Child maltreatment and substance abuse
You are in an archived section of the AIFS website
- Linking child maltreatment and substance abuse
- Research issues
- Types of abuse
- Future research directions
Though interest in substance abuse and family violence have developed relatively independently, even in ancient times there were references to the 'devastating effects of substance abuse on families' (Russell 1995, p.247). The perception that substance abuse had a detrimental effect on families has strengthened over time.
Gelles (1993) cites William Hogarth's early 18th century etching entitled, Gin Lane, which portrays the maltreatment that may befall children reared by alcohol-abusing parents. A century later, social workers in the United States firmly believed that alcohol was the cause of child maltreatment, an assumption which, in part, lead to the Prohibition Movement experienced by the United States in the 1920s (Gelles 1993).
In the decades since, the 'demon rum' explanation for violence and abuse in the home has become one of the 'most pervasive and widely believed explanations for family violence in the professional and popular literature' (Gelles 1993, p.182).
There has been some support for this contention, with research investigating homicide, assault and domestic violence all producing substantial associations between alcohol abuse and violence (Gelles 1993).
Similarly, as the popularity of alternatives to alcohol increased, other addictive, illicit drugs, such as cocaine, crack, heroin, marijuana and LSD, have also been considered to be causal agents in domestic violence and other forms of family violence (Flanzer 1993).
With the 'rediscovery' of child maltreatment in the 1960s by Kempe and his colleagues (Kempe et al. 1962), the perception that alcohol and drug abuse were closely linked to child maltreatment quickly emerged (Corby 1993). The earliest causal models of child maltreatment focused on parental psychopathology, with the two most prevalent disorders identified being depression and substance abuse (Chaffin, Kelleher and Hollenberg 1996).
Consistently over the last 30 years, substance abuse has been increasingly cited as a contributory factor in child maltreatment (Browne and Saqi 1988; National Research Council 1993). Such inferences have been based primarily upon the assessment of children and young people in child welfare, medical or psychiatric programs, rather than those presenting as part of a family unit at drug and alcohol treatment agencies (Freeman 1993).
This paper provides an overview of the relationship between substance abuse and child maltreatment, summarising current research and identifying areas requiring further investigation. Because of the size of the literature, a review of the development of substance abuse problems in maltreated children will be presented as part of a future Clearing House Issues Paper.
Substance abuse is often used as a global term which may encompass the use or abuse of a range of substances, such as alcohol, illicit drugs and prescribed drugs. The majority of studies incorporate those suffering from a chemical dependency, diagnostically defined as 'the intermittent and progressive compulsive use of the drug or drugs (including alcohol) with loss of control' (Hayes and Emshoff 1993, p.282).
Unless stated otherwise, the definition of substance abuse used throughout this paper encompasses those who are regularly misusing alcohol, illicit or prescribed drugs, and those who have progressed to a clinically defined chemical dependence. Child maltreatment is defined as the sexual, physical or emotional abuse or neglect of a child.
Linking child maltreatment and substance abuse
There has been a growing recognition that many social and human problems are highly related (Hayes and Emshoff 1993), and increased emphasis has been placed on the association between substance abuse and family violence as a whole. In this section the dynamics and interaction between child maltreatment and substance abuse are examined, highlighting the similarities between the two social problems.
A number of causal or 'risk' factors commonly associated with child maltreatment have also been associated with substance abuse. However, as with investigations of the causes of child maltreatment, most of the research that has investigated the causes of substance abuse has identified associative relationships but has failed to prove causation (Gelles 1993; Hayes and Emshoff 1993).
A number of personality and behavioural correlates of substance abuse and family violence as a whole have been identified (Hayes and Emshoff 1993). These include hyperactivity, a 'difficult' temperament, impaired mother - child bonding, early sexual activity, criminal or runaway behaviour, poor self-esteem, poor peer relations, social isolation and social deprivation, and growing up in a mobile family (moving home frequently during childhood).
It has been suggested that the factors showing the strongest connection to both substance abuse and child maltreatment are those relating to the parents and family, in particular, parenting behaviours and family structure (Finkelhor and Baron 1986; Hayes and Emshoff 1993).
Variables found to be associated with both substance abuse and child maltreatment are: parental inconsistency, poor limit setting, excessively harsh disciplinary measures, parental conflict, poor communication, parental absence or unavailability, and social isolation of the family (Hayes and Emshoff 1993).
While most of the research attempting to delineate the causes of child maltreatment and substance abuse has focused on familial and individual factors, the social environment clearly plays a role (Cicchetti and Olsen 1990).
Factors such as community norms, neighbourhood disorganisation, cultural disenfranchisement (particularly applicable to indigenous peoples), and the unavailability of community education on either substance abuse or child maltreatment have been posited as exacerbating the risk of both child maltreatment and substance abuse.
Poor school performance, truancy and leaving school early correlate with a greater risk of substance abuse in adolescence. These factors also correlate with the maltreatment of children from addicted families (Gottfredson 1986, as cited in Hayes and Emshoff 1993).
Despite the early identification of substance abuse as a potential causative factor, it has only been recently that the 'true dimensions of the interaction between substance abuse and violence against children [has] begun to surface in the professional literature' (Blau et al. 1994, p.84).
The US experience
Much of the available data has originated in the United States, which has been struggling with a significant substance abuse problem. Bays (1990, as cited in Hayes and Emshoff 1993) reported that there were approximately 10 million adult alcoholics, 500,000 heroin addicts, and between five and eight million regular cocaine users in the United States. It has been estimated that at least half of all parents whose children are known to the welfare system in the United States have substance abuse problems (Dore, Doris and Wright 1995). Barth (1994, as cited in Dore, Doris and Wright 1995) puts the estimate at closer to 80 per cent of families.
In 1986, a survey of children who were made Wards of the State in the United States indicated that over half came from chemically-dependent families (Chasnoff 1988, as cited in Hayes and Emshoff 1993). A further survey of United States voluntary child welfare services found that 57 per cent of client children were affected by parental substance abuse (Curtis and McCullough 1993).
Chasnoff (1988, as cited in Blau et al. 1994) used the case statistics kept by child welfare agencies to conduct an investigation of drug use during pregnancy. Chasnoff reported that 50 per cent of the 1987 maltreatment incidents for New York City involved substance abuse, and that at least 11 per cent of pregnant women in the United States used drugs or alcohol during pregnancy with more than 300,000 infants per year being born to cocaine/crack-using mothers.
Focusing on alcohol abuse, Black (1981, as cited in Hayes and Emshoff 1993) reported that up to 66 per cent of children raised by alcoholic parents were physically abused or witnessed family violence, and that 26 per cent of the children had been sexually abused. Physical or sexual abuse was reported to occur regularly in one-third of alcoholic homes. Depending upon the study, the reported rates of alcohol abuse in maltreating families in the United States have varied from 25 to 84 per cent (Blau et al. 1994).
