Child Abuse & Neglect 51 (2016) 379–389

Contents lists available at ScienceDirect

Child Abuse & Neglect

Research article

Association between maltreatment and polydrug use among

adolescents夽
M.J. Alvarez-Alonso a,∗ , R. Jurado-Barba a,b,c , N. Martinez-Martin d ,
J.C. Espin-Jaime d , C. Bolaños-Porrero e , A. Ordoñez-Franco e ,
J.A. Rodriguez-Lopez e , D. Lora-Pablos f , J. de la Cruz-Bértolo f ,
M.A. Jimenez-Arriero a,b,f,g , J. Manzanares h,i , G. Rubio a,b,f,h
a
Hospital 12 de Octubre” i+12 Research Institute, Av. Cordoba s/n, 28041 Madrid, Spain
b
Complutense University, Av. Séneca 2, 28040 Madrid, Spain
c
Camilo José Cela University, Castillo de Alarcón, 49, Villafranca del Castillo, 28692 Madrid, Spain
d
12 de Octubre University Hospital, Av. Cordoba s/n, 28041 Madrid, Spain
e
Addictions Institute “Madrid Salud”, Madrid City Hall, Juan Esplandiú 11, 28007, Spain
f
Clinical Research Unit, I+12-CIBERESP, Hospital 12 de Octubre, Av. Cordoba s/n, 28041 Madrid, Spain
g
Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM, Monforte de Lemos 3-5, 28029 Madrid, Spain
h
Networks for Cooperative Research in Health (RETICS-Addictive Disorder Network), Institute of Health Carlos III (ISCIII), MICINN and
FEDER, Madrid, Spain
i
Neurosciences Institute, Universidad Miguel Hernández, Campus San Juan, Alicante, Spain

a r t i c l e i n f o a b s t r a c t

Article history: Different studies have related sexual and physical abuse during childhood and adolescence
Received 9 March 2015 to the development of substance abuse disorders. Nevertheless, we are not aware of the
Received in revised form 14 July 2015 role that other more common maltreatment types, such as neglect, will play among the
Accepted 30 July 2015
most risky pattern of consumption: the polydrug use. A clinical sample of 655 adolescents,
Available online 25 August 2015
divided into two groups: polydrug users and non-polydrug users, were assessed on their pat-
tern of drug consumption, history of childhood maltreatment, current psychopathology and
Keywords:
their family history of alcoholism. Polydrug users had a greater prevalence of all types of
Polydrug users
maltreatment, although the most associated to this group were sexual abuse and emotional
Substance consumption
Adolescents neglect. Other relevant variables to adolescent consumption were: the diagnosis of depres-
Childhood maltreatment sive disorder, the presence of anxiety traits and the family history of alcohol dependence.
Polydrug users have higher risks of having had problems during infancy and adolescence,
such as maltreatment and other psychopathological conditions, with the addition of family
history of alcoholism. Accordingly, practitioners should take into account that those vari-
ables may influence polydrug abuse because it is the most risky pattern for subsequent
dependence of substances, and they should always be considered during treatment.
© 2015 Elsevier Ltd. All rights reserved.

Introduction

Alcohol consumption is a great global concern; the WHO reports that 2.5 million deaths are associated to alcohol every
year (WHO, 2014). When alcohol consumption in young people is taken into consideration, numbers are even more alarming:

夽 This research was funded by the “Plan Nacional Sobre Drogas” from the Ministry of Health, Social Services and Equality (Spain).
∗ Corresponding author.

http://dx.doi.org/10.1016/j.chiabu.2015.07.014
0145-2134/© 2015 Elsevier Ltd. All rights reserved.
380 M.J. Alvarez-Alonso et al. / Child Abuse & Neglect 51 (2016) 379–389

