Substance Abuse: The Impact on Children and Families

Substance Abuse: The Impact on Children and Families Present by: Connie Miles Pulaski County Health Center Please turn off all cell phones Restrooms

Food and Drink Objectives The Dynamics of Alcohol and Drug Abuse Indicators The of Substance Abuse Affect of Parental Substance Abuse on a child

Substance Abuse and Family Violence Substance Abuse The Impact on Children and Families The Dynamics of Alcohol & Drug Abuse Most studies indicate that nationally between onethird and

two-thirds of substantiated child abuse and neglect reports involve parental substance abuse. In the state of Missouri, the numbers reported indicate 80% of CAN reports involve parental substance abuse. Drug Abuse and Brain Chemistry Our brains work to promote our survival. Eating is governed by specific brain systems. When we eat (or do various other activities), the brains reward systems are activated. Activation of brain reward systems produces changes in affect ranging from slight mood elevation to intense pleasure and euphoria, and these psychological states help direct behavior toward natural rewards. Caffeine, alcohol, and nicotine all activate the brain reward mechanisms directly, and moderate use of these substances has grown socially

acceptable. Other drugs activate the brains reward centers much more intensely. Use of other drugs can elevate mood as well as other affective changes (relaxation, etc.) that are desirable. The enjoyment of this affect can lead to abuse. Since the activation is more intense, it begins to cause cravings for this heightened level of stimulation. Especially true with methamphetamine. Researchers have reported that as much as 50 percent of the dopamine-producing cells in the brain can be damaged after

prolonged exposure to relatively low levels of methamphetamine. Researchers also have found that serotonin-containing nerve cells may be damaged even more extensively. Although there are no physical manifestations of a withdrawal syndrome when methamphetamine use is stopped, there are several symptoms that occur when a chronic user stops taking the drug. These include depression, anxiety, fatigue, paranoia, aggression, and an intense craving for the drug. Patterns of Use Experimental Use Functional Use Dysfunctional Use Harmful Use

Dependent Use Abuse or Dependence Abuse and Dependence are seen very differently by the DSM-IV-TR which is used by mental health professionals to diagnose substance abuse problems. Substance Abuse precedes Substance Dependence. A person may be using a substance and not qualify as either a substance abuser or as substance dependent.

Substance Abuse A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period: Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household) Recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)

Recurrent substance-related legal problems (e.g., arrests for substancerelated disorderly conduct) Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments w/ spouse about consequences of intoxication, physical fights) AND The symptoms have never met the criteria for Substance Dependence for this class of substance. DSM-IV-TR, 2000 Substance Dependence A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:

Tolerance, either of the following: - a need for markedly increased amounts of the substance to achieve intoxication or desired effect - markedly diminished effect with continued use of the same amount of the substance A great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chainsmoking), or recover from its effects Important social, occupational, or recreational activities are given up or reduced because of substance use Substance Dependence Cont. Withdrawal, either of the

following: - the characteristic withdrawal syndrome for the substance - the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms The substance is often taken in larger amounts or over a longer period than was intended

There is a persistent desire or unsuccessful efforts to cut down or control The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaineinduced depression, or

continued drinking despite recognition that an ulcer was made worse by alcohol consumption) What is Addiction Addiction Alcohol and drug addiction are diseases that, while treatable, are chronic and relapsing. Chronic and relapsing mean that the addiction is never cured, and that substance use may persist or reappear over the course of an individuals life.

Indicators of Substance Abuse Signs and Symptoms Gender Differences Men Men have more access to drugs. Men are more likely to abuse alcohol and marijuana than women. Men in treatment programs are more likely to have graduate high

school and be employed than women in treatment. More likely to enter treatment because of referral by the criminal justice system, whereas Women Women are more likely to become addicted to or dependent on sedatives and drugs that reduce anxiety or sleeplessness. Women are more likely

to have other health problems, seek treatment multiple times, and attempt suicide. Several research studies indicate that Child Signs and Symptoms Note: It is possible for there to be other explanations beyond substance abuse in the home for these signs/symptoms. It is important to consider alternate explanations as well. The child of a substance abuser may: Appear unkempt. Can be result of neglect by a substance abusing parent. Be frequently sleepy--can be connected to fighting, arguing, or violent behavior in the home in the evening.

