Child abuse and neglect pose an increasingly recognized and
serious threat to the nation's children. The reported cases
of abused and neglected children have more than doubled from
1.4 million in 1986 to more than 3 million in 1997. Research
suggests that adults with histories of child abuse and neglect
are at high risk for developing substance abuse disorders. Moreover,
these childhood abuse and neglect issues may negatively affect
clients' chances for recovery from substance abuse. Compounded
with these problems is the increased likelihood of substance-abusing
parents abusing their own children. By most accounts, substance
abuse contributes to almost three fourths of the incidents of
child abuse or neglect for children in foster care.
Two major reports released in 1999 highlight the need to address
this intergenerational cycle of substance abuse and child abuse
if effective progress is to be made on either problem. These
studies are Blending Perspectives and Building Common Ground:
A Report to Congress on Substance Abuse and Child Protection by the U.S. Department of Health and Human Services (DHHS)
and No Safe Haven: Children of Substance-Abusing Parents
by the National Center on Addiction and Substance Abuse (CASA)
at Columbia University. Both reports emphasize that the rise
in substance abuse as a factor in child abuse and neglect cases
has severely complicated efforts by child welfare systems to
protect children and rehabilitate families. In response to these
issues, this Treatment Improvement Protocol (TIP) presents information
to assist alcohol and drug counselors and other treatment providers
to work more effectively with adults who have histories of childhood
abuse or neglect and adults who abuse or who are at risk for
abusing their own children.
The effects of childhood abuse and neglect perpetrated by
family members and the intergenerational transmission of the
cycle of substance abuse and child abuse and neglect are the
focus of this TIP. However, not all clients in treatment have
a history of childhood abuse, not all children who are maltreated
become substance abusers or child abusers, and not all child
abusers have a history of childhood abuse or current substance
abuse. Although these are common factors that often arise in
substance abuse treatment, they are not present in every case.
This TIP does not address the treatment needs of children
who are currently being abused, as that area of concern is extensively
addressed in multidisciplinary literature. This TIP also does
not address children who are abusing substances, many of whom
may have experienced abuse and neglect. The issues involved
in treating children and adolescents for substance abuse differ
greatly from those encountered with an adult client population.
Guidelines for screening, assessing, and treating adolescents
with substance abuse disorders are offered in TIP 31, Screening
and Assessment of Adolescents for Substance Use Disorders(CSAT, 1999a), and TIP 32, Treatment
of Adolescents With Substance Use Disorders (CSAT,
1999b). A third group not addressed here is pedophiles.
The Consensus Panel considers pedophilia to be a separate category
of child sexual abuse beyond the scope of this document. The
most pervasive form of child maltreatment is neglect (60 percent);
however, because most research has focused on childhood physical
and sexual abuse, this TIP will primarily address these two forms.
Definitions of the types of behaviors and specific acts that
constitute physical, emotional, and sexual abuse and neglect
are provided in Chapter 1 so that counselors
can better understand the range of potential experiences of their
clients. In Chapter 2, the TIP discusses
common signs and behaviors that suggest a history of childhood
emotional, physical, and sexual abuse and neglect, as well as
indicators that clients might be abusing their own children.
Chapter 3 addresses the distinct treatment
issues that counselors may encounter in working with adults who
have been abused or neglected in childhood. Among the factors
that can complicate treatment for this population are comorbid
mental disorders and trauma-related symptoms.
Because of the abhorrent nature of child abuse and the emotional
difficulty of working with traumatized individuals and with individuals
who harm children, personal issues for counselors are discussed
throughout this TIP and are the focus of Chapter
4. Substance-abusing parents who may be abusing or neglecting
their children are the subject of Chapter
5. In working with child abusers, many of whom are ordered
into treatment by the courts, treatment counselors must understand
the structure of the child protective services (CPS) system and
the family and criminal courts in order to help clients negotiate
these systems. The TIP provides some guidelines for communicating
with these systems; however, treatment providers must learn the
particulars of how these services are structured in their State
and local jurisdictions. Chapter 6 discusses
the relevant laws on reporting current child abuse and maintaining
client confidentiality; recent legislation on family preservation,
fast-track adoption, and reunification laws are reviewed in
Chapter 7.
