,involved in the CPS system in one urban catchment area,
(a)comparing MAP females to MAP males; (b) comparing to(a)comparing MAP females to MAP males; (b) comparing to
ON population matched on age and SESON population matched on age and SES
 The MAP administers the OSDUHS questionnaire at 3The MAP administers the OSDUHS questionnaire at 3
testing points: 1, 2 and 3 yearstesting points: 1, 2 and 3 years
 The MAP examines longitudinal trajectories on mental health,The MAP examines longitudinal trajectories on mental health,
substance use/abuse, risky sexual practices and teen datingsubstance use/abuse, risky sexual practices and teen dating
violenceviolence
 The MAP considers various mediators and moderators of theThe MAP considers various mediators and moderators of the
child maltreatment – adolescent impairment relationshipchild maltreatment – adolescent impairment relationship

7. MAP ProceduresMAP Procedures
Lists of all current
active caseloads
(sorted by CPS ID)
between 14 - 17 years
of age forwarded to
MAP team
Lists of youth
randomly selected for
each CPS branch. List
forwarded to MAP
CPS liaison member
at each branch
CPS Liaison contacts
worker affiliated with
each youth. Workers
determine eligibility of
youth for participation
Workers contact
youth on their
caseload to explain
the study and obtain
permission for MAP
researchers to contact
the youth
Worker faxes signed
“recruitment form” if
the youth agrees,
“inability to recruit
form” if youth
ineligible/refuses
MAP researchers meet
youth for consent/data
collection. Consent
forms and data separated
to maintain
confidentiality. Guardian
signs consent for youth
under 16 yrs.

8. Initial TestingInitial Testing –– DemographicsDemographics
 N=453 child welfare-involved youth (52% female) participants atN=453 child welfare-involved youth (52% female) participants at
the initial time point (data collected Oct. 2002 – March 2009)the initial time point (data collected Oct. 2002 – March 2009)
 Mean age @ initial testing: M=16.4 years (SD=0.99)Mean age @ initial testing: M=16.4 years (SD=0.99)
 CAS status: 63% crown ward, 16% society ward, 16%CAS status: 63% crown ward, 16% society ward, 16%
community family, 5% temporary carecommunity family, 5% temporary care
 Self-endorsed ethnicity: 30% two or more; 30% White, 25%Self-endorsed ethnicity: 30% two or more; 30% White, 25%
Black, 3% Hispanic, 12% OtherBlack, 3% Hispanic, 12% Other
Living arrangements: 44% with foster parents, 24% in a groupLiving arrangements: 44% with foster parents, 24% in a group
home, 8% with a single parent, 5% with one biological parenthome, 8% with a single parent, 5% with one biological parent
and one other parent, 5% living on own or with a friendand one other parent, 5% living on own or with a friend

9. Alcohol Use – MAP vs. OSDUHSAlcohol Use – MAP vs. OSDUHS
 Most used substances among youth: (1) alcohol; (2) cannabis; (3)Most used substances among youth: (1) alcohol; (2) cannabis; (3)
non-medical use of pain relieversnon-medical use of pain relievers
 Abstinent for Alcohol use – MAP (44%) and OSDUHS (20%)Abstinent for Alcohol use – MAP (44%) and OSDUHS (20%)
 Easy access for all youth – 72% vs. 75% -Easy access for all youth – 72% vs. 75% - no sign diffno sign diff..
 Alcohol use before 13 years – 22% vs. 23% -Alcohol use before 13 years – 22% vs. 23% - no sign diffno sign diff..
 Average age of use = 13.18 years (SD=2.33)Average age of use = 13.18 years (SD=2.33)
 Ever consumed past 12 months – 57% vs. 78%; age 16-18 years,Ever consumed past 12 months – 57% vs. 78%; age 16-18 years,
non-CAS youth over twice as likely (OR=2.75) controlling for SESnon-CAS youth over twice as likely (OR=2.75) controlling for SES
 Weekly use – 12% vs. 10%Weekly use – 12% vs. 10%
 Weekly binge drinking – 11% vs. 19%Weekly binge drinking – 11% vs. 19%
 Problem drinking (AUDIT) – about 20% hit cut-off –Problem drinking (AUDIT) – about 20% hit cut-off – no sign diff.no sign diff.
 Problem drinking most correlated with emotional abuse “I believe IProblem drinking most correlated with emotional abuse “I believe I
was emotionally abused” (CTQ) over 2 times more likely to scorewas emotionally abused” (CTQ) over 2 times more likely to score
above AUDIT cut-offabove AUDIT cut-off

10. Percentage of youth reporting
lifetime and past year drug use
Youth in care CAS youth Non-CAS youth
OnLAC MAP (N=220) OSDUHS (N=2,522)
Life time use (%) Past year use (%)
Life time
use (%)
Past year
use (%)
Life time
use (%)
Past year
use (%)
9-15 yrs 16-20 yrs 9-15 yrs 16-20 yrs 16-18 yrs 16-18 yrs 16-18 yrs 16-18 yrs
Cannabis 25.0 55.0 19.0 39.0 56.0 40.5 51.1 43.6
Other
drugs
8.0 20.0 6.0 10.0 25.9 20.0 21.1 18.1
Source:
Ontario Looking After Children Project, 2006-2007 (OnLAC) (2008);
Maltreatment and Adolescent Pathways (MAP) Project (2009);
OSDUHS (2007)

