Child maltreatment was a terrible problem for people since ancient period
to late modern period. A good deal of studies used to explain the association
between maltreatment and drug use in the later life (Hussey et al.,
2006). All types of maltreatment including emotional abuse are related
to higher level of substance use and should be considered as a risk factor
for substance use during later life (Moran et al., 2004; Dube et
al., 2003). Although the relationship between substance abuse and
child maltreatment has been relatively established, it is not a simple
cause-effect relationship (MacMillan et al., 2001). Meanwhile few
studies have examined the relationship between illicit drug use and childhood
maltreatment considering other social factors (Dube et al., 2003).
A study explored the relationship among substance abuse, family functioning
and abuse/neglect in a clinical sample in which generally high percentages
of parental substance abuse, neglectand low level of family competence
were identified (Dube et al., 2003). In the study the relationship
between illegal drug use and categories of Adverse Childhood Experiences
(ACEs), child hood abuse, neglect and household dysfunction including
divorce and parental separations were examined and each category of ACEs
was associated with 2-4 fold increase in like hood of illicit drug (Dube
et al., 2003). Replicating these results in other communities will
further strength the importance of childhood maltreatment.
Considering the alarming state of illicit drug use in Iran (Meimandi
et al., 2005), we conducted this study to further clarify the relationships
of ACEs to substance misuse in an Iranian sample.
MATERIALS AND METHODS
A case control study was conducted in Kerman, a city located in southern
Iran in 2005. Cases were 200 men and women referred to outpatient clinics
of the city seeking treatment for substance use disorder. The diagnosis
of substance use disorder was made by means of semi-structural clinical
interview for DSM-IV axis I disorder (DSM-IV-TR, 2000). Controls were
selected from the general population and were individually matched to
cases on 5 year age intervals. With emphasizing the confidentiality and
oral consent the subjects were asked to fill out a questionnaire including
demographic variables and 27 questions concerning 2 categories of ACEs
according to Dube et al. (2003). The categories investigated were
classified as: 1) questions about child maltreatment including abuse (physical,
emotional, or sexual) and neglect (physical or emotional); and 2) questions
measuring household dysfunction including household substance abuse, mental
illness or suicidal attempt among household members, criminality of household
members and parental separation or divorce.
The validity of questionnaire was acceptable according to the reference
(Dube et al., 2003) and an expert panel and Cronbach`s alpha in
items measuring childhood maltreatment was calculated as 0.81 as a whole.
Mental health status of the subjects was measured by General Health Questionnaire
(GHQ-12) (Montazeri et al., 2003). Using multivariate logistic
regression the associations between sociodemographic, childhood maltreatment
and household dysfunction variables and substance use disorder were analyzed.
The Hosmer-Lemeshow test was used to assess model fit. Statistical analyses
were performed using SPSS for Windows software (version 13.0).
Totally 400 subjects enrolled in the study. The mean age of case group
was 32.5±8.3 and in control group was 28±9.3 (p<0.01).
The mean number of children in case group was 7.3±2.6 and 6.8±2.2
in control group (p>0.05).
Subjects in the case group were mostly opium user (43.5%), other drugs were
heroin (24.5%), Shirea (opium extract) (9.5%), a combination of them (19.5%)
and other substances (3%). Baseline characteristics of 2 groups are shown
in Table 1
Only the prevalence of sexual abuse was higher in substance dependent
patients. Meanwhile household substance use and household criminality
were more prevalent in the case group (Table 2).
The final results of the multivariate logistic regression analyses are
shown in Table 3. The highest odds of substance use
disorder was associated with household substance abuse (OR: 2.50, 95%
CI: 1.53-4.10). Sexual abuse was the only type of childhood maltreatment
which showed significant association with substance use disorder (Table
3). GHQ score more than 12 may be a related factor for substance use
||Characteristics of substance use patients (n = 200)
and controls (n = 200)
||Prevalence of each type of childhood abuse/neglect and
the household dysfunction variables in substance use patients (n =
200) and controls (n = 200)
||Logistic regression analysis to assess the association
between subject's report of childhood maltreatment, household dysfunction
variables and substance use disorder
Although substance abuse is not a novel issue in Iran, it has had an
increasing rate during the recent years (Mokri, 2002), so that in some
studies about 21% of university students in Iran had a history of opium
abuse during the last 6 months (Ghanizadeh, 2001). It is necessary for
the government to have comprehensive information about the risk factors
of drug abuse to control it (Jenkins, 2001). Childhood abuse has been
considered as a pervasive and devastating predictor of drug use during
adolescence and later life in a substantial body of research which most
of them has been conducted in Western countries (Moran et al.,
2004; Dube et al., 2003). To our knowledge this is the first study
to examine the link between all types of child maltreatment and substance
use disorder in later life in an Eastern Mediterranean country.
Before interpreting the results of the study, its main limitations should
be stated here: First, the study was based on a clinical sample which
may limit generalizability. Second, childhood events were questioned via
self-report retrospective questions which may be underreported owing to
Data gathered from a clinical sample provided new information on the link
between all types of abuse, neglect, age, gender, educational level, household
functioning and substance abuse. The results indicated sexual (40%) and
physical abuse (32.5%) the most frequent type of abuse/neglect in the substance
dependent and control group, respectively (Table 2
report studies conducted in US show that 25-35% of women report childhood
sexual abuse (Downs and Harrison, 1998). So the prevalence of sexual abuse
seems to be high in the substance dependent group in comparison to both
the control group and other relevant studies. Although other types of child
abuse and neglect showed no statistically significant difference between
the two groups but the overall prevalence of all types of childhood maltreatments
were to some extent higher in the substance dependent subjects. Sixty percent
of substance dependent subjects reported household substance use which was
two times higher than findings by Dube et al.
(2003). The difference
may be due to hidden of sexual abuse by victim and his/her family, because
the problem is the stigma.
After adjusting for age, sex and other baseline characteristics the only
variables that showed a significant relationship with drug use in later
life were household substance abuse, sexual abuse and GHQ score in order
of strength of association (i.e., OR) (Table 3). According
to Moarn et al. (2004) sexual abuse was a potent predictor of substance
use in later life comparing to other types of childhood maltreatment (Moran
et al., 2004). The association with higher score of GHQ-12 confirms
the relationship of psychiatric morbidity and substance dependency which
may be a mutual correlation (MacMillan et al., 2001).
Although the subject's educational status showed no significant association
statistically but the figures are in favor of its protective effect (Table
3). The higher risk of drug use in subjects who reported childhood
sexual abuse may be an indirect clue to the household dysfunction (Dube
et al., 2003). In many cases, the experience of abuse appears to
lead in later life to increased feelings of depression and anxiety which,
while not sufficient to result in the diagnosis of a mental health. Disorders
may place the victims at greater risk of developing substance abuse or
dependency, as a result of self medication (Stein et al., 2003).
Finally it should be emphasized that some variables we studied, such as
household dysfunction seem to play a causal role in the occurrence of
other exposures which should be considered in the interpretation
of the results.
In conclusion the related factors uncovered by the study conduct us to
early interventions among dysfunctional families to decrease the maladaptive
lives and stressful household environments.
We thank all participants for their enthusiastic support of our efforts
and for their cooperation in filling the questionnaires.