In comparison, Trocmé, McPhee and Tam (1995) presented the descriptive findings from the Ontario Incidence Study of Reported Child Abuse and Neglect (OIS), which was the first Canadian study to examine the incidence and characteristics of reported child maltreatment.
Using data compiled by child protection workers on a representative sample of 2447 investigated children, the incidence rate was calculated at 21 per 1000 children, with a 27 per cent substantiation rate. It was reported that alcohol abuse was identified as occurring in 13 per cent of investigations, and in 38 per cent of substantiated cases. Drug abuse was reported to occur in only 7 per cent of investigated cases, but 31 per cent of substantiated cases.
The Australian experience
It has been estimated that 17.6 per cent of Australian men aged 18 years and over and 10.8 per cent of Australian women drink alcohol at levels defined as hazardous or harmful by the National Health and Medical Research Council (AIHW 1996).
Reliable estimates of the prevalence of illicit drug use are more difficult to obtain and the available data are likely to be an underestimate. However, the prevalence of opiate addiction at ages 15 - 39 years has been estimated at between 0.5 per cent and 0.8 per cent (National Drug Abuse Information Centre 1988, as cited in AIHW 1996).
There have been few Australian attempts to determine accurately the extent to which child maltreatment and substance abuse interact (Keys Young 1993). The child maltreatment case information provided by the various Australian States and Territories to the Australian Institute of Health and Welfare for inclusion in the national child maltreatment data summaries, does not enable an accurate estimation of the extent to which substance abuse is identified in cases.
However, in the 1994 - 95 national child maltreatment statistics, Angus and Hall (1996), indicated that 22 per cent of all substantiated emotional abuse cases in New South Wales were reported to result from a parent's substance abuse problem. No specific category was provided for cases of neglect or other abuse where parental substance abuse may have contributed to the maltreatment experienced by the child.
Clark (1994) cites an analysis of 75 randomly selected cases from the Protective Services Branch, Health and Community Services Victoria (now the Department of Human Services), which showed that 41.5 per cent of families sampled had substance abuse concerns recorded as contributing to protective concerns.
In cases of neglect (of which 80 per cent occurred in single parent families), 57 per cent of cases had a substance abuse concern recorded. Typically, such concerns were linked to the mother or both parents. In physical abuse cases, alcohol abuse was the most commonly recorded family problem, and in each instance was recorded in association with a report of family violence.
The male partner was usually identified as the perpetrator of violence, and in two-thirds of cases was also perceived to have the alcohol problem; otherwise both parents were implicated. Substance abuse did not figure prominently in sexual abuse or emotional abuse cases (Clark 1994).
The only other major source of Australian data has been Victorian case tracking studies conducted by Monash University researchers. In 1987 Hiller, Goddard and Diemer tracked 206 cases labelled as physical and sexual abuse by hospital professionals through a hospital setting and the child protection and criminal justice systems (Hiller, Goddard and Diemer 1989). For the purposes of the study, cases were defined as abusive where it was known or strongly suspected by medical and/or social work staff that a child was maltreated by a caregiver or another member of the child's household.
In 94 cases where data was available, workers identified alcohol problems in 41 per cent of physical abuse cases, compared with 31 per cent in cases of sexual abuse. In a further 86 cases where data was available, workers identified drug problems in 15 per cent of physical abuse cases, compared with 8 per cent in cases of sexual abuse.
Similar findings were reported in another hospital-based tracking study, where in nine of 30 families (30 per cent) labelled as sexually abusive, and in 18 of 36 families (50 per cent) labelled as physically abusive, at least one was identified as having an alcohol problem (Goddard and Hiller 1992). Drug problems were identified by workers in 3 per cent of sexual abuse and 19 per cent of physical abuse cases (Goddard and Hiller 1992).
Finally, Tomison (1994) reported on the results of a large-scale tracking of suspected child abuse and neglect cases involving a number of agencies and professions in a Victorian regional child protection network. A valid case of child abuse or neglect was defined as any suspected case of child abuse or neglect where the professionals involved felt there was sufficient concern to investigate, refer and/or treat or counsel the child.
Overall, in 76 of 295 suspected cases of child maltreatment (25.8 per cent), workers had identified at least one caregiver in the family as having an alcohol problem. Further analysis indicated that an alcohol problem was identified in 16.9 per cent of sexual abuse, 40 per cent of physical abuse, 31.3 per cent of emotional abuse, and 28.0 per cent of neglect.
In 15.6 per cent of cases (46 of 295) a worker identified a drug problem in the family. Again, further analysis indicated that a drug problem was identified in 6.45 per cent of sexual abuse, 16.7 per cent of physical abuse, 41.3 per cent of neglect.
Aboriginal and Torres Strait Islander populations
In the latest national statistics on child maltreatment (Angus and Hall 1996), Aboriginal and Torres Strait Islander children were significantly overrepresented. The rate of substantiated child maltreatment for Aboriginal and Torres Strait Islander children was 19.1 per 1000 children aged 0 - 16 years, compared with a rate for other children of 5.6 per 1000 children.
Similarly, Aboriginal and Torres Strait Islander peoples have been significantly overrepresented in studies of domestic violence. Domestic violence is estimated to occur in up to 70 per cent of families in some Aboriginal and Torres Strait Islander communities (Sam 1992).
The Royal Commission into Aboriginal Deaths in Custody (1991) identified a number of problems seriously affecting Aboriginal society and their causes. Alcohol abuse was linked to family violence and Aboriginal deaths in custody (Sumner 1995). Though accurate estimations of the extent of alcohol or drug-related violence are unavailable, it appears that in a substantial proportion of cases, family violence has been committed by people under the influence of alcohol. For example, in Tasmania, a survey indicated that 99 per cent of family violence incidents in Aboriginal families were directly related to alcohol abuse (Sam 1992).
Large numbers of factors and combinations of factors have been shown to be associated with various types of child maltreatment, and it is generally acknowledged that child maltreatment is a multi-determined phenomenon that cannot be explained by any one factor (Ammerman 1990; National Research Council 1993).
The key to the argument that alcohol or drugs cause child maltreatment and other family violence is the proposition that alcohol acts as a disinhibitor for the release of violent tendencies (Flanzer 1993). Alcohol is perceived to be a 'superego solvent' that reduces inhibitions and allows violence to emerge (Gelles 1993). Other drugs, such as crack, cocaine, heroin, LSD and marijuana have also been proposed as direct causal factors that 'reduce inhibitions, unleash violent tendencies, and/or directly elicit violent behavior' (Gelles 1993, p.183).
How is this disinhibition achieved? First, the use of alcohol and/or drugs may exacerbate any psychiatric or emotional instability in the user, including such conditions as poor impulse control, bipolar disorder, low frustration tolerance and tendencies towards violence (Curtis 1986; Cicchetti and Olsen 1990).
