Recommended
Recommended
More Related Content
What's hot
What's hot (19)
Viewers also liked
Viewers also liked (20)
Similar to Wekerle CIHR Team - Child Maltreatment and Adolescent Problem Drinking Among Child Welfare-Involved Youth
Similar to Wekerle CIHR Team - Child Maltreatment and Adolescent Problem Drinking Among Child Welfare-Involved Youth (20)
More from Christine Wekerle
More from Christine Wekerle (20)
Recently uploaded
Recently uploaded (20)
Wekerle CIHR Team - Child Maltreatment and Adolescent Problem Drinking Among Child Welfare-Involved Youth
- 1. CHILD MALTREATMENTAND ADOLESCENT PROBLEM DRINKING AMONG CHILD WELFARE-INVOLVED YOUTH Sherry H. Stewart, PhD Departments of Psychiatry and Psychology & Neuroscience Dalhousie University sstewart@dal.ca CAPHC Webinar, March 30, 2016
- 2. Overview • Study 1 – Sex-Specific Pathways from Childhood Sexual Abuse to Problem Drinking Among Child Welfare Youth • Study 2 -- From Childhood Maltreatment to Adolescent Problem Drinking: Mediation through PTSD Symptoms and Drinking to Cope • Conclusion – Clinical Implications; Tailored Treatments
- 3. SEX-SPECIFIC PATHWAYS FROM CHILDHOOD SEXUAL ABUSE TO PROBLEM DRINKING AMONG CHILD WELFARE YOUTH Hudson, A., Wekerle, C., Goldstein, A., Ellenbogen, S., Waechter, R., Thompson, K., Stewart, S. H.
- 4. Background Childhood sexual abuse (CSA) number of enduring negative outcomes Substance use and misuse • Early initiation of illicit drug use • Polysubstance use • Risk of fatal overdose • Increased alcohol use • Alcohol use disorders Dube et al 2003; Harrison et al., 1997; Brems et al., 2004
- 5. Background Links between CSA and alcohol use well-established Mechanisms? • A large proportion of CSA victims experience emotion symptoms: depression, anxiety, and anger • Research suggests: Briere & Runtz, 1988; Faulkner et al., 2014; Hannan et al., 2015; Trautmann et al., 2015 Emotion Symptoms Maltreatment/ Violence Alcohol Problems
- 6. Current Study Objective: to understand links between CSA and alcohol problems in a sample of youth involved in child welfare services • Emotion symptoms as mediators of CSA-alcohol problems relation • Gender as potential moderator • Dep; Anx - Females • Anger - Males Briere & Elliott, 2003; Goldstein et al., 2010
- 7. Method – Participants & Design • Subset of participants from the Maltreatment and Adolescent Pathways (MAP) project (Wekerle et al., 2009) • Participants randomly selected through child welfare services (Children’s Aid Societies; CAS) • N = 301; 56% female • Mage =15.9 years (SD = 1.1) • Cross-sectional design • Data from single wave of MAP study
- 8. Childhood Experience of Violence Questionnaire (CEVQ; Walsh et al., 2008) Physical, emotional, and sexual abuse (six items) 0 = never 1 = 1–2 times 2 = 3–5 times 3 = 6–10 times 4 = more than 10 times Females Mean = 1.68 (SD 2.62)* Males Mean = 0.41 (SD 1.13) *Females significantly higher
- 9. Trauma Symptom Checklist for Children (TSCC; Briere, 1996) Emotion symptomology in children/ adolescents Likert scale 0 (never) to 3 (almost all of the time) Females Males Anxiety M = 5.9 (6.31)* M = 3.27 (3.78) Depression M = 6.85 (6.82)* M = 3.8 (4.58) Anger M = 7.42 (7.57) M = 6.24 (6.06) *Females significantly higher
- 10. Rutgers Alcohol Problem Index (RAPI; White & Labouvie, 1989) • Measure of problem drinking in adolescents • 23 negative consequences of drinking • Frequency in past 12 mths 0 (never), 1 (1-2 times), 2 (3-5 times), 3 (6-10) to 4 (10+) Females Males Problem Drinking M = 9.41 (12.47) M = 10.28 (12.39)
- 11. Results Males
- 12. Results Females
- 13. Discussion • Emotion symptoms pertinent for predicting problem drinking in females • Anxiety + Anger had explanatory roles • Only the emotion symptom of anger important in explaining CSA alcohol problems in males • Emotion symptoms were full mediators in females, but only partial mediators in males More complex in males?