Throughout this TIP, the term "substance abuse" has been used
in a general sense to cover both substance abuse disorders and
substance dependence disorders (as defined by the Diagnostic
and Statistical Manual of Mental Disorders, 4th Edition [DSM-IV]
American Psychiatric Association, 1994).
Because the term "substance abuse" is commonly used by substance
abuse treatment professionals to describe any excessive use of
addictive substances, in this TIP it will be used to denote both
substance dependence and substance abuse disorders. The term
relates to the use of alcohol as well as other substances of
abuse. Readers should attend to the context in which the term
occurs in order to determine what possible range of meanings
it covers; in most cases, however, the term will refer to all
varieties of substance use disorders as described by DSM-IV.
To avoid both sexism and awkward sentence construction, the
TIP alternates between the pronouns "he" and "she" in generic
examples.
The Consensus Panel's recommendations, summarized below, are
based on both research and clinical experience. Those supported
by scientific evidence are followed by (1); clinically based
recommendations are marked (2). Citations to the former are
referenced in the body of this document, where the guidelines
are presented in detail.
The Consensus Panel recommends that, when working with clients
with substance abuse problems and histories of childhood abuse
and neglect, counselors adopt a broad approach that considers
the meaning of the experience to the client, not just legal definitions
of child abuse and neglect. (1) Counselors must, therefore,
understand how clients interpret their experiences. Not all
abuse meets the legal or commonly held criteria for abuse, nor
do all clients perceive as abusive behavior that which might
be legally defined as "abuse."
Without proper screening and assessment, treatment providers
may wrongly attribute symptoms of childhood trauma-related disorders
to consequences of current substance abuse. Comprehensive screening
for root causes of clients' presenting symptoms may greatly increase
the effectiveness of treatment. However, counselors face many
challenges when screening for and assessing childhood abuse or
neglect. Many abuse survivors are ashamed of having been victims
of childhood physical, emotional, or sexual abuse and may believe
that the abuse was self-induced. Screening and assessment, therefore,
should be designed to reduce the threat of humiliation and blame
and should be done in a safe, nonthreatening environment. (2)
While conducting screenings and assessments, counselors should
be mindful that adult survivors of childhood trauma commonly
suppress memories of certain traumatic events or minimize their
symptoms, either intentionally or unintentionally. Moreover,
issues of confidentiality, mandated reporting, and trust may
influence the responses to interviews and questionnaires by making
some clients less inclined to reveal personal histories of abuse
or neglect. Given the variable reliability of clients' responses,
counselors should neither overemphasize nor overvalue the role
of standardized instruments.
Counselors who will be screening for and assessing histories
of child abuse or neglect should receive specific training in
these areas. (2) Although there are no rigid rules regarding
who should conduct screenings, having certain skills will increase
the likelihood that the screening process is conducted appropriately.
Staff members should have an understanding of the types of psychiatric
disorders and symptoms that are commonly associated with histories
of childhood abuse and neglect.
Counselors who conduct screenings will be prompting clients
to recall painful and traumatic events. The reemergence of painful
memories may cause intense reactions from clients. Treatment
staff should be sensitive to this and prepare for the interview
in the following ways:
Inform clients that talking about such
issues might create discomfort; clients should be given a choice
to disclose such information, being aware of the possible aftermath.
(2)
Have proper supervision and support mechanisms in place for
clients in case a crisis occurs following disclosure (e.g., accessibility
to mental health practitioners or medical personnel). (2)
Assess the sources of social and emotional support available
to clients when they return home. (2)
There are many potential barriers to successful screenings
and assessments of childhood trauma. To reduce some of these
barriers, the Consensus Panel recommends the following:
Be sensitive to cultural concerns. (1)
Recognize potential language differences. (2)
Become aware of gender issues. (2)
Be nonjudgmental and sensitive. (1)
If counselors experience intense discomfort and anxiety when
conducting screenings and assessments, the Consensus Panel recommends
that they receive guidance and support from a clinical supervisor
and consider whether they could benefit from therapeutic assistance
to explore the reasons for their discomfort. (2) A variety of
instruments for screening and assessment are discussed in Chapter 2.