9% of 15–29 year-olds die direct or indirectly due to alcohol use and abuse (WHO, 2009). Alcohol is in many cases consumed
in combination with another illegal drug in a pattern defined by some scholars as polydrug use (European Monitoring Centre
for Drugs and Drug Addiction, 2009).
Alcohol and drug use among adolescents is a worrying fact because it is known that almost half of 13–15 years-olds have
already used drugs, and this amount will increase in the following few years (Johnston, O’Malley, Bachman, & Schulenberg,
2012).
The European project on the prevalence of alcohol consumption in high-school 15–16 year-old students (ESPAD, 2011)
found that 87% of survey respondents had consumed alcohol; 79% of them during the last year and 57% in the 30 days before
the study. Data from Spanish assessments (ESTUDES, 2012–2013) were similar to those found in the European Project. Habit
of alcohol consumption is frequently combined with the abuse of other drugs; negative consequences of consumption will
be therefore greater after the combination of multiple substances (Armour, Shorter, Elhai, Elklit, & Christoffersen, 2014).
One of the most studied relationships between substance consumption and drinking inducement among young people
is childhood maltreatment, which entails a higher risk of developing an alcohol-use disorder later in life (Enoch et al., 2009).
Nowadays, most of results highlight the association between childhood maltreatment and substance abuse. Researches
mostly belong to clinical and epidemiologic retrospective studies conducted amongst representative samples of adults (Afifi,
Henriksen, Asmundson, & Sareen, 2012; Armour et al., 2014; Dube, Anda, Felitti, Edwards, & Croft, 2002; Dube et al., 2006),
and only some piece of research was carried out regarding adults with alcohol or drug abuse disorders (Lake et al., 2014;
Rothman, Edwards, Heeren, & Hingson, 2008; White & Widom, 2008; Widom, DuMont, & Czaja, 2007; Young-Wolff, Kendler,
Ericson, & Prescott, 2011), since data from the USA’s NESARC epidemiologic study (Bierer et al., 2003) showed that having
suffered childhood maltreatment situations increased by 1.4 times the risk of developing a future abuse-dependence of
alcohol (Pilowsky, Keyes, & Hasin, 2009).
Concerning studies carried out with adolescents, two aspects were the most common: some were performed among
community adolescents (Arata, Langhinrichsen-Rohling, Bowers, & O’Brien, 2007; Goldstein, Faulkner, & Wekerle, 2013)
and found high rates of childhood maltreatment with a strong relationship between adverse experiences and alcohol and
drug use; the occurrence of more types of maltreatment yielded to more symptomatic individuals, and the magnitude of
psychopathological moderators were emphasized. Some studies (Hyucksun Shin, 2012; Shin, Hong, & Hazen, 2010; Shin,
Hong, & Wills, 2012; Shin, Miller, & Teicher, 2013; Wekerle, Leung, Goldstein, Thornton, & Tonmyr, 2009), have assessed
high risk adolescents, investigating whether the occurrence of particular types of maltreatment might have an effect on drug
consumption and binge drinking.
In summary, more of studies carried out so far confirm a consistent relationship between maltreatment and substance
abuse; nevertheless, few are the studies that had centered their attention precisely on those adolescents that sought help due
to problems related to substance consumption. Clark, De Bellis, Lynch, Cornelius, and Martin (2003) conducted a research
in which adolescents receiving treatment for alcohol use disorders were evaluated on the occurrence of physical and sexual
abuse as well as on the presence of depressive disorders that could mediate in the relation of consumption and maltreatment.
Clinical studies executed to date among adolescents omitted two facts that are of special relevance to us; it has been
relatively frequent to put the focus in alcohol or illegal drugs intake, missing the pattern of polydrug use. This pattern of
consumption is common among youth and is the more associated with the risk of developing subsequent alcohol, tobacco or
other drugs dependence disorders (Font-Mayolas et al., 2013; Hodgins, Lovenhag, Rehn, & Nilsson, 2013; Huang et al., 2011).
The other remarkable element among clinical studies is that they centered their attention in sexual and physical abuse,
thus impact over drug abuse concerning other types of maltreatment such as emotional abuse or neglect, has sometimes
underestimated (Armour et al., 2014; Clark et al., 2003; Darke & Torok, 2014; Fergusson, Boden, & Horwood, 2008; Lo &
Cheng, 2007; Molnar, Buka, & Kessler, 2001; Nelson & Wampler, 2002; Shin et al., 2010). As a matter of fact, those called
“minor” types of maltreatments might have great impact on the risk of substance consumption (Arata et al., 2007; Shin,
Edwards, & Heeren, 2009).
Taking these reports into consideration, the main objective of this study was to conduct an exhaustive search for the
possible associations between different types of maltreatment, including emotional abuse and neglect and the polydrug use
pattern of drug consumption (alcohol and other illegal drug intake) amongst adolescents seeking treatment.
In this study we considered as polydrug users adolescents reporting abusive consumption of alcohol plus any illegal
drug, assessed through the Alcohol Use Disorders Identification Test (AUDIT) and the Personal Experience Inventory. For
the assessment of childhood maltreatment, Childhood Trauma Questionnaire (CTQ) (Bernstein & Fink, 1998) was employed,
since it includes assessment of principal maltreatment types: physical abuse (PA), sexual abuse (SA), emotional abuse (EA),
physical neglect (PN) and emotional neglect (EN).
This report constitutes an extension of previous studies, complemented with some elements that may help to increase
understanding of the relationship between drug consumption and prior childhood maltreatment, since all kinds of substances
of abuse were considered, as well as different patterns of consumption. In addition, the assessment of psychopathologies
was conducted within a clinical environment, pursuing methodological accuracy and reliability through clinical interviews,
in order to increase consistency in relation with previous studies in which accuracy in the clinical context has not always
been followed (Winters, Latimer, & Stinchfield, 2002).
Since we assessed a clinical sample, we expected to find adolescents in high risk of developing a substance abuse disorder.
Among them, patterns of consumption and their association with all types of experiences of childhood maltreatment were
evaluated. Our hypothesis of work was that we would find more maltreatment situations among adolescents showing more
 M.J. Alvarez-Alonso et al. / Child Abuse & Neglect 51 (2016) 379–389 381

substance consumption, and also an association between polydrug abuse and presence of psychopathological conditions, in
comparison to adolescents from community samples.

Methods

Sample

The participants were 655 adolescents (mean age: 16.4; range: 13–19 years) recruited from clinical programs (n = 355)
and community sources (n = 300) in Madrid (Spain). Following the baseline adolescent assessment, subjects were classified
into two groups according to their baseline lifetime status on substance abuse: Polydrug users (n = 165) and non-polydrug
users (n = 490).
Polydrug users were adolescents reporting abusive consumption of alcohol plus another illegal drug. Polydrug use was
defined as scores of more than 6 points in the Alcohol Use Disorders Identification Test (AUDIT), or a binge drinking pattern
(consumption of 5 or more SDUs – 4 or more for women – on a single occasion at least once in the last two weeks) coupled
with other illegal drug consumption, more than once in a month (data from the AUDIT and Personal Experience Inventory,
PEI). In order to compare with the group of adolescents that seek treatment due to problems with alcohol intake, we chose
a group of 300 adolescents, matched by age and gender, which did not report the use of more than one substance, but could
be alcohol consumers. They were recruited from Primary Attention Units of the same Assistance Centres. These participants
were included as the non-polydrug users group.
Laws in force about alcohol use in Spain are similar to other European countries: alcohol consumption and purchase is
not allowed to minors, it is, to less than 18 years-olds.

Procedure

Recruitment was conducted in three steps: (1) consent to contact, (2) eligibility assessment, and (3) baseline assessment.
Adolescents were engaged from licensed alcohol and drug and other mental disorders Treatment Programs or at Primary
care centers. Treatment Programs belong to the Spanish National Health System, and embrace psychiatric and psychological
help to abstain from drug consumption.
Adolescents with psychosis, mental retardation, neurodevelopmental disorders, uncorrectable sensory handicaps, or
severe medical illnesses were excluded as indicated in the eligibility assessment. Also, participants that exhibited problems
understanding or reading Spanish or those without parental consent, were excluded. After a complete description of the
study, written informed consent was obtained from the adolescent, as well as from their parent or guardian. The University
Institutional Review Board approved the study.