Be late to school--may be in charge of getting themselves there because their parent is still in bed. Their responsibilities in the morning may include preparing breakfast, taking care of younger siblings, etc. Have unexplained bruises due to inadequate supervision or abuse from a parent. Fluctuate regarding school performance, esp. at the end of the day as the child dreads returning home. May have an unchildlike odor (not poor hygiene) but chemical in nature (metallic or cat urine smell). This could indicate drug usage and manufacturing in the home. Signs and Symptoms (cont.) The child of a substance abuser may: Know too much about drinking for their age or they may be

extremely guarded when the topic of substances are approached. Appear withdrawn/depressed Display behavioral problems. Be frequently absent from school in order to take care of the substance abuser Complain of stomachaches, headaches, or other physical ailments, with no explainable cause, often at the same time every day Peers may tease/hint about problem in the childs home. Parents can be predictably hard to reach and often do not show for childs activities at school Parent(s) may attend school related functions drunk or high. Questions for the social service

worker to ask or situations to consider Is the client driving with the children in the car while under the influence? Are the children being left in unsafe care with an inappropriate caretaker or unattended while parent is partying? Parent may neglect or sporadically address the childrens needs for regular meals, clothing and cleanliness. Even when the parent is in the home, the parents use may leave children unsupervised. Behavior toward children may be inconsistent, such as a pattern of violence and then remorse.

Questions cont. Despite a clear danger to children, the parent may engage in addiction-related behaviors, such as leaving children unattended while seeking drugs Is the parent able to work? Is the cost of the substance of abuse causing financial issues? Funds are used to buy alcohol or other drugs, while other necessities, such as buying food are neglected A parent may not be able to prioritize childrens needs over his or her own for the

substance Substance Abuse Risk Assessment Questions 1. What were the issues that brought the children and/or family to my attention? 2. What is the familys perspective of this problem? 3. How do the current problems impact the immediate safety of the children? 4. Am I relying on labels to influence this assessment? If so, what are the behaviors that impact the risk or safety of the children? 5. Have I considered the familys cultural background? 6. How is my personal framework affecting my assessment of the familys problems? 7. What is the evidence that supports my conclusions?

8. What is the evidence that disputes my conclusions? 9. What other evidence should I explore? 10. What could be another explanation for the clients behavior? 11. Have I examined precipitating events as well as consequences of behaviors? Click icon to add picture Substance Abusing Families Dynami c of Family Disease

Substance abuse affects the entire family. The need for the substance puts a constant strain on financial resources, and the effects of the substance can threaten long-term employment. The increasing stress level in the home can lead to arguing and hostility, verbal, physical, and sexual abuse, and overall chaos for the family. The pandemonium in the home leads to anxiety, confusion, and conflict in the children who live there. Family Disease No one member escapes the effect of a

substance abuser in the home, which makes substance abuse a family disease Children whose parents or other siblings are alcoholics or drug users are at greater risk of developing a substance use disorder. Having an alcoholic family member doubles the risk of a male child later becoming alcohol or drug dependent. Communication in the Home Marked by inconsistency and unpredictability Open and honest communication declines and silence and secrets

prevail When communication occurs, it is usually fluctuates between silence and anger Difference in Legal vs. Illegal Use Additional Element of Secrecy Barrier to Community Resources Increased Vulnerability Violence Incarceration of a parent Illegal activity for financial gain Rate of Addiction Reassignment of roles/ responsibilities Children begin to learn that they cannot rely on

the substance abuser to follow through on what they have said. Family members adapt by reassigning family roles/responsibilities Children may be easily overburden with the tasks of taking care of themselves and their siblings, preparing meals, getting to school alone, caring for the substance abusing parent, etc. Due to the familys secret, the child has less support for the stress of their increased responsibilities. Redefined roles in a substance abusing family

Dependent Enabler Hero Scapegoat Lost Child Mascot Dependent In the alcoholic home, it is the drinker. In a dysfunctional home, it may be the angry one, the

stern disciplinarian, or the unloving and rigidly religious one. (Angry, charming, aggressive, grandiose, righteous, rigid, perfectionist) Job description: Aggressor Manipulative Perfectionist Baggage: Fear Pain Shame Guilt