11. Cannabis use in past 12 months amongCannabis use in past 12 months among
OSDUHS and MAP youth, 2007 to 2009OSDUHS and MAP youth, 2007 to 2009

12. Illicit Drug Use – MAP vs. OSDUHSIllicit Drug Use – MAP vs. OSDUHS
(16-18 year olds)(16-18 year olds)
 MAP - Cannabis (10% under 13) = 13.57 years (SD=1.76)
 Abstinent for Cannabis: MAP (60%) and OSDUHS (56%), when most youth are inAbstinent for Cannabis: MAP (60%) and OSDUHS (56%), when most youth are in
the 16-17 year rangethe 16-17 year range
 Abstinent for Other Drug Use: MAP (80%) and OSDUHS (82%)Abstinent for Other Drug Use: MAP (80%) and OSDUHS (82%)
 Frequent cannabis use (at least 10 times in past 12 month) more likely for MAPersFrequent cannabis use (at least 10 times in past 12 month) more likely for MAPers
(OR=1.43) than OSDUHS(OR=1.43) than OSDUHS
 MAPers more likely to use other drugs (OR=1.44) past 12 monthsMAPers more likely to use other drugs (OR=1.44) past 12 months
 MAPers more likely to score in the clinical range on the CRAFFT scale thanMAPers more likely to score in the clinical range on the CRAFFT scale than
OSDUHS (OR=1.78)OSDUHS (OR=1.78)
 Range of Other Drugs = 0- 10 (MAP; Mean=.53, SD=1.43: OSDUHS Mean=.46,Range of Other Drugs = 0- 10 (MAP; Mean=.53, SD=1.43: OSDUHS Mean=.46,
SD= 1.29)SD= 1.29)
 Sign correlation among alcohol – cannabis (r=.5)Sign correlation among alcohol – cannabis (r=.5)
 Sign correlation cannabis-other drugs (.5)Sign correlation cannabis-other drugs (.5)
 Smoking correlated > r=.5 (alcohol, cannabis) and > r=.3 (number of other drugsSmoking correlated > r=.5 (alcohol, cannabis) and > r=.3 (number of other drugs
used)used)

13. Psychotropic MedicationPsychotropic Medication
 46% of Crown Wards on medication46% of Crown Wards on medication
 29% receiving therapy (in 2006)29% receiving therapy (in 2006)
 From the MAP study, 5% males and 4% ofFrom the MAP study, 5% males and 4% of
females prescribed Ritalin (OSDUHS ques)females prescribed Ritalin (OSDUHS ques)
 From the MAP, 32% females and 29% of malesFrom the MAP, 32% females and 29% of males
on anxiety/mood medications (OSDUHS ques),on anxiety/mood medications (OSDUHS ques),
as compared to 13% of Ontario females and 7%as compared to 13% of Ontario females and 7%
of males (matched on age and SES; OSDUHSof males (matched on age and SES; OSDUHS
dataset)dataset)
 On CES-D from OSDUHS, no significantOn CES-D from OSDUHS, no significant
difference between MAP and ON youthdifference between MAP and ON youth

14. Child Maltreatment & ImpairmentChild Maltreatment & Impairment
Child Maltreatment is related to Self-HarmingChild Maltreatment is related to Self-Harming
Behaviour in TeensBehaviour in Teens
• 2.0 Year testing on MAP Ss (N-=126; 57% female;
Mean Age=18.2 years; SD=.9)
• 31% engaged in some form of DSH; reporting 250
unique DSH acts
• No Gender Difference in number of DSH acts
Gender Differences in type of act:
• Males > Females on burning with cigarettes;
• Females > Males on cutting, severe scratching,
head banging, preventing wounds from healing,
putting themselves in dangerous situations
• 53% of DSH no-to-1 hr of premeditation - ”impulsive”
• Top 4 DSH reasons: (1) to punish myself (2) to
escape (3) to stop bad feelings (4) to feel something
Suicidal Ideation Deliberate Self-Harm (DSH)
Note: n=428 (53% female); Mean age: 16.39 (SD=0.99); 31% Caucasian, 24% African Canadian, 32%
bi/multi-racial, 13% other. Severe maltreatment: been kicked, bit or punched by an adult, been choked, burned
or attacked in other physical form by an adult, someone touched private parts or been made to touch
someone’s private parts, or someone sexually forced himself on youth against their will.

15. Future DirectionsFuture Directions
 Understanding the impact of child maltreatment isUnderstanding the impact of child maltreatment is
critical to service practices in:critical to service practices in:
 Screening and early detection – females, cannabisScreening and early detection – females, cannabis
 Prevention of substance abusePrevention of substance abuse
 Assessment of co-morbidity (mental health; substanceAssessment of co-morbidity (mental health; substance
abuse)abuse)
 Assessment of substance use as it relates to suicidalityAssessment of substance use as it relates to suicidality
 Approaches to treatment of substance abuse within aApproaches to treatment of substance abuse within a
trauma context? (DBT for adolescents; TF-CBT)trauma context? (DBT for adolescents; TF-CBT)
 Treatment where co-morbidity – e.g., CAMH First ContactTreatment where co-morbidity – e.g., CAMH First Contact
programprogram