- 14. FROM CHILDHOOD MALTREATMENT TO ADOLESCENT PROBLEM DRINKING: MEDIATION THROUGH PTSD SYMPTOMS AND DRINKING TO COPE Stewart, S. H., Hudson, A., Thompson, K., & Wekerle, C.
- 15. Background Childhood maltreatment (abuse and neglect) myriad negative consequences School drop out Violence perpetration Internalizing symptoms (e.g., PTSD) Alcohol/other drug misuse Langeland et al., 2004; Stewart, 1996
- 16. Background Links between childhood maltreatment and alcohol misuse well-established Mechanisms? • PTSD is a possible negative outcome of child maltreatment • Research suggests: e.g., Zahradnik et al., 2011 PTSD Symptoms Childhood Maltreatment Alcohol Problems
- 18. Motives: Links to Problems CopingEnhancement Social Conformity Source Valence Positive Negative External Internal Cooper, 1994
- 19. Current Study Objective: to understand links between childhood maltreatment and alcohol problems in a vulnerable sample of youth (child welfare sample) • Examine both PTSD symptoms and coping drinking motives as mediators of childhood maltreatment- alcohol problems relation • Examine chained mediation model • Maltreatment PTSD coping motives alcohol problems Stewart, 1996
- 20. Method – Participants & Design • Subset of participants from the MAP project (Wekerle et al., 2009) • N = 568; 54% female • Mage =15.9 years (SD = 1.07) • Used pseudo-longitudinal design • Two waves of data over 6 months • 74% retention over two waves
- 21. Childhood Trauma Questionnaire (CTQ; Bernstein & Fink, 1998) – wave 1 When you were growing up…. Physical abuse Emotional abuse Sexual abuse Emotional neglect (28 items total) 1 = never . . . 5 = very often
- 22. Trauma Symptom Checklist for Children (TSCC; Briere, 1996) – waves 1 and 2 PTSD scale Hyperarousal Reexperiencing Avoidance Numbing Suitable for children / adolescents Likert scale 0 (never) to 3 (almost all of the time) Good psychometric properties (Ohan et al., 2002; Elliot & Briere, 1994)
- 23. The Drinking Motives Questionnaire-Revised (DMQ-R, Cooper, 1994) – waves 1 and 2 • Four motives for drinking: • Social “To celebrate a special occasion with friends” • Enhancement “Because it’s fun” • Coping “To forget about your problems” • Conformity “To fit in with a group you like”
- 24. Rutgers Alcohol Problem Index (RAPI; White & Labouvie, 1989) – waves 1 and 2 • Measure of problem drinking in adolescents • 23 negative consequences of drinking • Frequency in past 12 mths 0 (never), 1 (1-2 times), 2 (3-5 times), 3 (6-10) to 4 (10+)
- 25. Results
- 26. Discussion • PTSD symptoms pertinent for explaining relation of maltreatment in childhood to problem drinking in adolescence • Extends Zahradnik et al. (2011) beyond First Nations youth • Idea that maltreatment survivors are drinking to deal with PTSD evidenced by further mediation through drinking to cope • Both mediators were necessary for mediation More complex than PTSD or drinking to cope alone Suggests pathway that unfolds over time
- 27. Limitations • Issues with retrospective self-reports of CSA (e.g., unwillingness to disclose, memory distortions) and self- reports of alcohol use (accuracy issues, esp. in youth) • Study 1: Gender norm influences on self-reported emotion symptoms • Study 1: Cross-sectional data (cannot infer causality) • Study 2 Pseudo-longitudinal design (2 waves vs optimal 4)
- 28. Implications Study 1 • Screening for CSA • Emotion symptoms as targets for tailored interventions • ‘Gendered’ approach Study 2 • Screening for maltreatment • PTSD symptoms and coping motives as targets for tailored interventions • Focus on both mediators What do these studies mean for targeted interventions in youth receiving child welfare services? Negative affect management; CBT for PTSD; motivation- matched interventions for substance misuse
- 29. Motivation-matched Interventions • Motivation-matched treatments ― Individualized coping skills ― Target at-risk youth with specific risky, motivations for substance use • Evidence of effectiveness ― Higher abstinence; lower concern ― Abstinence, reduced binging, reduced problem drinking Conrod et al., 2000 Conrod et al., 2006