Unhealthy, irresponsible behavior Relief: Therapy skill building support (sponsor) Enabler The closest one to the Dependent. They enable their behavior to continue out of love, loyalty, shame and fear. Job description: Responsible for the alcoholic Compensates for

alcoholics loss of power Baggage: Anger Martyrdom Self-righteous Relief: Positive adult connections Validation of self worth (Powerless, self-pities, self-blames, serious, fragile, manipulative, Hero

Usually the oldest child Learns they can help the family most by being very, very good. The Enabler leans heavily on them for support. The Mascot tags on them for attention. Job description: Perfectionist Excellent student Over-achievers Makes family look good Follows rules Baggage: Guilt Hurt

Inadequacy Relief: Permission to make mistakes and not be perfect Opportunities to play Opportunities to express feelings and needs Scapegoat Usually the second child Cannot compete with the Hero. Attracted to peers who are in negative environments. Job description: Problem child

Accepts blame for family problems Seeks approval outside family Provide distraction and focus to family Aggressive Behavior problems Acting out may include use of ATOD Baggage: Anger Hurt Rejection Jealousy Relief:

Permission to be successful Supportive confirmation Structure and consistency (Strongly values peers, withdraws, unplanned pregnancy, chemical abuser, sullen, acts out, defiant) Lost Child Usually the third child Handles the chaos by withdrawing. Does not feel close to parents or siblings. Passive and never sure where they fit. May get lost in alcohol and drug abuse.

Job description: Forgotten Child Dreamer Attaches to things, not people Solitary, anti-social Artistic Provides relief to family Baggage: Rejection Invisibility Anxiety Depressed, suicidal Relief: Positive attention Encouragement to take chances

Feel connected to other people (Withdrawn, aloof, eating disorder, quiet, distances, rejects, super independent) Mascot Usually the youngest child Develops wit and humor becoming the family clown. Their task is to help the family relax. May be hyperactive and be put on drugs, becoming dependent. Primary emotion is fear. May imagine physical disaster with every pain.

Job description: Clown Cute Hyper-active No honest communication Manipulative Baggage: Fear Insecurity Relief: To be taken seriously To hear that your opinions count Support and validation of all feelings (Humorous, hyperactive, fragility,

clown, always attracting attention, thrives on being super cute) The affect of Parental Substance Abuse on a child Behavior Consequences Substance abuse interrupts normal child development Family life is often chaotic since parental substance abuse is often combined with several of the following factors: domestic violence, divorce, unemployment, mental illness, legal

problems, physical and sexual abuse As a result of these stressors, children of substance abusers often have difficulty in school. They may distracted from school work by their concerns at home. COSA are more likely to skip school, repeat grades, transfer schools, be expelled, and have difficulty learning. Medical Consequences Stress-related health problems Health care utilization Child abuse and neglect

Alcoholism and other drug dependence Psychiatric Consequences Disorders of childhood Eating disorders Anxiety and Depressive disorders Pathological gambling Sociopathy Educational

Consequences Learning disabilities Repeating grades Changing school environment Truancy Drop-out Expulsion Emotional Consequences Mistrust

Guilt Shame Confusion Ambivalence Fear Insecurity Conflicts about sexuality Effects lasting

into adulthood Pre-natal Exposure Birth defects Fetal Alcohol Syndrome Primary symptoms Prenatal and postnatal growth deficiency (failure to grow). FAS children tend to begin with a lower birth weight and grow significantly less than other children their age. Their growth is below the 5th percentile for their age. Characteristic facial features include: flattened mid-face, epicanthal folds on the eyes, short/upturned nose, thin upper lip Average I.Q = 68 to 70 (mild range of mental retardation) Irritability in infancy, hyperactivity, and other emotional and behavioral disorders throughout childhood, including attention deficit disorder (ADD) or with hyperactivity (ADHD), and poor social judgment. Dysfunction in fine motor control: weak grasp, poor eye-hand coordination, and tremulousness Fetal Alcohol Effects