Second, it has been contended that alcohol or other drugs lower the inhibitions that keep people from acting upon physically or sexually violent impulses (Araji and Finkelhor 1986). This may be achieved by a direct physiological disinhibition which enables the person to act out physically or sexually violent tendencies, or it may be that substance use enables an offender to disregard or disavow the societal taboos against child sexual abuse.
Furthermore, frustration tolerance may be lowered by alcohol or drugs, leaving a parent more likely to physically abuse a child when under their influence. Substance abuse may also diminish or anaesthetise any shame or guilt a perpetrator feels after maltreating a child or another adult (Hayes and Emshoff 1993). The failure to experience negative emotions or inhibitors may perpetuate maltreatment as it minimises the negative consequences for the offender following an assault.
McGagy (1968, as cited in Hayes and Emshoff 1993) constructed Disavowal Theory to explain the uncharacteristic violent behaviour which may occur after the consumption of alcohol. Under this theory, alcohol is blamed for any deviant behaviour, thus evading or 'disavowing' any personal responsibility for actions. Gelles (1974, as cited in Hayes and Emshoff 1993) contended that offenders may disown their behaviour by using alcohol or other drugs to gain the courage to carry out violent acts. For example, a father may drink in order to beat his partner and/or children with minimal guilt.
Later, however, Gelles (1993) argued that the purported relationship between substances and the breaking down of inhibitions, thus causing violent behaviour, was undermined by a number of methodological flaws which reduce the frequently claimed strong association between substance abuse and family violence and, more importantly, limit the ability to infer a causal link (Orme and Rimmer 1981; Gelles 1993; National Research Council 1993).
The key terms in studies linking substance abuse and family violence are often ill-defined, limiting the comparability of studies. Terms such as violence, abuse, domestic violence and family violence are often used interchangeably, and often without the provision of any specific definition (Orme and Rimmer 1981; Gelles 1993).
When investigating substance abuse and child maltreatment, researchers often examine more than one form of maltreatment, but combine the various types under the global construct child maltreatment. As Gelles states:
When physical abuse and neglect are combined under the same term, it is impossible to know whether an association between alcohol and/or drug use and maltreatment is the result of alcohol and drugs producing disinhibition and thus violent behaviour, whether the alcohol and drug use is itself considered a sign of neglect, or whether the alcohol and drug use led to neglect because of the debilitating effects of chronic or excessive alcohol and/or drug use. (1993, p.189).
Thus, the wide variation in the definition of 'maltreatment' ensures that many studies of substance abuse and child maltreatment cannot be compared with one another. The employment of terms like alcohol use, alcohol abuse, alcoholism, drug use, drug abuse and drug addiction interchangeably across studies has further compounded the problem (Gelles 1993).
Additional issues affect the comparability of studies. First, few studies attempt to explicitly define and measure alcohol or drug consumption in anything beyond a simple classification or report by professionals or the self-report of users. Second, gathering conclusive data on the effects of specific drug or alcohol use has been hindered by the frequent use of a variety of different drugs and alcohol in combination, a practice indulged in by women in particular (Dore, Doris and Wright 1995). Third, while some studies incorporate a personal history of substance use and abuse and determine the association with violence, others stipulate a specific time frame within which substance use is determined. This can vary from an assessment made at the time of the last violent incident, or involve an assessment over six months or a year (Gelles 1993), making comparisons all the more difficult.
Flanzer (1993) describes three criteria which must be satisfied in order to demonstrate a causal relationship. First, proof of significant associations between the key variables must be shown. Gelles (1993) contends that the many reported strong associations between substance abuse and violence are limited because of the failure of researchers to use an appropriate control or comparison group. Thus it is unclear whether the associations reflected in 'clinical' samples are reflected in the general population.
Second, a clear temporal relationship should be demonstrated wherein one factor precedes the other with the causal variable clearly occurring before the dependent variable (Flanzer 1993). First, was there alcohol or other drug use before, during, or instead of child maltreatment? Second, is there a pattern connecting substance abuse and child maltreatment when an assessment is conducted over time?
While it is plausible that violence occurs after the consumption of alcohol or drugs, given that the majority of studies investigating the role of substance abuse are cross-sectional with data collected only at one point in time, researchers have difficulty meeting a 'time order' criterion.
Third, an analysis of the relationship of intervening factors as catalysts or products must show that the causal relationship is not spurious, that is, results do not occur as a function of the contributions of other variables (Flanzer 1993). As Gelles (1993) notes, few studies attempt to determine the effects of mediating variables, such as social environmental factors which may affect the links between substance abuse and child maltreatment.
Finally, it is commonly agreed that in order to logically determine a causal relationship, it is necessary to conduct prospective studies (Tomison 1996). As in most investigations of potential causal relationships between child maltreatment and other factors, the majority of studies have employed retrospective methods, thereby removing the chance of determining a causal relationship. The few prospective studies which have looked at aspects of substance abuse and child maltreatment are described in the following sections. For a more detailed discussion of retrospective and prospective designs, see Tomison (1996).
Prospective studies facilitate the unveiling of causal rather than associative relationships between factors (Tomison 1996). Prospective studies collect data on risk factors present in families (such as substance abuse), and follow the families forward over time to determine the proportion who go on to maltreat their children. However, because of the significant resources required for longitudinal designs, the majority of studies adopt a retrospective approach (Lewis 1988).
One exception has been Chaffin, Kelleher and Hollenberg (1996) who used data from the United States National Institute of Mental Health's Epidemiology Catchment Area (ECA) study to create a prospective investigation of risk factors for physical abuse and neglect.
Using a probabilistic community sample, 7,103 parents who did not self-report physical abuse or neglect of their children at Wave I were followed to determine the psychiatric and social risk factors associated with child maltreatment.
At Wave II, and after correcting for sampling irregularities, 63 parents (0.8 per cent) reported physical abuse having occurred, while 84 (1.1 per cent) reported neglect. Four parents reported both physical abuse and neglect.
Substance abuse disorders appeared to be the most common, and among the most powerful, factor associated with both physical abuse and neglect, approximately tripling the risk of maltreatment when other factors were controlled. In addition, they were the most prevalent disorder in both the sample of parents who admitted maltreating their child at Wave II, and the sample of parents who denied maltreatment at Waves I and II.
Chaffin, Kelleher and Hollenberg also contended that substance abuse appeared to play a mediating role between socio-economic and other demographic variables in cases of neglect, or may significantly increase the risk of neglect in some populations.
As noted previously, a number of case tracking studies have assessed substance abuse as one of a number of family stressors that may increase the likelihood of maltreatment and be important factors for consideration in case management decisions.
Similarly, substance abuse is often employed as a risk factor in attempts to model child protection case management decision-making and/or develop risk assessment tools; for example, Dalgleish and Drew (1989). (Risk assessment tools are designed to help protective workers identify situations where children are 'at risk' of maltreatment; to improve consistency in service delivery; and to help protective services determine the appropriate priorities within protective services caseloads (Browne and Saqi 1988)).