- 30. Acknowledgements MAP Collaborators, advisory board, and research staff Ontario Association of Children's Aid Societies Child Welfare League of Canada First Nations Child and Family Caring Society Youth Participants
- 31. Acknowledgements
Editor's Notes
- Tailored Treatments – to meet unique needs of these youth
- Previous research has indicated that post-traumatic symptoms, including anger, were predictive of alcohol and illicit drug use among adolescents involved with child welfare (Goldstein et al., 2011). Indeed, in testing the mediating roles of several trauma symptom clusters, Faulkner et al. (2014) found that anger was the only significant mediator of the effects of childhood maltreatment on problem drinking in youth in child protective services. Post-traumatic symptoms associated with anxiety and depression (e.g., sleep problems and rumination) have also been identified as risk factors for heightened alcohol consumption following stressful events, such as military deployment (Trautmann et al., 2015). Support for negative emotion-mediated pathways from maltreatment/ violence to alcohol problems Although existing work elucidates trauma-centered mechanisms linking stressors and abuse to alcohol use, it does not answer whether separate pathways exist for males and females.
- In the current study, we aimed to provide a more detailed account of links between CSA and alcohol use in a vulnerable population (youth in the child welfare system), by exploring potential mechanisms involving negative emotions. In light of different prevalences of emotional symptoms in men and women (Briere & Elliott, 2003; Campbell, 2007; Weiss et al., 1999), and based on gender-specific links between childhood maltreatment, reasons for drinking, and drinking problems (Goldstein et al., 2010), we examined gender as a potential moderator. We expected internalizing symptoms (anxiety; depression) to be important mediators for female adolescents and the externalizing symptom of anger to be an important mediator for male adolescents.
- White (28%), Black (21%), Biracial (31%), Asian (4%), Latin American (3%), Native (2%), and other (11%) Cross sectional design from a single wave of the MAP study
- frequency of experiencing that form/ example of sexual abuse (0 = never, 1 = 1–2 times, 2 = 3–5 times, 3 = 6–10 times, 4 = more than 10 times). “Did anyone ever threaten to have sex with you when you did not want them to?”
- For each item, participants report the frequency with which they have experienced the listed concern on a 4-point scale ranging from 0 (never) to 3 (almost all of the time). Subscale scores are calculated by summing scores for all items within the given subscale Normative Data: Mayo Clinic (nonclinical – routine med check ups or minor med complaints) Males 13-16 Anx 4.5 Dep 4.5 Ang 8.3 Females 13-16 Anx 7.0 Dep 7.9 Ang 9.3 Wolfe study?
- Participants indicate the frequency with which they have experienced each negative outcome in the past 12 months. Response options include 0 (never), 1 (1-2 times), 2 (3-5 times), 3 (6-10 times), and 4 (more than 10 times).
- Results showed that the constrained model fit significantly worse than the unconstrained model (χ2 = 75.52, df = 22, p < .001), indicating significant moderation by gender. Therefore, the final path models are presented separately for male and female adolescents. For male adolescents, the results of the path models showed that CSA was positively associated with higher levels of all three mediators (Figure 1b). As hypothesized, there was a significant indirect effect of CSA on problem drinking through anger (.08, p = .03; Table 2). However, for males, there was still a significant direct association between CSA and problem drinking, such that higher levels of CSA were associated with higher levels of problem drinking even after accounting for the effects of anger. Thus, the results suggest only partial mediation of the association between CSA and problem drinking via trauma symptoms for males. The model accounted for 23% of the variance in problem drinking. Emphasize need for future research here – on what other factors (other than anger) help explain the association of CSA with adolescent problem drinking if not negative emotions like anger.