Lesser degrees of alcohol-related birth defects Hughes, 1998 Pre-natal Exposure (cont.) Developmental Effects Pre-maturity, low birth weight, decreased head circumference, impaired neurological function, neuromotor problems, intraventricular hemorrhage, strokes, & congenital malformations. Behavior Effects High-pitched cries, tremors, inconsolability, irritability, inability to organize normal sleep-wake cycles, and hyperactivity when exposed to multiple stimuli. (May foster poor child-caregiver attachment and affect later development). Later on: more insecure, more disorganized, and more poorly attached to their primary caregiver, more

inattentive, and impulsive. Besharov, 1994 Pre-natal Exposure (cont.) FAS & overall substance abuse long-term prognosis Sleeper Effect The research on pre-natal substance exposure is difficult to generalize since it often only takes into consider one drug and its affect on one particular age group and population. It is also unknown to what extent the effects seen in the child are due to the pre-natal drug exposure or the childs current environment and their caregivers interaction with them. Pre-natal damage is largely unpredictable, one woman who excessively abused substances may give birth to a normal infant and another woman who casually drank on occasion may give birth to a child with severe substance abuse

related difficulties. (Hughes, 1998, Haack, 1997, & Besharov, 1994) Environmental Risk Factors Inconsistency of family & home environment Women who continue to abuse substance after the birth of their child often lose custody of their child within 1 year of their childs birth. In some areas of the country, as many as 60% of drugexposed infants are placed in foster care. This removal may begin a series of placements in different foster homes. This will result in

multiple caregiver relationships from which the child is expected to attach and unattached. The resulting loss and grief makes the child more vulnerable to experience emotional and behavioral problems during their childhood. Haack, 1997 Exposure to Violence Drug-abusing mothers are more than likely to be around other drug abusing family members and friends. The mothers and children living in these type of environments are more likely to witness violence as well as be victims of it. A growing body of evidence indicates that witnessing violence can have a profound affect on childrens social and emotional outcomes. Underscoring this point, some researchers have concluded that children growing up in

violent neighborhoods have begun to display symptoms of post-traumatic stress disorder, including depressed interest in activities, guilt, violent outbursts and rage, difficulty concentrating, and a decline in cognitive performance. Besharov, 1994 Caregiver-Child Interactions Neglect Physical and Sexual Abuse Emotional Disorders Lack of social support systems and social skills Limited knowledge of child development

Neighborhood Environment of stress and poverty Dangerous or unsanitary living Conditions Stable families move from the area The parent develops a loyalty to neighbors that exceeds the loyalty to their child Little supervision High unemployment (potential for dangerous teenagers and adults to be home during the time a child is left alone after school). CAUTION- meth environments Click icon to add picture Substan

ce Abuse & Family Violence Scope of the problem The risk of child abuse and neglect is higher in families where parents abuse substances. The highest incidence of abuse and neglect occurs in families where both parents abuse alcohol. Parental substance abuse may leave children more vulnerable to sexual abuse by family members or by strangers Laws in several states support that maternal drug use is a form of child abuse and neglect.

Understanding the Link: Substance Abuse & Family Violence Substance abuse is one of the top two problems exhibited by families in 81% of reported cases of child abuse and neglect. Bersharov 11 percent of US children (8.3 million) live with at least one parent who is either alcoholic or in need of treatment for substance abuse Between 30 and 40 percent of family violence cases were committed while the abuser was taking a psychoactive substance prior to the episode of intimate partner violence. Most commonly reported illegal substance from the urinalysis was marijuana. Highest rates of removal of a child were found for parents who abused illicit drugs, with about 90% of these parents remaining unable to care for their children, compared with an approximately 60% rate of removal for children whose parents abused alcohol. Haack A Green Greene County study shows that 60% of clients served in its

shelter were assaulted by methamphetamines users at the time of the offense. Why alcohol is co-related with violence? Cognitive disorganization hypothesis Alcohol abuse increases the likelihood of violence because it interferes with communication among family members and results in misinterpretation of social cues, overestimation of perceived threats and underestimation of the consequences of violence. Deviance Disavowal hypothesis Perpetrator attributes the violence to his or her alcohol abuse and thus avoids or minimizes personal responsibility for the violent behavior. The disinhibition hypothesis Alcohol pharmacological actions on the brain interfere

with the actions of those brain centers that control (i.e., inhibit) socially unacceptable behaviors. Haack, 1997 Assessing for Substance Abuse Biological Testing Methods Urinalysis