Assessments

Substance Use Disorders. Information on alcohol use disorder (AUD), as well as other substance use disorders, was collected
with an expanded version of the relevant sections of the Structured Clinical Interview for DSM-IV Axis I Disorder (clinician
version) (SCID-I), a semi-structured diagnostic interview based on an efficient but thorough clinical evaluation (First, Gibbon,
William, & Benjamin, 1997).
Structured Clinical Interview for DSM-III-R, including additional items for DSM-IV was used. For each symptom, ages of
onset were recorded to the nearest month. The interviewers had Master-level education in mental health related fields, and
were individually trained to obtain over 90% agreement with an experienced interviewer.
The alcohol pattern of abusive consumption was assessed with AUDIT (Alcohol Use Disorders Identification Test) in its
Spanish validation by Rubio, Bermejo Vicedo, and Santo-Domingo Carrasco (1998) The test has 10 items and is considered
as a highly reliable, sensible and specific instrument for screening abuse and alcohol dependence (Rubio et al., 1998).
The Personal Experience Inventory (PEI) of maltreatment (Winters & Henly, 1989) was administered. This is an instrument
designed for adolescents that includes dimensions such as severity of the dependence, start of consumption, personal risk
factors, environmental risks, traumatic events or behaviors related to simulation and falsehood.

Mental Disorder Diagnoses. Other mental disorder diagnoses were determined using a version of the Schedule for Affective
Disorders and Schizophrenia for School Age Children (K-SADS) (Kaufman et al., 1997). These interviews were conducted with
the adolescent and one parent. Diagnoses were made by consensus among the interviewer, the assessment coordinator, and
a clinically experienced faculty psychiatrist or clinical psychologist.

Maltreatment. Maltreatment was assessed through the CTQ (Childhood Trauma Questionnaire) (Bernstein & Fink, 1998), a 28-
item questionnaire that evaluates the existence of different types of maltreatment: physical abuse (PA), sexual abuse (SA),
emotional abuse (EA), physical neglect (PN) and emotional neglect (EN). Positive reports of maltreatment were considered
when obtaining more than 5 points in every sub-scale. Severity of maltreatment was determined by punctuation in every
sub-scale.
382 M.J. Alvarez-Alonso et al. / Child Abuse & Neglect 51 (2016) 379–389

Psychological Assessments. The Multidimensional Anxiety Scale for Children (MACS) (March, Parker, Sullivan, Stallings, &
Conners, 1997), was constructed to assess four theoretically meaningful domains of anxiety symptoms: affective, physi-
cal, cognitive, and behavioral, within the dimensions of childhood anxiety: physical symptoms, social anxiety, separation
anxiety, and harm avoidance.
The Children Depression Inventory (CDI), which is designed to be used in a normal adolescent sample or as a measure of
symptom severity, was administered. It is useful for providing the clinician with structured, age and gender norm-referenced
information about the child’s symptomatology (Kovacs, 1981).

Statistics. Socio-demographic descriptive analyses of the sample were carried out in order to obtain the data used for preva-
lence examination of drug use, maltreatment incidence and psychiatric disorders frequencies. These socio-demographic
variables were presented as mean and standard deviations or relative and absolute frequencies. All characteristics were
stratified according to polydrug use; individuals showing a pattern of polyconsumption versus individuals that consume
one substance or none. Differences between groups of polydrug users and non-polydrug users were measured using Chi-
square or exact Fisher’s test. Comparisons of sample distribution of ordinal or continuous measures were conducted using
the suitable test, Wilcoxon–Mann–Whitney or Student’s t-test.
Logistic regression analyses were conducted in order to estimate the magnitude of the association between the variables
of polydrug use, socio-demographic characteristics, maltreatment types, psychiatric diagnoses and personality traits, in their
crude and adjusted by gender and age odd ratios. Eventually, a final model relating characteristics from subjects was carried
out. Interactions between variables were studied. Results are presented as Odd Ratios (OR) and 95% Confidence Intervals
(CI).
All statistical analyses were conducted using SPSS 19.0 for Windows.

Results

Descriptive data

Principal descriptive socio-demographic characteristics and prevalence of substance consumption and differences among
groups of participants: non-polydrug users and polydrug users are described in Table 1, in which we can observe that all
polydrug users were alcohol consumers and that few non-polydrug users consumed illicit drugs. Most common polydrug
use implied alcohol and cannabis use.
When looking for polydrug use among our sample of adolescents, we wanted to check whether most of the adolescents
exhibiting this type of consumption belonged to the clinical group, as it is known that persons involved in a clinical context
tend to have worst outcomes and to be involved in more consuming behaviors, psychopathological histories or personal
antecedents. When analyzing the characteristics of the polydrug-users, we found out that actually 69% of polydrug users
were from the clinical group, however, percentages of psychopathological conditions were similar among groups, with
the exception of ADHD (13.2% in clinical group and 2% in community group) and Eating Disorder (8.8% in clinical group
and 2% in community group). Family histories of alcoholism were also analogous (alcoholic father: 31.6% among clinical and
31.4% among community; alcoholic mother: 13.2% in clinical and 9.8% in community). Regarding maltreatment antecedents,
neglect records were alike in both groups although abuses were greater among the clinical group, especially concerning
sexual abuse, that was triple in this group.
Percentages of positive scorings in maltreatment types’ assessment are displayed in Table 2. Greater percentages of
maltreatment were found among polydrug users in every measured type of maltreatment; 10.6% of non-polydrug users had
a history of physical abuse, 18.8% of emotional abuse, 2.7% were victims of sexual abuse, 8.6% experienced physical neglect
and 48.8% emotional neglect. Among polydrug users, numbers are higher: 30.3% suffered physical abuse, 26.7% emotional
abuse and 27.3% sexual abuse. 29.7% experienced physical neglect and 63% emotional neglect.
Prevalence of descriptive data on psychiatric diagnoses and anxiety traits are shown in Table 3. Childhood trauma occur-
rence and psychopathological disorders were significantly more prevalent among polydrug users, as well as reports of
parents having alcohol dependence.