The Consensus Panel suggests screening for child abuse and
neglect histories early in the assessment process to identify
individuals who exhibit signs and symptoms associated with child
abuse and neglect (such as posttraumatic stress disorder [PTSD],
major depression, or mood disorders) and to identify those who
may benefit from a comprehensive clinical assessment. (2) Screenings
should also be conducted at different times throughout the treatment
process. Repeated screenings help elicit information about these
traumatic experiences--especially after trust has been established
in the therapeutic relationship. (2) To conduct a screening
effectively, treatment staff should
Learn and understand ways in which childhood
abuse and neglect can affect adult feelings and behaviors. (2)
Identify those individuals who appear to exhibit these symptoms.
(2)
Identify the trauma-related treatment needs of these clients.
(2)
Provide or coordinate appropriate treatment services that
will help meet clients' treatment needs. (2)
Screening for childhood abuse or neglect can set in motion
a proactive plan with the following benefits:
Stopping the cycle. Although not
all adults who were abused or neglected during childhood abuse
their own children, they are at greater risk for doing so. (1)
Decreasing the probability of relapse. Many substance
abusers consume substances to self-medicate posttraumatic stress
symptoms related to past physical or sexual abuse or trauma.
(1)
Improving a client's overall psychological and interpersonal
functioning. Childhood sexual abuse and neglect may affect
the individual's self-concept, sense of self-esteem, and ability
to self-actualize. (2)
Improving program outcome. Screening for a history
of child abuse or neglect will help a program to determine the
needs of its clients, thus improving treatment outcomes. (2)
The primary purpose of an assessment is to confirm or discount
a positive screening for childhood abuse or neglect, as well
as to identify clients' needs so that treatment can be tailored
to meet them. The more clinical information a program has about
clients' particular treatment needs, the better the program can
accommodate them. All clients who screen positive for a history
of childhood abuse or neglect should be offered a comprehensive
mental health assessment. (2) There is no standard trauma-oriented
assessment tool, and no single tool can be considered truly comprehensive.
Rather, wisely selected, each of these tools can be a valuable
component of a comprehensive assessment process.
When deciding whether to conduct assessments for a history
of child abuse or neglect, the treatment team should evaluate
clients'
Current substance use or quality and length
of abstinence
Commitment to the treatment and recovery process
Risk of relapse
The Consensus Panel believes that treatment decisions and
activities are best conducted within the context of a multidisciplinary
treatment team, with members having special knowledge in such
areas as mental health, child abuse and neglect, and family counseling.
(2) Each member of the treatment team should help decide if
and when to conduct assessments for childhood trauma, and clients
should be asked to evaluate their own readiness to confront child
abuse or neglect issues.
Trauma-related assessments are important because they can
help the treatment staff understand the types of childhood traumatic
events experienced by clients, their subjective response and
perceptions of these events, and common current symptoms that
may result from childhood trauma. Decisions regarding the types
of instruments to use should be influenced by the purpose of
the assessment, the setting of the assessment, the population
being treated, and the individual client and the severity of
his problems. (2)
Assessing histories of childhood trauma can provoke or exacerbate
a psychological emergency that must be addressed; therefore the
Consensus Panel recommends that the treatment team include a
licensed mental health professional to handle medical issues
that may arise and to conduct more formal assessments that may
be required.