Breath Test Blood Test Hair Follicle Drug Test Fingernail Drug Test Saliva Test See notes See notes See notes

See notes The Change Process Change Process Stages of Change PreContemplation Contemplation Preparing for Change Action

Lapse Maintenance Older adolescents and adults who use drugs tend to go through several stages before finally controlling their drug use. Pre-contemplation stage In this stage, the user is not considering giving up drugs. In response, you work at forming a

relationship with the person and try to raise his/her awareness of the consequences of drug use for him/herself, his or her family, and the community. But dont push too hard! At this point, your main job is to make a connection with them to involve him/her in thinking about changing his/ her life. DENIAL- Dont Even kNow I Am Lying Contemplation stage Now the user begins to think about doing something about his or her drug use, but has not yet reduced his or her level of use. You help the user at this stage by discussing the advantages and

disadvantages of using, and the advantages and disadvantages of quitting. Make observations and provide information, but avoid arguing. se-m4a-relationship-drugabuse.pdf Preparing for change When the person accepts that he/she needs to make changes in drug use, it is time to undertake a full assessment to prepare for the change. It is important to know such things as: What drugs are being used? How much are used? How frequently are which drugs used (e.g., daily, 3 time per day, or weekly)?

What methods of administration are used (e.g., inject, inhale, swallow) and if, how and why the methods may have changed? How is the user paying for the drugs? Whether the person is an experimental, functional, dysfunctional, harmful or dependent user? How he/she may have tried to give up or cut down in the past? What functions does the drug use serve? What supports the person has? Whether the drugs are used when the user is alone, with others, or both in both situations? Action stage At this point, the user attempts to quit, or at least reduce, his or her intake of substances. You can be more active at this

stage by helping the person learn skills and develop strategies that are needed to live substance-free. The user will need to figure out, by looking at his or her own life, what people, places, feelings or things make him or her more likely to use drugs. Skills training, therapy, and, above all, supports, Once the user has identified some personal prompts for using, he/she

can begin trying to eliminate them from his/her life. For some users, this may mean throwing away inhalant equipment, such as plastic bags and smoking instruments. For others, it may mean finding a job to avoid boredom. Yet other users may have to avoid friends who use drugs. Lapse stage After trying to abstain, most drug users will go

through a stage in which they resume taking drugs at the same level as before, or, at a slightly reduced level. This may even happen multiple times. This is not failure, but simply a part of the process of changing. You need to prepare the user in advance for this stage and then Not all change strategies work for all

users. When the user is ready to try to quit again, you can help the individual make a more effective plan of action. Relapse plancognitive in nature, discuss patterns & triggers, individualized plan. Average of 3 lapses per person before Maintenance stage The person in this stage is usually abstinent and wants to

remain that way. You help the individual develop a healthy lifestyle, which might include moving to a neighborhood where drugs are less prevalent, finding activities that keep him/her off the streets and away from users and dealers, and spending free time It is very difficult to maintain the change. The drugs had been

helpful to them in so many ways, despite bringing them problems. They may grieve over the loss of the drugs, like the death of a good friend. It is important to keep in mind why they had used drugs in the past and what he/she is missing (e.g., pleasant Adult Drug Court 85% retention rate (reach graduation) Takes an average of 24 months to complete the program.

1% recidivism rate Statistics on Family Drug Court not yet available since the program is too new. Noble, 2005 Any Questions Contact me at CONNIE MILES 101 12TH STREET CROCKER, MO 65452 [email protected] 573-736-2217 EXT. 242 References American

Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed-TR). Washington, DC: Task Force. American Council for Drug Education. Facts for Health Professionals. Retrieved September 1, 2005, from Bersharov, D. J. (Eds.). (1994). When Drug Addicts Have Children. Washington, DC: CWLA Press. Bozarth, M.A. (1994). Pleasure systems in the brain [Electronic version]. Behavioral Neuroscience Program. Retrieved August 24, 2005, from Briggs, D.C. (1970). Your child's self-esteem. New York: Doubleday.