Bivariate Analyses

After conducting bivariate analyses in order to analyze polydrug use and the influence of modulating variables, all the
studied variables significantly predicted polydrug use in adolescents, OR, IC and p-value of these relations are displayed in
Table 4. Very strong relationships were found, i.e. the odds for polydrug abuse increased in more than 13 times when sexual
abuse was present (OR: 13.760; CI: 7.192–26.325; p = 0.000), more than 9 times when the individual had an alcoholic mother
(OR: 9.517; CI: 3.946–22.957; p = 0.000), or more than 8 times (OR: 8.116; CI: 4.490–14.672; p = 0.000) when a post-traumatic
stress disorder (PTSD) was diagnosed. When controlling for gender and age, the obtained odd ratios and confidence intervals
were similar for gender and for age group.
 M.J. Alvarez-Alonso et al. / Child Abuse & Neglect 51 (2016) 379–389 383

Table 1
Socio-demographic data and substance consumption records.

Socio-demographic variables Non-polydrug Poly-drug users t-Test df 2 p-Value

users (n = 490) (n = 165)

n % n %

Gender
Male 337 81.7 94 56.8 7.645 0.006
Female 153 18.3 71 4,302
Economic status
Low 438 124 20.53 0.000
Medium 52 41
Ages
13–19 16.6 ± 1.3 16.3 + 1.4 2.243 257.4 0.026
Education years
13–19 16.4 ± 1.3 16.4 ± 1.4 3.423 653 0.001
Tobacco
No 374 76.3 45 27.3 −12.829 261.9 0.000
Abuse 14 2.9 – –
Dependence 102 20.8 120 72.7
Alcohol
No 116 23.7 –
Abuse 363 74.1 137 83 −10.669 343.1 0.000
Dependence 11 2.2 28 17
Cannabis
No 489 99.8 23 13.9 −28.594 165.4 0.000
Abuse 1 0.2 137 89
Dependence – – 5 3
Cocaine
No 488 99.6 119 74.6 −7.398 165.5 0.000
Abuse 2 0.4 40 24.2
Dependence – – 6 3.6
Amphetamines
No 489 99.8 160 97 −2.087 171.6 0.038
Abuse 1 0.2 5 3
Sedatives
No – 0 – 0 −2.541 164.0 0.012
Abuse – 0 – 0
Other drugs
No 490 100 161 97.6 −2.019 164.0 0.045
Abuse – 0 4 2.4

Analyses of the Interaction of Variables

The combination of some maltreatment types with psychiatric diagnoses affected in different trends the risk of polydrug
use in adolescents. We observed that actual diagnose of PTSD Increased the risk of polydrug use in participants having
suffered PA and PN, meanwhile diagnose of ADHD increased the risk of polydrug use among adolescents with EA history.

Table 2
Maltreatment reports.

Non-polydrug users Polydrug users t-Test df p-Value

Physical Abuse (PA)


¯ (SD) 5.6 (2.6) 6.3 (2.8) 2.766 264.1 0.006
N (%) 52 (10.6) 50 (30.3)
Emotional Abuse (EA)

¯ (SD) 5.7 (1.7) 6.9 (4.9) −3.117 178.4 0.002
N (%) 92 (18.8) 44 (26.7)
Sexual Abuse (SA)

¯ (SD) 5.1 (0.6) 6.5 (3.4) −5.207 168.2 0.000
N (%) 13 (2.7) 45 (27.3)
Physical Neglect (PN)

¯ (SD) 5.5 (2.6) 6.5 (3.5) −3.303 229.6 0.001
N (%) 42 (8.6) 49 (29.7)
Emotional Neglect (EN)

¯ (SD) 6.7 (2.7) 8.9 (5.5) −4.881 191.8 0.000
N (%) 239 (48.8) 104 (63.0)
384 M.J. Alvarez-Alonso et al. / Child Abuse & Neglect 51 (2016) 379–389

Table 3
Psychopathology. Differences between groups.

Non-polydrug users Polydrug users t df  p-Value

N % Range N % Range

Depressive Disorder
Negative 449 91.6 120 72.7 38.68 0.000
Positive 41 8.4 45 27.3
Anxiety Disorders
Negative 450 91.8 131 79.4 19.07 0.000
Positive 40 8.2 34 20.6
Post-Traumatic Stress Disorder (PTSD)
Negative 472 96.3 126 76.4 61.914 0.000
Positive 18 3.7 39 23.6
Attention–Deficit Hyperactivity Disorder (ADHD)
Negative 474 96.8 149 90.3 10.988 0.003
Positive 16 3.2 16 9.7
Borderline Personality Disorder (BPD)
Negative 466 95.1 142 86.1 15.149 0.000
Positive 24 4.9 23 13.9
Eating Disorder (ED)
Negative 484 98.8 154 93.3 14.461 0.001
Positive 6 1.2 11 6.7
Other Disorders
Negative 490 100 162 98.2 0.016
Positive 0 0 3 1.8 8.95

Alcoholic Father
Negative 448 91.5 113 68.5 52.864 0.000
Positive 42 8.5 52 31.5
Alcoholic mother
Negative 483 98.6 145 87.9 35.708 0.000
Positive 7 1.4 20 12.1

Children Depression Inventory (CDI) 9.5 (2.5) (6–20) 11 (3.6) (7–24) 5.087 221.9 0.000
MASC Physical 9.23 (3.6) (4–27) 12.5 (5.3) (5–25) 7.21 218.3 0.000
MASC Social 7.6 (2.7) (4–18) 11 (4.02) (5–21) 10.06 215.4 0.000
MASC Harm-avoidance 9 (3.8) (4–15) 12.7 (4.9) (5–25) 10.2 232.8 0.000
MASC Separation anxiety 8.07 (3.3) (4–20) 10.4 (3.7) (4–22) 6.992 255.4 0.000

General Exploratory Model

After analyzing the effect of each variable separately, a general exploratory model was carried out, which yielded that
polydrug use was mainly influenced by several types of childhood maltreatment: SA, EN, PA and PN, diagnostics of depression,
and the report of a parent (mother or father) exhibiting problems with alcohol. Relevant data from MASC was slight. Table 5
reports odds and statistical values for each variable. Variability was explained by R2 = 0.500.