- For females, results from the path models showed that CSA was positively associated with higher levels of anger, anxiety, and depression (Figure 1a). As hypothesized, there was a significant indirect effects of CSA on problem drinking through anxiety (.15, p = .02). Unexpectedly, there was also a significant indirect effect through anger (.13, p = .005) similar to that seen in the boys. Higher levels of CSA predicted higher levels of both anxiety and anger symptoms in the girls, which in turn predicted higher levels of problem drinking. Unlike in the boys, there was no direct association between childhood sexual abuse and problem drinking after the influence of negative emotions was controlled, suggesting full mediation in girls – negative emotions fully explain the link of CSA to adolescent problem drinking in girls. Emphasize emotions fully mediated for girls and only partially mediated for boys. Emphasize need for future research here – path from CSA to anger to prob drinking unexpected in females. Explain suppressor effect with depression (because multiple symptoms in model – aspects of depression that overalp with anger and anxiety that might relate with prob drinking already accounted for ). Aspects of depression that are unique – anhedonia/ apathy – might neg relate with drinking b/c those individuals would be less likely to socialize/ leave house/ be in settings where they would consume alcohol. Wolfe et al. Girls with a history of maltreatment had a higher risk of emotional distress compared with girls without such histories (e.g., odds ratios [OR] for anger, depression, anxiety, and posttraumatic stress–related problems were 7.1, 7.2, 9.3, and 9.8, respectively). Female adolescents with a history of maltreatment were more than 7 times as likely to have clinically significant difficulties with anger and depression and more than 9 times as likely to experience clinically significant levels of anxiety and posttraumatic stress as were those without a maltreatment history.
- Last point - This suggests that, while connections between CSA and problem drinking in females can fully be accounted for by emotional symptoms, relations may be more complex and multi-faceted in males. Other contributors to problem drinking that merit investigation, alongside trauma symptoms, in male victims of CSA include motivational factors (reasons for drinking), cognitive factors (beliefs, attitudes, expected outcomes), and social factors (susceptibility to peer pressure and peer modelling). Future research will need to evaluate these possibilities. While it is clear why anxiety might lead to prob drinking (self-mediation/ drinking as anxiolytic) – less intuitive why anger would do so…could also be way of dulling anger…or may, alt, reflect that CSA leads to dysregulation of behavior that appears in the form of increased anger/ aggression as well as increased alcohol use
- Cooper’s 1994 model of drinking motives. Drinking motives can be classified along two dimensions: valence or type of reinforcement (positive or negative) and source of reinforcement (external or internal). Valence refers to the nature of the emotion that is being targeted by drinking…be it to achieve a positive emotional outcome or to avoid a negative emotional state. The other dimension is source. Source can be identified as internal or external, meaning that the individual drinks to change their internal experience or to fulfill external, social goals. By combining these dimensions, we end up with four separate motives for drinking: enhancement (internally motivated to increase a positive state), coping (internally motivated to reduce a negative state), social (externally motivated to increase a positive state), conformity (externally motivated to reduce a negative state). Give examples…… Enhancement –to get an emotional high, to have fun….might be thought of as taking place in a party context Coping – to deal with negative emotional states, to escape or forget about problems, to numb emotional pain/distress Social – for reasons such as social affiliation, to enjoy social gatherings Conformity – due to peer pressure, feel like you need it to fit in
- Cooper’s 1994 model of drinking motives. Drinking motives can be classified along two dimensions: valence or type of reinforcement (positive or negative) and source of reinforcement (external or internal). Valence refers to the nature of the emotion that is being targeted by drinking…be it to achieve a positive emotional outcome or to avoid a negative emotional state. The other dimension is source. Source can be identified as internal or external, meaning that the individual drinks to change their internal experience or to fulfill external, social goals. By combining these dimensions, we end up with four separate motives for drinking: enhancement (internally motivated to increase a positive state), coping (internally motivated to reduce a negative state), social (externally motivated to increase a positive state), conformity (externally motivated to reduce a negative state). Give examples…… Enhancement –to get an emotional high, to have fun….might be thought of as taking place in a party context Coping – to deal with negative emotional states, to escape or forget about problems, to numb emotional pain/distress Social – for reasons such as social affiliation, to enjoy social gatherings Conformity – due to peer pressure, feel like you need it to fit in
- In the current study, we aimed to provide a more detailed account of links between CSA and alcohol use in a vulnerable population (youth in the child welfare system), by exploring potential trauma-focused mechanisms. In light of different prevalences of emotional symptoms in men and women (Briere & Elliott, 2003; Campbell, 2007; Weiss et al., 1999), and based on gender-specific links between childhood maltreatment, reasons for drinking, and drinking problems (Goldstein et al., 2010), we examined gender as a potential moderator. We expected internalizing symptoms (anxiety; depression) to be important mediators for female adolescents and the externalizing symptom of anger to be an important mediator for male adolescents. Note that although this study includes emotion symptoms as mediators – not motives as in study 1 – some similarities – they are often drinking to cope with neg affect like anx and depression. So, in that way – studies are interconnected.