In addition, Keys Young (1993), produced qualitative data on the perceptions of 200 Australian agencies/groups, including police, child protection workers, welfare and health professionals, regarding the role of alcohol misuse in domestic violence and child maltreatment. Respondents generally agreed that alcohol played a very limited role in sexual abuse, but was a very significant factor for neglect cases. Physical and emotional abuse were not considered to be strongly linked to alcohol. Overall though, it was thought that alcohol-dependent parents were more likely to abuse or neglect their children.
However, Keys Young indicated that the findings were tentative due to the failure of most groups to keep reliable statistics on the identification of substance abuse in families suspected of child maltreatment, and the apparent unfamiliarity of the subjects with the idea that close attention should be paid to the role of alcohol in child maltreatment. Until reliable substance abuse data is available in Australia, attempts to conduct detailed investigations of the role of substance abuse in child maltreatment are unlikely to be productive.
Types of abuse
The relationship between substance abuse and child maltreatment is complex, though it appears that all types of child maltreatment may be affected by parental alcohol or drug abuse.
For example, the United States National Clinical Evaluation Study was used to determine the frequency of various problems exhibited by families involved in the various forms of maltreatment (Daro 1988). Substance abuse was identified in 61 per cent of cases classified as emotional abuse cases, in 58 per cent of physical abuse cases, 53 per cent of neglect cases, 50 per cent of sexual abuse cases, and 39 per cent of cases classified as 'high risk'. Substance abuse was significantly more likely to be identified in families where a number of types of maltreatment were identified as having occurred.
Substance abuse was identified in 53 per cent of families identified as committing one type of maltreatment; the proportion of cases identified as involving substance abuse rose to 71 per cent in cases where the family was experiencing all four types of maltreatment (Berkeley Planning Associates 1983, as cited in Daro 1988).
The following sections summarise the available research on the relationship of substance abuse to specific forms of child maltreatment.
Finkelhor (1984) noted that substance abuse was one of a number of risk factors which may increase the likelihood of sexual offending, where would-be abusers use alcohol or drugs in order to overcome inhibitions towards sexual offending or the inhibitions of the victim. In addition, a child who is inadequately cared for or supervised by an intoxicated caregiver may provide a perpetrator with the opportunity to commit sexual assaults.
As mentioned previously, the use of alcohol, or alcoholism, is the most frequently reported and well-established method employed to lower inhibitions associated with sexual offending (National Research Council 1993). Alcohol has been estimated to be used as a disinhibitor in between 19 to 70 per cent of reported cases (National Research Council 1993).
Smith and Kunjukrishnan (1985, as cited in Hayes and Emshoff 1993) reported that alcoholism was identified as a problem in 71 per cent of families where sexual abuse was occurring, and in 56 per cent of families where sexual and physical abuse was found. Many studies have shown that alcohol involvement accompanies sexual abuse, that is, involved an offender who was alcoholic and/or drinking at the time of the offence (Araji and Finkelhor 1986).
Other studies have reported that incest offenders were more likely to be characterised as alcoholics and to have used alcohol at the time of the offence, than were non-incestuous sex offenders. Indeed, incest offenders appear to have the most extensive histories of alcohol involvement of all sex offenders (Aarenset al. 1978; Morgan 1982, both cited in Araji and Finkelhor 1986).
This finding has some face validity. It would seem likely that sexually abusing one's own child would require the breaking down of more inhibitions than the abusing of a child for which there was no existing familial bond, and less stringent social taboos.
In contrast, Hayes and Emshoff (1993) provided another way in which substance abuse in a family may result in the sexual and physical abuse of a child. First, adult intimate relationships where one or both partners is a substance abuser, are often characterised by distorted or dysfunctional communication patterns (Dulfano 1985, as cited in Hayes and Emshoff 1993).
Closely related to such problems is the common occurrence of sexual problems due to the physical effects of substance abuse and the inability or unwillingness of a partner to respond to an addict's advances, leading to a sense of rejection and inadequacy in the addict. Hayes and Emshoff (1993) contended that the resultant stress and frustration may manifest itself as violence towards the spouse or children, and/or the sexual abuse of a child to fulfil adult sexual needs.
The United States National Research Council (1993) contended that depression, anxiety and antisocial behaviour (such as substance abuse) were central to the characterisation of the physically abusive parent.
Roy (1988, as cited in Hayes and Emshoff 1993) investigated the incidence of parental substance abuse for 146 children aged from 11 to 17 years who were living in a battered women's shelter or refuge in the United States. All of the children had a mother who had been battered by her spouse, and 48 per cent of the children had been physically abused by at least one parent.
Generally, the fathers were reported to be physically abusive, and the mothers neglectful when the families had been intact. The children reported that 41 per cent of the fathers had a drinking problem which exacerbated the abuse they suffered, 8 per cent reported their fathers used marijuana, and 2 per cent believed their fathers used other illicit drugs. Approximately one-quarter of the mothers were reported to use alcohol.
Recent prospective studies of parental characteristics have identified antisocial behaviour such as aggressiveness or substance abuse as part of a set of parental personality traits that are frequently associated with physically abusive parents (Pianta, Egeland and Erickson 1989).
A history of mental illness or substance abuse was also one of 13 risk factors identified in the United Kingdom by Browne and Stevenson (1983, as cited in Browne and Saqi 1988), to be associated with physical abuse cases in infants.
However, rather than providing clarification, studies such as Browne and Stevenson (1983, as cited in Browne and Saqi 1988), and Pianta, Egeland and Erickson (1989), which subsume the effects of parental substance abuse into a global 'antisocial behaviour' factor, create further difficulties in determining the specific relationship between substance abuse and child maltreatment.
Other factors may further increase the probability of physical abuse in substance abusing families. First, the partners of substance abusers may also be prone to violence. If a non-addicted spouse attempts to take on the responsibilities of the addicted partner, the additional workload, in combination with the chaotic and inconsistent behaviours which may be exhibited by the addict, may be quite stressful. Under a frustration - aggression hypothesis, a non-addicted spouse may lash out at the children in a misdirected response to stress (Hayes and Emshoff 1993).
Second, the potential for physical and verbal violence may also be heightened by the stress and tension which results when a child, whose physical and/or emotional needs are not being met within the family, demands attention or engages in power struggles with the parents (Garbarino, Guttman and Seeley 1986).
Specific substance abuse
Much of the research investigating the relationship between substance abuse and child physical abuse, as described above, is focused on the role of alcohol in child maltreatment. Though the general aggression literature indicates that alcohol use, particularly at high levels, is related to the probability and severity of aggression (Milner and Chilam-kurti 1991), few studies have investigated the association between alcohol abuse and child physical abuse.