Table 4
Effect of studied variables on the polydrug use among adolescents.

Variables OR CI p-Value ORa CI p-Value

Sexual Abuse 13.760 7.192–26.325 0.000 14.515 7.233–29.127 0.000

Physical Abuse 3.662 2.361–5.682 0.000 4.595 2.882–7.326 0.000
Emotional Abuse 1.573 1.041–2.377 0.031 1.680 1.102–2.560 0.016
Physical Neglect 4.506 2.845–7.137 0.000 4.473 2.805–7.133 0.000
Emotional Neglect 1.791 1.246–2.572 0.002 1.916 1.324–2.773 0.001
Children depression Inventory 1.174 1.109–1.242 0.000 1.159 1.094–1.228 0.000
MASC Physical 1.166 1.121–1.214 0.000 1.166 1.120–1.214 0.000
MASC Social 1.328 1.255–1.406 0.000 1.321 1.248–1.399 0.000
MASC Harm-avoidance 1.202 1.153–1.254 0.000 1.208 1.157–1.260 0.000
MASC Separation anxiety 1.190 1.32–1.252 0.000 1.178 1.120–1.240 0.000
Depression Disorder 4.107 2.570–6.562 0.000 3.791 2.348–6.122 0.000
Anxiety Disorder 2.920 1.777–4.799 0.000 2.929 1.768–4.851 0.000
Post Traumatic Stress Disorder 8.116 4.490–14.672 0.000 8.40 4.608–15.314 0.000
Attention Deficit Hyperactivity Disorder 3.181 1.553–6.516 0.002 3.655 1.758–7.596 0.001
Borderline personality Disorder 3.145 1.723–5.742 0.000 2.934 1.589–5.416 0.001
Eating Disorder 5.762 2.096–15.837 0.001 4.876 1.712–13.886 0.003
Alcoholic father 4.909 3.111–7.744 0.000 5.523 3.450–8.842 0.000
Alcoholic mother 9.517 3.946–22.957 0.000 10.489 4.293–25.626 0.000
a
Adjusted by age and gender.
 M.J. Alvarez-Alonso et al. / Child Abuse & Neglect 51 (2016) 379–389 385

Table 5
General model of the different variables influencing polydrug use.

Polydrug-use OR CI p-Value

Sexual Abuse 16.384 5.487–48.924 0.000

Physical Abuse 2.957 1.462–5.978 0.003
Physical neglect 2.515 1.314–4.814 0.005
Emotional Neglect 11.608 5.538–24.332 0.000
MASC Social 1.501 1.333–1.691 0.000
MASC Harm avoidance 1.112 1.027–1.204 0.009
Depressive Disorder 2.301 1.157–4.576 0.018
Alcoholic father 2.382 1.243–4.564 0.009
Alcoholic mother 17.542 4.060–75.788 0.000

Discussion

Consumption of alcohol and other substances is recurrent among adolescents living in occidental countries. Great concern
about different patterns of consumption is highlighted over health professionals due to the elevated association between
youth consumption and later substance dependence disorders.
In our study, most relevant data were that the most associated variables explaining the risk for polydrug use were all
types of maltreatment, specifically sexual abuse and emotional neglect, also having a depression diagnosis and the existence
of a family history of alcoholism.
Consumption of substances was frequent in our sample; we observed that more than 75% of non-polydrug users were
alcohol consumers, thus high rates of consumption might seem related to the fact that our sample was taken from clinical
contexts (Winters et al., 2002), although that great prevalence of consumers was a similar to the found in the State surveys
conducted in our country among general population (ESTUDES, 2012–2013). Polydrug consumption was observed in 1 out
of 4 adolescents interviewed, coinciding with the rates found in a recent Danish study (Armour et al., 2014) regarding
patterns of polydrug use and maltreatment conducted among community adolescents, consequently, our sample seemed
to be representative.
When looking for polydrug use among our sample of adolescents, we wanted to check whether most of the adolescents
exhibiting this type of consumption belonged to the clinical group, as it is known that persons involved in a clinical context
tend to have worst outcomes and to be involved in more consuming behaviors, psychopathological histories or personal
antecedents. When analyzing the characteristics of the polydrug-users, we found out that actually 69% of polydrug users
were from the clinical group, however, percentages of psychopathological conditions were similar among groups, with the
exception of ADHD and Borderline Personality Disorder, higher in the clinical group. Family histories of alcoholism were also
analogous. Regarding maltreatment antecedents, neglect records were alike in both groups although abuses were greater
among the clinical group, especially concerning sexual abuse, that was triple in this group.
Reports of maltreatment are large in our sample, as predicted. Emotional neglect was found to be in greater prevalence
in both groups assessed, and percentages of occurrence were observed to be higher than in other studies. By adolescence,
or even childhood, young people sometimes hurt themselves and misuse substances especially when victimization is part
of their background. Then mental health problems are more likely to appear and there is an increased risk of polydrug use
(Biehal, 2005), adolescents frequently use alcohol and other drugs to cope and manage emotions. Chances of unsupervised
or unrestricted access to alcohol will have negative consequences to those adolescents (Foley, Altman, Durant, & Wolfson,
2004) but has not been studied among all reviewed researches, with some exceptions like the relation between adolescents
and binge drinking from Shin et al. (2013).
Physical and sexual abuse are the types of maltreatment that predicted later substance consumption in many studies
(Moran, Vuchinich, & Hall, 2004), although our data showed that not just SA but also EN were the most influencing mal-
treatment types for polydrug use. The presence of SA and EN increased 16 and 11-fold, respectively, the odds for polydrug
use in those individuals who suffered them. Shin et al. (2010) have previously reported the relation between SA and poly-
consumption in girls that had been maltreated in their childhood. The present study found a connection between polydrug
abuse and every type of maltreatment, even when controlling for age and gender. Nevertheless, EN has not frequently been
reported to predict substance consumption, the results observed from our sample may be related to the high prevalence
of familiar history of alcoholism that was discovered. Children raised in homes with alcoholic parents are more prompt to
experience traumatic situations that usually include feelings of abuse and neglect, thus, the connections between neglect
and substance use disorders among parents may be in relation to the high values of EN and the relationship of this type of
maltreatment and a worrying pattern of drug consumption.
All types of childhood maltreatment were predictors of substance polydrug use with the exception of EA, a probable reason
for this finding is that EA is always associated with other types of maltreatment, and then analyses of the isolated variable
did not give evidence of the connection between substance use and childhood maltreatment. This aspect was somehow
unexpected, as adverse emotional circumstances are known to be strong influences for behavior and decision making in
adolescence (Afifi et al., 2008; Arata et al., 2007; Green et al., 2010), although these results are in line with literature that
usually find PA and SA as predictors of drug consumption (Moran et al., 2004) and do not link emotional abuses with higher
likelihoods of substance consumption among adolescents.
386 M.J. Alvarez-Alonso et al. / Child Abuse & Neglect 51 (2016) 379–389