- White (28%), Black (21%), Biracial (31%), Asian (4%), Latin American (3%), Native (2%), and other (11%) Used pseudo-longitudinal design (two waves of data over 6 months); 74% retention over the two waves
- frequency of experiencing that form/ example of sexual abuse (0 = never, 1 = 1–2 times, 2 = 3–5 times, 3 = 6–10 times, 4 = more than 10 times). “Did anyone ever threaten to have sex with you when you did not want them to?”
- For each item, participants report the frequency with which they have experienced the listed concern on a 4-point scale ranging from 0 (never) to 3 (almost all of the time). Subscale scores are calculated by summing scores for all items within the given subscale Normative Data: Mayo Clinic (nonclinical – routine med check ups or minor med complaints) Males 13-16 Anx 4.5 Dep 4.5 Ang 8.3 Females 13-16 Anx 7.0 Dep 7.9 Ang 9.3 Wolfe study?
- The DMQ-R (Cooper, 1994) is a 20-item self-report questionnaire that assesses four motives for drinking: coping, conformity, social, and enhancement. Exemplar items include “To forget about your problems” (coping), “To fit in with a group you like” (conformity), “To celebrate a special occasion with friends” (social), and “Because it’s fun” (enhancement). Respondents rate how frequently they drink for each reason, ranging from 1 (almost never/never) to 5 (almost always/always).
- Participants indicate the frequency with which they have experienced each negative outcome in the past 12 months. Response options include 0 (never), 1 (1-2 times), 2 (3-5 times), 3 (6-10 times), and 4 (more than 10 times).
- Our hypothesized chained mediation model provided an good fit to the data, 𝜒2(4) = 5.88, p = .21; RMSEA = .03, 90% CI [.00, .08]; CFI = 1.00. Consistent with our hypothesis, higher levels of childhood trauma were associated with higher levels of PTSD symptoms at T1 ( = .43, p < .001), which in turn predicted higher levels of coping motives at T2 ( = .15, p < .05), which was associated with higher levels of drinking problems at T2 ( = .48, p < .001) (Figure 1). The indirect chained mediated effect through both PTSD and coping motives was significant (indirect effect = .03, p = .04). The indirect single mediator effects were not significant (via only one mediator) providing stronger support for chained mediation. As there was no significant direct effect between childhood trauma and alcohol problems once mediators were accounted for, it can be concluded that the association between childhood trauma and alcohol problems was fully mediated by PTSD and coping motives.
- There are potential issues with our use of self-report data on CSA in that such reports are often influenced by unwillingness to disclose (Fergusson et al., 2000) and problems in remembering or interpreting incidences (i.e., memory is repressed or unclear, incident is not understood as assault). The issue of reluctance to report CSA is particularly noteworthy in studies on gender differences, as barriers to reporting might be greater in males (i.e., threatened masculinity, fears of skepticism or disbelief; Collin-Vézina et al., 2013). Limitations associated with studying gender effects also exist with regard to emotional symptom measures, in that females might be more inclined to endorse items associated with depression or anxiety (e.g., crying), whereas males might preferentially endorse items assessing anger (e.g., wanting to yell and break things). Indeed, Feingold (1994) suggest that gender differences in reports of certain symptoms and traits might, in part, reflect tendencies to respond in a way that is consistent with gender norms (i.e., favoring masculine or feminine attributes). However, gender differences in emotional symptoms are replicated when using measures other than self-report, such as ethological observation of behavior (Troisi & Moles, 1999). Potential constraints also exist when using self-reports of alcohol use given that youth might feel hesitant to give accurate information regarding their drinking habits. Nonetheless, research suggests that, when confidentiality is ensured, respondents’ self-reports of drinking are highly accurate (Sobell & Sobell, 1990). It should also be noted that our measure of CSA reflected occurrence and frequency of incidences, but did not consider other aspects of CSA, such as the duration of abuse or age when abuse occurred or who the perpetrator was. Finally, because our data are of a cross-sectional nature, causal inferences cannot be made. Future research should replicate the findings presented here, but using a longitudinal study design.