The degree to which the use of illicit drugs is associated with physical abuse also remains to be fully investigated (Milner and Chilamkurti 1991). There is currently little empirical research on the relationship between drug abuse and child maltreatment (Corby 1993). However, in a survey of family violence in families in the United States, Wolfner and Gelles (1993) noted that parents who reported 'getting high on marijuana or some other drug' at least once a year also reported higher rates of violence and violence directed towards children.
Attempting to determine the extent of a link between drug use and child maltreatment has been hampered in the past by a failure of researchers to include information on any substance other than alcohol (Kaufman, Kantor and Straus 1989, as cited in Gelles 1993). In addition, many different drugs have been implicated in acts of violence, and each drug has a different physiological effect. Despite this, there has been some consistent evidence of a link between drug abuse and child maltreatment.
It has been found that the crime rates for the users of opiates such as heroin are commonly unusually high, with violence often part of the criminal act. However, the apparent link between opiate usage and violence may be more a function of the opiate user committing crimes to feed a habit, rather than a property of the drug itself. In fact opiates are commonly used as sedatives and anaesthetics (Gelles 1993).
Despite producing a short, intense effect, there also appears to be little evidence of a causal relationship between cocaine and aggressive behaviour (Gelles 1993). It should be noted that, to date, Australia has not been exposed to the widespread use of cocaine or crack.
The one group of drugs which does appear to be a possible cause of violent behaviour is amphetamines. These drugs raise excitability and muscle tension, which may lead to impulsive behaviour (Gelles 1993). However, effects appear to be dependent on the dosage taken and the pre-use personality of the user. High dosage users with an aggressive personality are likely to become more aggressive when using the drug (Johnson 1972, as cited in Gelles 1993).
Billing et al. (1994) conducted a prospective study in which 65 Swedish children born to women who used amphetamines during pregnancy were followed up until the age of eight years. Of an original sample of 71, six children died before two months of age. Of the surviving sample, 26 children were taken into custody within their first year of life. After eight years, 44 children (68 per cent) had been adopted or were living in foster homes.
Billing et al. found a significant correlation between exposure to amphetamines, socio-environmental factors and the children's behavioural characteristics. In particular, by eight years-of-age the extent (amount and duration) of foetal amphetamine exposure was significantly correlated with children's behavioural problems, particularly aggressiveness and poor peer relations.
Emotional abuse and neglect
Parents preoccupied by substance abuse may neglect or emotionally abuse their children. A child's physical needs might be neglected by the parents' inability to provide adequate nourishment, to attend to medical needs, or to provide an adequate living environment (Hayes and Emshoff 1993). The parents may ignore or reject the child, which, apart from the emotional consequences for the child, may result in inadequate supervision and/or a failure to ensure the child's safety.
Other emotional consequences may result from parental verbal and physical violence, and/or the parent's emotional unavailability. Parental absence or unavailability has also been associated with sexual abuse (Finkelhor and Baron 1986). Finkelhor and Baron (1986) noted that in cases of father - daughter incest, significantly more mothers of abused daughters were sick with disabling conditions which included alcoholism, depression and psychosis. Mothers may also be absent from the home because of a spouse's substance abuse, or as is often the case, the need to work to support the family (Hayes and Emshoff 1993).
Families with a substance-abusing parent are often isolated from outside supports. As a result, the children in the family may be used by the non-addicted spouse as a source of support, thus acting in a surrogate spousal role (Hayes and Emshoff 1993).
This form of role reversal, commonly known as parentification, places additional, inappropriate adult functioning on a child and can be considered abusive (Grisham and Estes 1986). Parentification may involve the child attempting to meet parental needs that are age inappropriate. For example, a parentified child may take care of parents' emotional and physical care, or that of younger siblings, and may involve the performance of inappropriate household duties (Hayes and Emshoff 1993).
Within child neglect is a subset of cases often defined as 'chronic' neglect cases. These can be characterised by their 'chaotic and unpredictable character' (National Research Council 1993), their long-term involvement with family support and child protection services (Nelson, Saunders and Landsman 1993; Tomison 1994), and a lack of cognitive stimulation and emotional nurturance for the child (Polansky, Gaudin and Kilpatrick 1992, as cited by National Research Council 1993).
Chronic neglect cases usually involve families that are significantly disadvantaged, having a multitude of problems to deal with. These often include parental substance abuse and/or residing in an area noted for substance abuse problems (Nelson, Saunders and Landsman 1993).
Child maltreatment, at its most severe, may result in the death of a child. Between July 1989 and December 1993, 126 homicides involving children under the age of 15 years (Strang 1996) were reported; 26 per cent of these (32 cases) were assessed as being fatalities due to child abuse. That is, 'the assault upon the child was sudden and impulsive, the offender was the caregiver at the time of the incident and the offender appeared to be expressing his or her rage or frustration through the imposition of "punishment" or "discipline" upon the child' (Strang 1996, p.4).
The major focus on the role of substance abuse in child or adult homicides has been on family suicide/murders and neonaticides (for example, Polk 1994, Strang 1996). Little research to date has looked at the role of alcohol and drug abuse in child abuse fatalities reported in the homicide literature.
However, substance abuse in families is frequently reported in child death inquiries conducted by child protection services. For example, Justice Fogarty, in summarising the findings of 12 child death inquiries held in Victoria up until June 1993, noted that at least five, and possibly seven of the 12 cases investigated, involved the deaths of young babies from parental neglect.
The pattern was 'of a very young child, born prematurely and/or drug dependent, discharged home, sometimes on Court order, sometimes not. The custodian was in a number of cases drug dependent or otherwise led a chaotic lifestyle and was objectively incapable of adequately looking after a vulnerable young baby' (Fogarty 1993, p.106).
Summarising research into child deaths in the United Kingdom, Greenland (1987) identified 18 factors (nine parent-related, nine child-related) which he believed could predict situations where a child was at high risk. A high risk situation was predicted if at least half of the 18 factors were identified in a family. Parental substance abuse was one of the parent-related factors.
In utero and post-natal violence
The link between substance abuse and child maltreatment has particular implications for the unborn child (Russell 1995). Infants from substance-abusing families frequently inherit the consequences of their parents, particularly their mother's, actions. The prenatal effects of alcohol and drug use in pregnancy include spontaneous abortion, premature birth, foetal distress, physical and/or mental retardation, birth defects and withdrawal symptoms upon birth (Russell 1995).
In addition, victims of violence have a higher rate of pregnancy, with pregnancy itself leading to an increased incidence of domestic violence (Hayes and Emshoff 1993). Thus, domestic violence is not merely traumatising for the mother, but may also result in physical damage to the foetus (Thomas 1988).
In the longer term, the effects of in utero exposure to alcohol or drugs include impulsivity, learning disabilities, antisocial behaviour, neurological deficits and increased risk of sudden infant death syndrome (Dore, Doris and Wright 1995).