Additionally, higher percentages of psychopathology were expected (Hussey, Chang, & Kotch, 2006), since our clinical
sample was mainly composed of adolescents abusing substances and it is known that psychopathology and alcohol abuse
are commonly related. Different studies estimate an increase of up to 3 times the lifelong alcohol consumption after mal-
treatment (Dinwiddie et al., 2000; Fergusson, Lynskey, & Horwood, 1996; Kendler et al., 2000; Molnar et al., 2001; Nelson
et al., 2002), in both community (Kilpatrick et al., 2000; Moran et al., 2004) and clinical samples (Moncrieff & Farmer, 1998;
Simpson & Miller, 2002). Thus, high percentages of dual pathology diagnoses are common among individuals that con-
sume; among our sample of adolescents, diagnoses of psychopathology were high, above all in the polyconsumption group,
corroborating data found in the literature.
Depressive disorders and anxiety disorders were higher in the polydrug use group, probably because psychiatric conse-
quences that result from childhood maltreatment are commonly found to be worst when maltreatment experiences are more
severe, since psychological sequels of those experiences will be stronger (Arnow, 2004) as well as measures of consump-
tion (Copeland, Shanahan, Costello, & Angold, 2011; Dube et al., 2005; Romano & De Luca, 2001). Furthermore, substance
consumption is common in depressed children and adolescents (Hussong & Hicks, 2003; King & Chassin, 2004; Pardini,
Lochman, & Wells, 2004).
Distinct anxiety traits are also related to substance consumption and measure different possible consequences in the
behaviors and patterns of consumption. Higher scores in harm avoidance are associated with individuals that reject risk
taking (Kaplow, Curran, Angold, & Costello, 2001; Wills, Sandy, & Shinar, 1999), and high scores in social anxiety are related
to greater risk behaviors (Kashdan, Elhai, & Frueh, 2006) as behaviors of abuse and polydrug consumption.
In the data analyses, the presence of an alcoholic parent was related with an increased risk for polyconsumption. Children
of alcoholic parents are more vulnerable to alcohol consumption, probably due to genetic aspects, the risk for imitation of
observed behaviors and the greater likelihood they have to become victims of maltreatment (Gilbert et al., 2009; Johnson &
Leff, 1999; Laslett, Room, Dietze, & Ferris, 2012). They are more prompt to the abuse of drugs and other psychiatric diseases,
although it is not clear if those risks would be the same if socio-demographic factors were different (Diaz et al., 2008; Dube
et al., 2001). It was observed that an alcoholic father and, above all, an alcoholic mother are strong predictors of polydrug
use during adolescence; alcoholism in the family carries a negative impact in children’s lives, as homes are usually chaotic,
dysfunctional and surrounded in many occasions by violence and abuse (Dube et al., 2002). The American Social Services
estimate that in approximately 30% of the cases of childhood maltreatment an alcoholic parent is involved, and in more than
half of violent acts one of the parents was under the effects of alcohol (Collins, Ellickson, & Bell, 1998). Family history of drug
and alcohol dependence together with neglect are indeed a additive risk factors hard to separate, nevertheless, we conducted
an analysis of data in which adolescents having suffered from neglect, and whose parents were not alcohol-dependent, were
compared to adolescents having both risk factors, and the results were the same.
From our point of view, and taking into consideration the observed results, we may hypothesize that adolescents that
had lived stressful situations in their childhood (Aseltine & Gore, 2000; Wills, Sandy, Yaeger, Cleary, & Shinar, 2001) may
be searching for the positive effects they find in drug consumption in order to reduce stress, to handle problems related to
adverse experiences and to deal with the typical adolescent difficulties (Wisdom & Green, 2004). The suffered stress may
affect reward brain circuits and then increase vulnerability to drug abuse (Aseltine & Gore, 2000; De Bellis, 2002). This is
why some paradigms suggest the use of alcohol and other drugs as auto-medication (Donovan & Jessor, 1985) and way to
cope with emotions (Hussong, Jones, Stein, Baucom, & Boeding, 2011).
But not all who report maltreatment present psychological difficulties in their adulthood. Consequences are matched
to how individuals perceive, assume and process their lived circumstances (Williams & Smith, 1993). The duration, the
frequency (Keyes, Hatzenbuehler, Grant, & Hasin, 2012), the age in which maltreatment occurred and the authorship of the
maltreatment (Crowley & Seery, 2001; Johnson, Pike, & Chard, 2001; Ruggiero, McLeer, & Dixon, 2000), plus the quality of the
adolescent’s social relationships (Kidd, Hamer, & Steptoe, 2011) are important factors that impact in the personal response
to stress and future consequences.

Limitations

Prevalence of maltreatment has a strong dependence on some factors such as social desirability during assessment, time,
severity of maltreatment and closure to the perpetrator (Hardt & Rutter, 2004; Widom, Ireland, & Glynn, 1995; Widom, White,
Czaja, & Marmorstein, 2007). Socio-demographic characteristics between the groups differed significantly even though were
statistically controlled. The variable age was found to differ between groups although this difference is not relevant to the
conclusions of our research. The fact that our sample was composed by adolescents seeking treatment limits the extrapolation
to other populations of consumers. Accounting that participants went to consultation accompanied by a relative, it is possible
that only less severe maltreatment cases accepted to complete the study, and that those who perpetrated maltreatment were
not their family members. Furthermore, retrospective collection of data has the risk to enlarge or reduce past experiences.