How clients remember traumatic events can shape their psychological
response more than the actual circumstances can; counselors,
therefore, need to obtain subjective information about these
events. Such information is necessary in order to plan appropriate
treatment. Information that should be obtained includes:
What the client thought about during the
abuse
What the client felt during the abuse
How the client understood, as a child, what was happening
to her and what she thinks about it now
How the client thinks and feels about how the abuse has affected
his adulthood and substance abuse, and how he deals with the
aftereffects of the abuse now
The feelings most closely associated with the abuse experience
The client's memories of the abuse
The unique aspects of the client's perceptions about the
abuse
The client's coping strategies, and their effectiveness for
the client
The assessment should inquire about childhood symptoms and
family characteristics that are consistent with and suggest a
history of childhood abuse or neglect. (2) Symptoms to look
for include
Depression (including thoughts of death,
passive suicidal ideation, and feelings of hopelessness)
Dissociative responses during childhood
Aggressive behavior or other "acting out," including
Early sexual activity or sexualized behavior
Physically abusing or harming pets or other animals
Other destructive behaviors
Poor relationships with one or both parents
Attachment disorder, difficulty trusting others
Excessive passivity
Passive/aggressive behavior
Inappropriate age/sexuality formation
Blacked-out timeframes during childhood
Excessive nightmares, extreme fear of the dark, or requested
locks on doors
Family-of-origin characteristics to consider include
A very important factor in predicting treatment success is
the number of services clients receive (e.g., case management,
parenting education, counseling for PTSD and childhood abuse).
(1) Clients receiving more specialized services, often concurrently
with substance abuse treatment, are more likely to stay in recovery.
(1) Treatment planning for clients with childhood abuse histories
should be a dynamic process that can change as new information
is uncovered, taking into account where a client is in the treatment
process (e.g., confronting abuse issues too early in treatment
can lead to relapse). (2)
However, it is also important for counselors to remember that
until some degree of sobriety is achieved, a client's sense of
reality is likely to be distorted and her judgment poor. When
disclosures of past abuse take place before a client has achieved
sobriety, information on childhood abuse and neglect should be
heeded, but full exploration of the issue should be postponed
until later. (2) Listed below are general recommendations and
guidelines counselors should be aware of when planning a client's
treatment.
Counselors should exhibit unconditional
positive regard, a nonjudgmental attitude, and sincerity--therapist
characteristics that are essential for effective treatment, regardless
of therapeutic modality. (1)
Providers must be sensitive to their clients' cultural issues
and how they interact with clients' child abuse or neglect history.
The Consensus Panel strongly urges alcohol and drug counselors
to be aware of how clients' backgrounds may affect treatment.
(2)
Sympathetic listening can be an important first step in helping
a formerly abused client begin the healing process. (2)
In the initial crisis that often follows a disclosure, the
counselor's most important task may be affect management, such
as keeping the client calmer by using relaxation techniques.
(2)
Clients who suffered severe childhood abuse may need to be
reassured that they are in a safe environment and will not be
abused in the present. They may also have to be taught techniques
to stay focused in the present. (2)
Some clients may require medical supervision in inpatient
or intensive outpatient programs (at least during the early stages
of abstinence) in order to deal with their feelings of rage,
anxiety, depression, or suicidality. (2)
Clients with past trauma should be reassured in treatment
that they have the capacity to deal with traumatic memories or
related destructive behaviors stemming from childhood abuse.
(2)
Counselors must carefully pace the client's treatment by
monitoring anxiety and depression levels and by taking other
cues directly from the client. (2)
Counselors need to isolate the symptoms of substance abuse
disorders caused by trauma due to childhood abuse. (2)
Counselors should search for and apply any available leverage
to help clients endure the short-term pain--until some treatment
benefits can be realized. Clients must be engaged in a way that
will give them hope and increase their beliefs in their own power
to create a new life. (2)
For clients entering substance abuse treatment, the mere
act of completing a questionnaire acknowledging a history of
abuse can be tremendously healing and can lead to change, even
without the intervention of a counselor. For other clients,
however, actively confronting the fact of childhood abuse may
be highly disturbing, and counselors must be prepared to respond
supportively. (2)
In acknowledging the client's history of childhood abuse
and neglect, the counselor must validate the client's experience
by recognizing the issue, refocusing the treatment, and addressing
the issue. (2)
The counselor can help the client develop interpersonal skills
through modeling behavior, by empathizing and respecting the
client, and by setting boundaries. (2)
For victims of abuse, the process of reattaching--or attaching
for the first time--to other individuals, to a community, or
to a spiritual power has tremendous therapeutic value. (2)