Given the potential vulnerability of children prenatally exposed to alcohol or drugs, and/or the challenging behaviours exhibited by children born to substance abusing mothers, the parenting skills of the primary caregiver (usually the mother) become even more important (Dore, Doris and Wright 1995). However, because of substance abuse, mothers of such infants may be ill-equipped to cope with the child's special needs (Lief 1985, as cited in Dore, Doris and Wright 1995).
Jaudes, Ekwo and Van Voorhis (1995) conducted a retrospective-prospective study in Chicago of children born to mothers from 1985 to 1990 who abused illicit drugs in pregnancy - that is, heroin, cocaine, opiates, marijuana, phencyclidine (PCP). Using case data from the Illinois State Central Registry of Child Abuse and Neglect, it was found that approximately one-third (30.2 per cent) of 513 children exposed to in utero drug use had been reported as suspected child maltreatment cases leading up to a five-year follow-up. After protective investigation, child abuse or neglect was substantiated in cases involving 102 children.
The substantiation rate was two to three times higher than that of children living in the same geographical area who were not exposed to in utero drug use. Neglect was the most frequently reported maltreatment (72.6 per cent of cases), with toddlers being the most vulnerable. Natural parents were reported to be responsible for the maltreatment in 88 per cent of cases.
The substantiation rate of 65.8 per cent of child maltreatment reports in this study was considerably higher than the substantiation rate across Illinois (37.2 per cent) or in the United States national statistics where the rate has been reported to range from 40 to 53 per cent. Jaudes, Ekwo and Van Voorhis (1995) argued that the higher proportion of substantiations may reflect the seriousness of the allegations and/or the overwhelming evidence of neglect by mothers who continue to use drugs.
The additional care needed by alcohol or drug-exposed children may also affect the quality of the mother - child bond (Dore, Doris and Wright 1995). This may be exacerbated by the tendency to separate infants exposed to drugs and alcohol in utero from their mothers at birth because of withdrawal, prematurity, birth defects or concerns about the parents' capacity to adequately care for the child (Russell 1995).
In an investigation of toddlers born to substance abusing parents, Hurt, Salvador and Brodsky (1989, as cited in Hayes and Emshoff 1993) found that toddlers raised in environments where substance abuse continued after the child's birth were more insecurely attached than toddlers raised in non-drug environments such as extended families or foster care.
An Israeli study, conducted by Michailevskaya, Lukashov, Bar-Hamburger and Harel (1996), produced results which cast doubt on the lasting, detrimental effects of in uterine exposure to heroin on child development, while emphasising the importance of the child's social environment.
A total of 339 children were examined for developmental delays and behavioural disorders from the age of six months to six years in a longitudinal study. The children were classified into the following groups: born to heroin-addicted mothers; born with heroin-addicted fathers; control group (low socio-economic status and environmental deprivation); control group (moderate to high socio-economic status); control group ('normal' children from preschools).
The children born to heroin-dependent mothers had lower birth weights and lower head circumferences when compared with the control groups. Children born to heroin-dependent parents had a high incidence of hyperactivity, inattention and behavioural problems. The children's developmental and intellectual capacities were lowest for the low socio-economic status and environmental deprivation group, followed by the two 'heroin-addicted' groups. The other control groups produced the highest levels of functioning.
It was found that children born to addicted mothers who were removed from the home at a young age and adopted, scored as well as the control groups, while the children raised at home scored significantly lower. Thus, for children exposed to heroin prenatally but not born with any significant neurological damage, developmental outcome appeared to depend more on the home environment than the heroin exposure.
Overall, it would appear that factors such as social supports, parenting skills, the parent - child relationship and family resources should also form part of a comprehensive assessment of substance abusing families and the determination of what is in the child's best interests (Azzi-Lessing and Olsen 1996).
Future research directions
Clearly there is a need to investigate the specifics of the relationship between substance abuse and child maltreatment. In particular, further research should be conducted into the effects of individual drugs on the different types of child maltreatment, and which factors mediate the development of maltreating behaviour.
In a statement which equally applies to drug abuse, the United States National Research Council concluded:
more needs to be known about the unique and immediate effects of alcohol, its co-occurrence with other problem behaviors such as antisocial personality disorder and substance abuse, the circumstances under which different types of drinking situations lead to or sustain violence against children, and cultural factors that mitigate or exacerbate connections between substance use or abuse and aggressions. (1993, p.119).
How can this be achieved? First, as was clear from the data presented above, the current availability of Australian data linking substance abuse and child maltreatment is less than satisfactory. It is therefore recommended that national and state child maltreatment statistics incorporate breakdowns of data on various causal or risk factors such as substance abuse, which may increase the likelihood of child maltreatment.
Given that most Australian States and Territories utilise some form of risk assessment method to make child protection decisions, or at least train their workers to look for risk factors in families, the issue would appear to be more a matter of effective data usage than a reorganisation of current child protection case practice.
Similarly, drug and alcohol centres should document cases where substance abuse is occurring in families with dependent children. Having such data available should increase the amount of Australian research being conducted in this area.
Second, if causal relationships are to be examined, prospective studies of the relationship between child maltreatment and substance abuse should be conducted where possible. Any such study would be substantially improved if uniform definitions of both child maltreatment and substance abuse were developed and adhered to in research and professional practice.
Third, it should be remembered that not all children living in a family with substance abusing parents will be maltreated. Nor will all children who have been abused grow up to abuse alcohol or drugs or maltreat their own children. While there is clearly a substantial associative relationship between substance abuse and child maltreatment as a whole, researchers have yet to fully determine the extent of the relationship between child maltreatment and substance abuse.
A number of community education campaigns and specialised family support services have been developed to help prevent substance abuse and the potentially harmful effects such abuse has on the family.
Yet just as single factor approaches to the causes of maltreatment have been flawed, so have attempts to prevent maltreatment which focus primarily on one factor. A comprehensive, interactive approach where the influence of constellations of factors, including substance abuse, are targeted in prevention programs is therefore advocated as a more effective means of preventing maltreatment.
The role of schools
Clearly the time demands on the school curriculum are increasing with the growing belief that education should not be limited to purely academic subjects (Conte and Fogarty 1990) and that the education system should take more responsibility for the production of capable, functioning members of society.
Many schools currently teach courses on a number of social problems, such as substance abuse, child maltreatment, AIDS and suicide. However, there is only a limited level of support available to resource such programs. One possible solution advocated by Conte and Fogarty (1990) is based on the premise that many of the different health/life skills programs share some basic goals: the encouragement of independent thinking, the resistance of peer pressure, the development of decision making, assertiveness and effective communication skills.
Conte and Fogarty perceive some benefit in developing a general prevention curriculum, primarily promoting mental health and empowering individuals, but with a secondary focus on applying the generic skills to specific problems and situations. In theory, the adoption of such a holistic approach to prevention would encourage cooperative ventures between a number of professional fields, such as drug and alcohol services and child protection services.