Conclusions

To our knowledge, this is the first study conducted on a Mediterranean sample, in which more than 650 adolescents from
a clinical population, including individuals that seek treatment on account of problems related with consumption, were
assessed through clinical interviews.
 M.J. Alvarez-Alonso et al. / Child Abuse & Neglect 51 (2016) 379–389 387

Psychopathological conditions, maltreatment and vulnerability to anxiety are directly related to alcohol use in adolescents
(Lammers, Kuntsche, Engels, Wiers, & Kleinjan, 2013), and in the exploration of our data, we found that maltreatment
experiences in childhood and psychiatric diagnoses were very common among clinical samples of adolescents, but it was in
relation to the pattern of consumption (polydrug abuse versus non-polydrug abuse) where we could distinguish between
associations and variables that could mediate in the process of drinking and drug consumption.
Taking into account the results from our study, we suggest that, when clinicians are facing the challenge of treating
an adolescent with a pattern of polydrug use, it is important to look into the history of maltreatment, the existence of
psychopathology and family antecedents of alcoholism that may be influencing drug consumption, and may be important
variables to consider to manage treatment. Reducing early onset consumption and giving strategies to manage emotions
and adverse experiences is important. Great proportions of adolescent consumers of substances are significant consumers in
their adulthood, and will suffer a SUD at some point, thus helping adolescents before their level of consumption is elevated
is a great challenge that we aim to achieve with the help of studies like ours.

Acknowledgements

We would like to thank all participants and practitioners that contributed to it.

References

Afifi, T. O., Enns, M. W., Cox, B. J., Asmundson, G. J., Stein, M. B., & Sareen, J. (2008). Population attributable fractions of psychiatric disor-
ders and suicide ideation and attempts associated with adverse childhood experiences. American Journal of Public Health, 98(5), 946–952.
http://dx.doi.org/10.2105/ajph.2007.120253
Afifi, T. O., Henriksen, C. A., Asmundson, G. J., & Sareen, J. (2012). Childhood maltreatment and substance use disorders among men and women in a nationally
representative sample. Canadian Journal of Psychiatry, 57(11), 677–686.
Arata, C. M., Langhinrichsen-Rohling, J., Bowers, D., & O’Brien, N. (2007). Differential correlates of multi-type maltreatment among urban youth. Child Abuse
and Neglect, 31(4), 393–415. http://dx.doi.org/10.1016/j.chiabu.2006.09.006
Armour, C., Shorter, G. W., Elhai, J. D., Elklit, A., & Christoffersen, M. N. (2014). Polydrug use typologies and childhood maltreatment in a nationally
representative survey of Danish young adults. Journal of Studies on Alcohol and Drugs, 75(1), 170–178.
Arnow, B. A. (2004). Relationships between childhood maltreatment, adult health and psychiatric outcomes, and medical utilization. Journal of Clinical
Psychiatry, 65(Suppl 12), 10–15.
Aseltine, R., Jr., & Gore, S. (2000). The variable effects of stress on alcohol use from adolescence to early adulthood. Substance Use and Misuse, 35(5), 643–668.
Bernstein, D. P., & Fink, L. (1998). Childhood Trauma Questionnaire: A retrospective self-report manual. San Antonio, TX: Harcourt Brace & Company.
Biehal, N. (2005). Working with adolescents: Supporting families, preventing breakdown.
Bierer, L. M., Yehuda, R., Schmeidler, J., Mitropoulou, V., New, A. S., Silverman, J. M., & Siever, L. J. (2003). Abuse and neglect in childhood: Relationship to
personality disorder diagnoses. CNS Spectrums, 8(10), 737–754.
Clark, D. B., De Bellis, M. D., Lynch, K. G., Cornelius, J. R., & Martin, C. S. (2003). Physical and sexual abuse, depression and alcohol use disorders in adolescents:
Onsets and outcomes. Drug and Alcohol Dependence, 69(1), 51–60.
Collins, R. L., Ellickson, P. L., & Bell, R. M. (1998). Simultaneous polydrug use among teens: Prevalence and predictors. Journal of Substance Abuse, 10(3),
233–253.
Copeland, W., Shanahan, L., Costello, E. J., & Angold, A. (2011). Cumulative prevalence of psychiatric disorders by young adulthood: A prospec-
tive cohort analysis from the Great Smoky Mountains Study. Journal of the American Academy of Child and Adolescent Psychiatry, 50(3), 252–261.
http://dx.doi.org/10.1016/j.jaac.2010.12.014
Crowley, M. S., & Seery, B. L. (2001). Exploring the multiplicity of childhood sexual abuse with a focus on polyincestuous contexts of abuse. J of Child Sexual
Abuse, 10(4), 91–110.
Darke, S., & Torok, M. (2014). The association of childhood physical abuse with the onset and extent of drug use among regular injecting drug users. Addiction,
109(4), 610–616. http://dx.doi.org/10.1111/add.12428
De Bellis, M. D. (2002). Developmental traumatology: A contributory mechanism for alcohol and substance use disorders. Psychoneuroendocrinology, 27(1–2),
155–170.
Diaz, R., Gual, A., Garcia, M., Arnau, J., Pascual, F., Canuelo, B., & Garbayo, I. (2008). Children of alcoholics in Spain: From risk to pathology. Results from the
ALFIL program. Social Psychiatry and Psychiatric Epidemiology, 43(1,), 1–10. http://dx.doi.org/10.1007/s00127-007-0264-2
Dinwiddie, S., Heath, A. C., Dunne, M. P., Bucholz, K. K., Madden, P. A., Slutske, W. S., & Martin, N. G. (2000). Early sexual abuse and lifetime psychopathology:
A co-twin-control study. Psychological Medicine, 30(1), 41–52.
Donovan, J. E., & Jessor, R. (1985). Structure of problem behavior in adolescence and young adulthood. Journal of Consulting and Clinical Psychology, 53(6),
890–904.
Dube, S. R., Anda, R. F., Felitti, V. J., Croft, J. B., Edwards, V. J., & Giles, W. H. (2001). Growing up with parental alcohol abuse: Exposure to childhood abuse,
neglect, and household dysfunction. Child Abuse and Neglect, 25(12), 1627–1640.
Dube, S. R., Anda, R. F., Felitti, V. J., Edwards, V. J., & Croft, J. B. (2002). Adverse childhood experiences and personal alcohol abuse as an adult. Addictive
Behaviors, 27(5), 713–725.
Dube, S. R., Anda, R. F., Whitfield, C. L., Brown, D. W., Felitti, V. J., Dong, M., & Giles, W. H. (2005). Long-term consequences of childhood sexual abuse by
gender of victim. American Journal of Preventive Medicine, 28(5), 430–438. http://dx.doi.org/10.1016/j.amepre.2005.01.015
Dube, S. R., Miller, J. W., Brown, D. W., Giles, W. H., Felitti, V. J., Dong, M., & Anda, R. F. (2006). Adverse childhood experiences and the association with ever
using alcohol and initiating alcohol use during adolescence. Journal of Adolescent Health, 38(4), 444. http://dx.doi.org/10.1016/j.jadohealth.2005.06.006,
e441–410
Enoch, M. A., Hodgkinson, C. A., Yuan, Q., Albaugh, B., Virkkunen, M., & Goldman, D. (2009). GABRG1 and GABRA2 as independent predictors for alcoholism
in two populations. Neuropsychopharmacology, 34(5), 1245–1254. http://dx.doi.org/10.1038/npp.2008.171
ESPAD. (2011). ESPAD. The European School Survey project on alcohol and other drugs. Retrieved from http://www.espad.org/
en/Reports–Documents/ESPAD-Reports/
ESTUDES. (2012–2013). Encuesta Estatal Sobre Uso De Drogas En Enseñanzas Secundarias en España. Retrieved from http://www.pnsd.msc.es/
Categoria2/observa/pdf/PresentESTUDES2012 2013.pdf
European Monitoring Centre for Drugs and Drug Addiction. (2009). Polydrug use: patterns and responses. Retrieved from www.emcdda.europa.eu
Fergusson, D. M., Boden, J. M., & Horwood, L. J. (2008). Exposure to childhood sexual and physical abuse and adjustment in early adulthood. Child Abuse and
Neglect, 32(6), 607–619. http://dx.doi.org/10.1016/j.chiabu.2006.12.018
388 M.J. Alvarez-Alonso et al. / Child Abuse & Neglect 51 (2016) 379–389