Linkages between substance abuse treatment and mental health
agencies are important if the two programs are to understand
each other's activities. In the interest of the client, a case
summary should be developed that includes the key issues that
should be addressed in the next program. (2)
When symptoms indicate mental health problems that are beyond
the scope of the counselor's ability to treat, a referral is
clearly warranted. Suicidal thoughts, attempts at self-mutilation,
extreme dissociative reactions, and major depression should be
treated by a mental health professional, although that treatment
may be concurrent with substance abuse treatment. (2)
Counselors should prepare clients for mental health treatment
by helping them realize
That their history of childhood abuse or
neglect has contributed to some of their errors in thinking,
behavior, and decisionmaking
That they self-medicated with substances in order to avoid
dealing with emotions
That they are not alone and that there are resources to help
(2)
Working with at-risk clients in today's litigious climate
requires counselors to adhere closely to the accepted standards
and ethics of practice as well as the legal requirements of their
position. Creating a multidisciplinary team and using proper
supervision will help ensure that the counselor maintains such
standards. (2)
Substance abuse counselors always must evaluate the appropriateness
of including childhood abuse and neglect survivors in group therapy
for other clients in substance abuse treatment. Abuse survivors
may not be able to handle the group process until they are able
to deal effectively with their attachment issues. (2)
It is a delicate matter to discuss past abuse in the presence
of family members who participated in or were present during
it. When such a decision is made, the counselor must bear in
mind that he does not, and should not, have the role of confronting
the perpetrator or perpetrators. (2)
It is inevitable that the counselor will react to the client
in ways that are not completely objective. Working with this
population may evoke powerful feelings in the counselor. It
is important that counselors be aware of and manage their own
countertransference reactions and seek supervision as necessary.
The Consensus Panel offers the following suggestions to help
counselors deal with personal issues when working with clients
with childhood abuse and neglect histories.
In order to teach and model appropriate
and healthy interactions, counselors should establish and maintain
clear and consistent boundaries with their clients. Adult survivors
of child abuse or neglect often need a great deal of affection
and approval, and counselors must make clear to the client that
they are not responsible for directly meeting all those needs.
(2)
Counselors should focus on empowering the client, recognizing
that getting overinvolved will rob clients of the opportunity
to draw on their own inner resources. (2)
Clients' previous experiences may cause them to be mistrustful
and suspicious of others, including the counselor. To facilitate
the development of a trusting relationship, the counselor should
not personalize negative responses but be open, consistent, and
nonjudgmental whenever interacting with the client. (2)
The level of violence and cruelty in disclosures about childhood
victimization and exploitation may be very disturbing to counselors.
When counselors find themselves manifesting symptoms of anxiety
or depression, they should seek direction and support through
supervision or peer support. (2)
Counselors must recognize their personal and professional
limitations and not attempt to work with abused clients if they
lack the clinical expertise or are not able to manage their own
countertransference reactions. (2)
Burnout, or secondary trauma responses, affects many counselors
and can shorten their effective professional life. If counselors
meet with a large number of clients (many with trauma histories),
do not get adequate support or supervision, do not closely monitor
their reactions to clients, and do not maintain healthy personal
lifestyles, counseling work of this sort may put them at personal
risk. To minimize the likelihood of burnout, counselors should
not work in isolation and should seek to treat a caseload of
individuals with a variety of problems, not only those who have
experienced childhood trauma. (1)
Alcohol and drug counselors are often subject to great stress.
They can be expected to function well and provide effective
treatment only if their agency gives them the appropriate support.
The agency's leadership should strive to impart a sense of vision
to staff members that communicates how important their work is
as part of the larger effort to break the cycle of abuse and
neglect and its impact on society. (2)
While many adults with substance abuse disorders do not abuse
their own children, they are at increased risk of doing so.
When children who are victims of maltreatment become adults,
they often lack mature characteristics: the ability to trust,
to make healthy partner choices, to manage stress constructively,
and to nurture themselves and others. Adults with child abuse
histories are then more likely than the general population to
develop substance abuse disorders. This intergenerational cycle
of substance abuse and child abuse and neglect reflects both
the direct and indirect relationship between parental substance
abuse and family dynamics, child and adult maltreatment, and
second-generation substance abuse. Unless effective intervention
occurs, there is an increased likelihood that these patterns
will be repeated in future generations. The following list offers
recommendations to address this cycle.