Multidisciplinary approaches to prevention
The need for a comprehensive, collaborative approach to substance abuse and child maltreatment has already been recognised. Hayes and Emshoff (1993) note that 'multi-disciplinary collaborative approaches to these issues are developing in response to the understanding that violence may lead to substance abuse, substance abuse may lead to violence, and environmental pathologies may result in either or both behaviors' (p.281).
Ensuring effective interagency cooperation between alcohol and drug services and child protection units is seen as one way forward in effectively preventing the maltreatment of children in 'at risk' substance abusing families, and/or protecting maltreated children from further harm.
In New South Wales, for example, interdepartmental guidelines have been operating since the 1980s that require Department of Health workers to report suspected child maltreatment to the Department of Community Services (Major 1995). Similarly, Victoria has not mandated drug and alcohol workers, but has developed a protocol between protective services and alcohol/drug services (Major 1995). One of the guiding principles of the protocol is that the protection of children is a shared responsibility.
Thus, while drug and alcohol workers are expected to report children at risk of maltreatment, protective services have been made equally responsible for consulting with drug and alcohol workers when substance abuse has been identified and specialist information is required, or in circumstances where the drug and alcohol worker may assist in developing a caseplan to protect the child.
However, such agreements must be supported with adequate training for both drug and alcohol workers and child protection workers. In 1992, the New South Wales Child Protection Council established a Drug-Using Parents and Child Protection Steering Committee, an interagency group which investigates the training needs of both groups to ensure efficient interagency collaboration and communication (Major 1995).
Aborigines and Torres Strait Islanders
Aboriginal and Torres Strait Islander peoples have long recognised the need for a comprehensive strategy to deal with substance abuse and associated problems, albeit one which is socially and culturally relevant (Sumner 1995; Wilson 1995).
The nation's indigenous peoples have often been reluctant to use mainstream drug and alcohol services, preferring to use services controlled by their own communities (Wilson 1995). In South Australia, for example, where the Drug and Alcohol Service Commission is the main provider of alcohol and drug services, only 5.7 per cent of clients in 1991 - 1992 were Aboriginal (Wilson 1995).
However, until recently, there had not been a substantial, community-controlled organisation which could develop a strategy or garner statewide support for a comprehensive approach to the prevention of substance abuse and violence among indigenous peoples (Wilson 1995). This gap is currently being remedied. In 1995, South Australia set up the Aboriginal Drug and Alcohol Council to provide a framework for the development of substance abuse programs that are socially and culturally relevant (Wilson 1995).
Child maltreatment results from a complex constellation of factors whose influence may increase or decrease over different developmental and historical periods (National Research Council 1993). Despite the difficulties associated with multiple factor investigations of maltreatment, any research on the topic needs to take account of the interaction of factors that may affect child maltreatment. Parental substance abuse, as one of the earliest factors identified as affecting the risk of child abuse or neglect, should be investigated in combination with other social, parental and child variables (National Research Council 1993).
It is also clear that to adequately prevent child maltreatment a holistic approach must be adopted to address what are often multi-problem, disadvantaged, dysfunctional families. This can only be achieved by a partnership between the various professions and agencies involved in child protection, child welfare, family support and community health. The multi-agency approach initiated to prevent child maltreatment in substance-abusing families is thus an example of what is required to protect children and to enhance family functioning as a whole.
- Ammerman, R.T. (1990), 'Predisposing child factors', in R.T. Ammerman and M. Hersen (eds), Children at Risk: An Evaluation of Factors Contributing to Child Abuse and Neglect, Plenum Press, New York.
- Angus, G. and Hall, G. (1996), Child Abuse and Neglect Australia 1994 - 95, Child Welfare Series no.16, Australian Institute of Health and Welfare, Canberra.
- Araji, S. and Finkelhor, D. (1986), 'Abusers: a review of the research', in D. Finkelhor, A Sourcebook on Child Sexual Abuse, Sage Publications, Beverly Hills.
- AIHW, (1996), Australia's Health 1996: The Fifth Biennial Report of the Australian Institute of Health and Welfare, AGPS, Canberra.
- Azzi-Lessing, L. and Olsen, L.J. (1996), 'Substance abuse-affected families in the child welfare system: new challenges, new alliances', Social Work, vol.41, no.1, pp.15 - 23.
- Billing, L., Eriksson, M., Jonsson, B., Steneroth, G. and Zetterstrandouml;m, R. (1994), 'The influence of environmental factors on behavioural problems in 8-year-old children exposed to amphetamine during fetal life', Child Abuse and Neglect, vol.18, pp.3 - 9.
- Blau, G.M., Whewell, M.C., Gullotta, T.P. and Bloom, M. (1994), 'The prevention and treatment of child abuse in households of substance abusers: a research demonstration progress report', Child Welfare, vol.73, no.1, pp.83 - 94.
- Browne, K. and Saqi, S. (1988), 'Approaches to screening for child abuse and neglect', in K. Browne, C. Davies and P. Stratton (eds), Early Prediction and Prevention of Child Abuse, John Wiley and Sons, Chichester.
- Chaffin, M., Kelleher, K. and Hollenberg, J. (1996), 'Onset of physical abuse and neglect: psychiatric, substance abuse, and social risk factors from prospective community data', Child Abuse and Neglect, vol.20, no.3, pp.191 - 203.
- Cicchetti, D. and Olsen, K. (1990), 'The developmental psychopathology of child maltreatment', in M. Lewis and S. Miller (eds), Handbook of Developmental Psychopathology, Plenum Press, New York.
- Clark, R. (1994), 'Responding to family violence', published in Alcohol, Drugs and the Family', Conference Proceedings, 1994 APSAD National Conference, Australian Drug Foundation, South Melbourne, pp.90 - 118.
- Conte, J.R. and Fogarty, L.A. (1990), 'Sexual abuse prevention programs for children', Education and Urban Society, vol.22, no.3, pp.270 - 284.
- Corby, B. (1993), Child Abuse: Towards a Knowledge Base, Open University Press, Buckingham, PA.
- Curtis, J.M. (1986), 'Factors in the sexual abuse of children', Psychological Reports, vol.58, pp.591 - 97.
- Curtis, P.A. and McCullough, C. (1993), 'The impact of alcohol and other drugs on the child welfare system', Child Welfare, vol.72, no.6, pp.533 - 542.
- Dalgleish, L.I. and Drew, E.C. (1989), 'The relationship of child abuse indicators to the assessment of perceived risk and to the court's decision to separate', Child Abuse and Neglect, vol.13, pp.491 - 506.
- Daro, D. (1988), Confronting Child Abuse: Research for Effective Program Design, Free Press, New York.
- Dore, M., Doris, J.M. and Wright, P. (1995), 'Identifying substance abuse in maltreating families: a child welfare challenge', Child Abuse and Neglect, vol.19, no.5, pp.531 - 543.