References Cenla Chemical Dependecy Council. Signs and Symptoms: Behavior Characteristics Associated with Substance Abuse. Retrieved August 24, 2005, from Children of Alcoholic Families. Medical and Psychiatric Consequences. Retrieved August 25, 2005, from Children of Alcoholic Families. Signs and Symptoms. Retrieved August 25, 2005, from Connors, G. J., Donovan, D.M., & DiClemente, C.C. (2001). Substance Abuse Treatment and the Stages of Change. New York, NY: The Guilford Press.

References Drug and Alcohol Rehab Services. Relapse Prevention. Received September 2, 2005, from FAS/E Support Network of BC. What is Fetal Alcohol Syndrome/Fetal Alcohol Effects? Retrieved August 25, 2005, from Haack, M. R. (Eds.). (1997). Drug-Dependent Mothers and Their Children. New York, NY: Springer Publishing Company, Inc. Howard, J., (2000) ESCAP HRD Course on Drug Abuse and Its Relationship with Sexual Abuse and Sexual Exploitation of Children and Youth.

Hughes, R.C. & Rycus, J.S. (1998). Developmental Disabilities and Child Welfare. Washington, DC: CWLA Press. References Narconon Arrowhead. Retrieved from The National Institute on Drug Abuse. (2000, September). Gender Differences in Drug Abuse Risks and Treatment. Retrieved August 24, 2005, from The National Institute on Drug Abuse. Diagnosis and Treatment of Drug Abuse in Family Practice. Retrieved September 1, 2005, from Noble, Keith (personal communication, April19, 2005)

SACS. The Substance Abusers Paraphernalia. Retrieved August 25, 2005, from SACS. Checklist: Signs and Symptoms of Substance Abuse. Retrieved August 25, 2005, from SATOP (personal communication, 2005) References United States Drug Enforcement Administration. Drug Paraphernalia: Tools of the Illegal Drug Trade. Retrieved August 25, 2005, from http://www.usdoj,gov/ dea/concern/paraphernaliafact.html WebMDHealth. Alcohol or Drug Withdrawal. Retrieved August 24, 2005, from paraphernalia/ Supplemental References Appleford, B. (1989) Family Violence Review: Prevention and Treatment of Abusive Behavior. Appleford Associates. Brooks, C.S. & Rice, K. F. (1997). Families in Recovery: Coming full circle. Baltimore, MA: Paul H. Brookes Publishing Co. Curtis, O. (1999). Chemical Dependency: A family affair. Pacific

Grove, CA: Brooks/ColeThomson Learning. Daley, D.C. & Raskin, M.S. (Eds.). (1991). Treating the Chemically Dependent and Their Families. Newbury Park, CA: Sage Publications, Inc. Freeman, E.M. (Eds.). (1993). Substance Abuse Treatment: A family systems perspective. Newbury Park, CA: Sage Publications, Inc. Hawkins, J. D., Catalano, R. F., & Associates (Eds.). (1992). Communities That Care: Action for drug abuse prevention. San Francisco, CA: Jossey-Bass Publishers. Supplemental References

Levy, S.J. & Rutter, E. (1992). Children of Drug Abusers. New York, NY: Lexington Books. Nowinski, J.K. (1999). Family Recovery and Substance Abuse: A twelve-step guide for treatment. Thousand Oaks, CA: Sage Publications, Inc. Ryles, K. (1994) Parental Substance Abuse. Guidelines for Protective Workers. Sher, K. J. (1991). Children of Alcoholic: A critical appraisal of theory and research. Chicago, IL: The University of Chicago Press. Tomison, A. (1996) Child Maltreatment and Substance Abuse. National Child Protection Clearinghouse VonderPahlen, B.(2002) The role of alcohol and steroid hormones in human aggression. National Public Health Institute Finland.

Widom, Cathy. Alcohol Abuse as a Risk Factor for and Consequence of Child Abuse. Alcohol Research & Health Vol 25 2001. Woerle, Sandra & Guerin Paul & Smith Lindsey. Understanding the Nexus: Domestic Violence and substance abuse among the arrestee population in Albuquerque. October 03, 2002.

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