- Implications – What does this mean… First, it suggests that clinicians may be able to build on existing interventions developed for use in youth from the general population, by refining these interventions to be more targeted for at risk youth. As we saw in Study 2, coping motives may be of particular importance in designing targeted interventions for at risk youth who are experiencing PTSD symptoms. In turn, such interventions may be able to provide at risk youth, such as those involved in child welfare services, with more adaptive coping skills that would reduce their reliance on alcohol as a way to cope. Motivation-matched coping skills might also serve youth well in other areas of their life, and may act as somewhat of a buffer against trauma that these youth may have endured …We need to consider patients’ general life circumstances when designing interventions….it’s not appropriate to take a one size fits all approach. Or… Need to consider contextual and social factors, such as the general life circumstances of youth who may seek treatment for alcohol-related problems, in addition to individual difference factors, like personality and motives. When we do this, we see that it’s imperative to avoid a one size fits all approach, but rather to see the patient or client for their individual needs, as well as in terms of their social and contextual realities. By taking so, we might be better able to serve high-risk youth so as to buffer against trauma and promote resilience, at least in the form of reduced substance use and problems. Analyses focused on risk, but also have preliminary analyses to suggest certain protective factors exist for these youth (stability – moving homes less than 5 times; not having been exposed to parent divorce or separation – lower levels of stressful transition associated with lifetime abstinence from alcohol) Implications study 2 - First, our results add to a substantial literature suggesting that CSA is a risk factor for later alcohol use problems (Miller et al., 1993; Simpson & Miller, 2002; Wilsnack et al., 1997). Therefore, individuals presenting for treatment for alcohol use disorders should be screened for histories of sexual victimization, and vice versa. Second, our findings pinpoint different mechanisms by which CSA leads to problem drinking in males and females. Both anger and anxiety may be important trauma symptoms to address in treating drinking problems in women with histories of sexual abuse. In men, anger may merit increased attention in a clinical setting, whereas internalizing symptoms are seemingly less important, at least in relation to alcohol use outcomes. A growing body of research suggests that targeted treatments are effective in reducing substance use problems in youth and adults (Conrod et al., 2006; Conrod et al., 2000). These targeted treatments adapt aspects of the treatment or intervention to meet individual needs, such as motivational or personality risk factors (Conrod et al., 2000a; Conrod et al., 2000b; Conrod et al., 2006). Based on our findings, tailored treatments for alcohol problems would do well to focus on emotional symptoms that arise following trauma (i.e., after sexual victimization). Moreover, such treatments should take a gendered approach, acknowledging that distinct trauma symptoms predict problem drinking in men and women, based on their CSA histories. Although recommendations based on our results may pertain to child welfare populations, in particular, they may also be informative for clinicians working with other vulnerable populations. Future work will need to examine these models with more diverse populations before concrete recommendations can be made.
- This research has been used to develop and improve more targeted treatments for individuals with substance use problems. Conrod et al., 2000– higher abstinence rates for alcohol and prescription drugs, less reports of concerns about use than mot mismatch or motivational control (motivational film and discussion with therapist)…at 6 month follow-up after intervention (sample of women who were dependent on or abused alcohol or a prescription drug(s)) Conrod et al. (2006) – superior results in terms of abstaining from drinking Personality matched intervention vs. control no-intervention group..interventions focused on psychoeducation (explaining personality risk and how it could influence decisions and coping strategie), behavioral coping strategies (discussing positive and negative coping strategies for coping with that particular personality dimension), and cognitive coping strategies (evaluate their thoughts, reframe their thoughts when appropriate)