Interventions aimed at breaking the
cycle of substance abuse, child neglect, and maltreatment are
more successful when they are family centered. (1)
Counselors can elicit information on a client's childhood
experience, which can be useful in predicting the nature of current
family relationships. (2)
Just as counselors can expect that substance-abusing parents
often will deny their drug use, they can also expect parents
to deny neglecting or abusing their children. Counselors should
help parents understand that their parenting behaviors may not
be appropriate and that these behaviors can negatively influence
their children's future development, especially their ability
to trust others and to develop self-esteem and pride. (1)
Counselors should remember to articulate the positive aspects
of clients' lives. (1) Focusing only on the negative or risk
factors results in shame and a sense of futility and is counterproductive.
Increasing clients' self-esteem and self-efficacy (their effectiveness
and ability to take responsibility) is a primary step to acceptance
of the child-rearing role.
In addition, it is critical that counselors be able to distinguish
between actual cases of child abuse and neglect and situations
that arise due to cultural differences, poverty, and lack of
education. Providers who work with clients from different cultures
should try to develop an understanding of that culture's norms
concerning child rearing and discipline.
Because many parents who abuse substances also neglect or
abuse their children, it is common for clients in substance abuse
treatment to have some involvement with the CPS system. Some
substance-abusing parents will be drawn into the CPS system
during treatment; others will be compelled into substance abuse
treatment by a CPS agency. In either case, it is critical that
treatment providers become familiar with the laws governing the
CPS system, including
How child abuse and neglect are defined
in their State
Whether, when, and how a counselor must report a parent or
other primary caretaker--or a parent who was maltreated in childhood--to
a CPS agency or police
What happens after a report is made
How State-mandated family preservation services operate
Although inappropriate child-rearing practices should be addressed
in treatment, they may not, in and of themselves, constitute
grounds for an abuse or neglect report. However, if counselors
have a reasonable suspicion or firm belief that abuse or neglect
has occurred, they are required to make a report. (2) It is
important for counselors to bear in mind that a parent who abuses
substances is not able to adequately supervise a child and, unless
other adults are known to be caring for the child, the counselor
should alert the CPS agency regarding potential neglect. It
will then be the CPS agency's responsibility to decide whether
or not to investigate the matter. (2)
Clients should be informed about the mandatory reporting laws
at the time of admission and provided with written documentation
regarding both the Federal regulations regarding confidentiality
and the counselors' duty to report suspected abuse or neglect.
The Consensus Panel recommends that the client be required to
acknowledge receipt of such notice in writing. (1)
Counselors are usually not under any obligation to report
childhood abuse experienced by an adult client many years ago.
However, if the known perpetrator now has custody of--or access
to--other children, the program should seek advice about its
responsibility to report potential abuse or neglect. (2)
Programs should ask staff members who are mandated reporters
to consult a supervisor or team leader before calling a CPS agency
to report suspected child abuse or neglect, unless the emergency
nature of the situation requires immediate action. Clinical
supervisors can help determine whether the staff members are
dealing with countertransference issues or inappropriate attachment.
Staff members should be guided primarily by a trained understanding
of the Federal requirements and the written procedures established
by the treatment program. Other staff members can offer support,
especially when the decision to report is difficult. (2)
Treatment organizations and agencies should provide orientation
for all new staff members to inform them about reporting policies
and procedures. It is recommended that these policies include
provisions requiring staff members to notify their supervisor
or appropriate program personnel whenever they make a report.
(2)
It is the decision of the client and his lawyer, not the counselor,
to determine whether communication or cooperation with a CPS
agency will benefit the client. Therefore, it is essential that
the counselor communicate with the client's attorney before taking it upon herself to communicate with a CPS agency,
except when there is a legal mandate to report. (2) If
a lawyer calls with questions about a client's treatment history
or current treatment, the counselor must avoid giving any information
(even that the client is indeed in treatment), unless the client
has consented in writing to the counselor's communicating with
the lawyer. (2)
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