- Finkelhor, D. (1984), Child Sexual Abuse: New Theory and Research, The Free Press, New York.
- Finkelhor, D. and Baron, L. (1986), 'High-risk children', in D. Finkelhor, A Sourcebook on Child Sexual Abuse, Sage Publications, Beverly Hills.
- Flanzer, J.P. (1993), 'Alcohol and other drugs are key causal agents of violence', in R.J. Gelles and D. R. Loseke (eds), Current Controversies on Family Violence, Sage Publications, Newbury Park, California.
- Fogarty, J. (1993), Protective Services for Children in Victoria, Department of Health and Community Services, Melbourne.
- Freeman, E.M. (1993), Substance Abuse Treatment: A Family Systems Perspective, Sage Publications, Newbury Park, California.
- Garbarino, J., Guttman, E. and Seeley, J.W. (1986), The Psychologically Battered Child, Jossey-Bass, San Francisco.
- Gelles, R.J. (1993), 'Alcohol and other drugs are associated with violence - they are not its cause', in R.J. Gelles and D. R. Loseke (eds), Current Controversies on Family Violence, Sage Publications, Newbury Park, California.
- Goddard, C.R. and Carew, R. (1993), Responding to Children: Child Welfare Practice, Longman Cheshire, Melbourne.
- Goddard, C.R. and Hiller, P.C. (1992), Tracking Physical and Sexual Abuse Cases from a Hospital Setting into Victoria's Criminal Justice and Child Protection Systems: A Report for the Victorian Law Foundation, vols 1 - 3, Department of Social Work and Department of Anthropology and Sociology, Monash University, Melbourne.
- Greenland, C. (1987), Preventing CAN Deaths: An International Study of Deaths Due to Child Abuse and Neglect, Tavistock, London.
- Grisham, K.J. and Estes, N.J. (1986), 'Dynamics of alcoholic families', in N.J. Estes and M.N. Heinemann (eds), Alcoholism: Development, Consequences and Interventions, C.V. Mosby, St Louis.
- Hayes, H.R. and Emshoff, J.G. (1993), 'Substance abuse and family violence', in R.L.Hampton, T.P. Gullotta, G.R. Adams, E.H. Potter III and R.P. Weissberg (eds), Family Violence: Prevention and Treatment, Issues in Children's and Families' Lives, vol.1, Sage Publications, Newbury Park, California.
- Hiller, P.C., Goddard, C.R. and Diemer, K.M. (1989), 'The nature of and institutional reaction to child abuse: continuities and discontinuities in the comparative analysis of cases of physical and sexual abuse', in Proceedings of the Second Annual Conference of the Victorian Society for the Prevention of Child Abuse and Neglect: Twelve Months On: Achievements and Future Directions, Vicspcan, Melbourne, pp.111 - 134.
- Jaudes, P.K., Ekwo, E. and Van Voorhis, J. (1995), 'Association of drug abuse and child abuse', Child Abuse and Neglect, vol.19, no.9, pp.1065 - 1075.
- Kempe, C.H., Silverman, F.N., Steele, B.F., Droegemuller, W. and Silver, H.K. (1962), 'The battered child syndrome', Journal of the American Medical Association, vol.18, no.1, pp.17 - 24.
- Keys Young (1993), Alcohol and Violence Against Women and Children in the Home, Report no.4, National Symposium on Alcohol Misuse and Violence, Commonwealth Department of Health, Housing, Local Government and Community Services, Canberra.
- Lewis, M. (1988), 'What can child development tell us about child abuse?', in K. Browne, C. Davies and P. Stratton (eds), Early Prediction and Prevention of Child Abuse, John Wiley and Sons, Chichester.
- Major, C. (1995), 'Invisible clients: children of substance abusing parents', Connexions, June - July, pp.8 - 14.
- Michailevskaya, A.O., Lukashov, I., Bar-Hamburger, R. and Harel, S. (1996), 'The developmental outcome of children born to heroin-dependent mothers, raised at home or adopted', Child Abuse and Neglect, vol.20, no.5, pp.385 - 396.
- Milner, J.S. and Chilamkurti, C. (1991), 'Physical child abuse perpetrator characteristics: a review of the literature', Journal of Interpersonal Violence, vol.6, pp.345 - 366.
- National Research Council (1993), Understanding Child Abuse and Neglect, National Academy Press, Washington DC.
- Nelson, K. E., Saunders, E. J. and Landsman, M. J. (1993), 'Chronic child neglect in perspective', Social Work, vol.38, no.6, pp.661 - 671.
- Orme, T.C. and Rimmer, J. (1981), 'Alcoholism and child abuse', Journal of Studies on Alcohol, vol.42, pp.273 - 287.
- Pianta, R., Egeland, B. and Erickson, M.F. (1989), 'The antecedents of maltreatment: results of the Mother - Child Interaction Research Project', in D. Cicchetti and V. Carlson (eds), Child Maltreatment: Theory and Research on the Causes and Consequences of Child Abuse and Neglect, Cambridge University Press, Cambridge, MA.
- Polk, K. (1994), When Men Kill: Scenarios of Masculine Violence, Cambridge University Press, Melbourne.
- Russell, K. (1995), 'Inmates with alcohol and other drug problems: what about the next generation?', Current Issues in Criminal Justice, vol.7, no.2, pp.245 - 257.
- Sam, M. (1992), Through Black Eyes: A Handbook of Family Violence in Aboriginal and Torres Strait Islander Communities, Secretariat of National Aboriginal and Islander Child Care, Fitzroy.
- Strang, H. (1996), 'Children as victims of homicide', Trends and Issues in Crime and Criminal Justice, no.53, Australian Institute of Criminology, Canberra.
- Sumner, M. (1995), 'Substance abuse and Aboriginal domestic violence', Aboriginal and Islander Health Worker Journal, vol.19, no.2, pp.16 - 17.
- Thomas, D. (1988), 'Infants of drug addicted mothers', Australian Paediatric Journal, vol.24, p.16.
- Tomison, A.M. (1996), The Intergenerational Nature of Maltreatment, Issues Paper no.6, National Child Protection Clearing House, Australian Institute of Family Studies, Melbourne.
- Tomison, A.M. (1994), An Evaluation of Decision Making in Child Abuse Services in the Barwon Region: A Report for the Victorian Health Promotion Foundation, vols I and II, Department of Social Work and Human Services, Monash University, Melbourne.
- Trocmé, N., McPhee, D. and Tam, K.K. (1995), 'Child abuse and neglect in Ontario: incidence and characteristics', Child Welfare, vol.74, no.3, pp.563 - 586.
- Wilson, S. (1995), 'Substance misuse', Aboriginal and Islander Health Worker Journal, vol.19, no.2, pp.12 - 13.
- Wolfner, G. and Gelles, R.J. (1993), 'A profile of violence toward children: a national study', Child Abuse and Neglect, vol.17, pp.197 - 212.
0 642259 36 4