Fergusson, D. M., Lynskey, M. T., & Horwood, L. J. (1996). Childhood sexual abuse and psychiatric disorder in young adulthood: I. Prevalence of
sexual abuse and factors associated with sexual abuse. Journal of the American Academy of Child and Adolescent Psychiatry, 35(10), 1355–1364.
http://dx.doi.org/10.1097/00004583-199610000-00023
First, M., Gibbon, M., William, S. J., & Benjamin, L. S. (Eds.). (1997). Structured Clinical Interviewfor DSM-III Axis I Disorders-Clinical Version (SCID-CV).
Washington, DC: American Psychiatric Press.
Foley, K. L., Altman, D., Durant, R. H., & Wolfson, M. (2004). Adults’ approval and adolescents’ alcohol use. Journal of Adolescent Health, 35(4), 345, e317–e326.
Font-Mayolas, S., Gras, M. E., Cebrian, N., Salamo, A., Planes, M., & Sullman, M. J. (2013). Types of polydrug use among Spanish adolescents. Addictive
Behaviors, 38(3), 1605–1609. http://dx.doi.org/10.1016/j.addbeh.2012.09.007
Gilbert, R., Widom, C. S., Browne, K., Fergusson, D., Webb, E., & Janson, S. (2009). Burden and consequences of child maltreatment in high-income countries.
Lancet, 373(9657), 68–81. http://dx.doi.org/10.1016/s0140-6736(08)61706-7
Goldstein, A. L., Faulkner, B., & Wekerle, C. (2013). The relationship among internal resilience, smoking, alcohol use, and depression symptoms in emerging
adults transitioning out of child welfare. Child Abuse and Neglect, 37(1), 22–32. http://dx.doi.org/10.1016/j.chiabu.2012.08.007
Green, J. G., McLaughlin, K. A., Berglund, P. A., Gruber, M. J., Sampson, N. A., Zaslavsky, A. M., & Kessler, R. C. (2010). Childhood adversities and adult
psychiatric disorders in the national comorbidity survey replication I: Associations with first onset of DSM-IV disorders. Archives of General Psychiatry,
67(2), 113–123. http://dx.doi.org/10.1001/archgenpsychiatry.2009.186
Hardt, J., & Rutter, M. (2004). Validity of adult retrospective reports of adverse childhood experiences: Review of the evidence. Journal of Child Psychology
and Psychiatry and Allied Disciplines, 45(2), 260–273.
Hodgins, S., Lovenhag, S., Rehn, M., & Nilsson, K. W. (2013). A 5-year follow-up study of adolescents who sought treatment for substance misuse in Sweden.
European Child & Adolescent Psychiatry, http://dx.doi.org/10.1007/s00787-013-0456-0
Huang, S., Trapido, E., Fleming, L., Arheart, K., Crandall, L., French, M., & Prado, G. (2011). The long-term effects of childhood maltreat-
ment experiences on subsequent illicit drug use and drug-related problems in young adulthood. Addictive Behaviors, 36(1–2), 95–102.
http://dx.doi.org/10.1016/j.addbeh.2010.09.001
Hussey, J. M., Chang, J. J., & Kotch, J. B. (2006). Child maltreatment in the United States: Prevalence, risk factors, and adolescent health consequences.
Pediatrics, 118(3), 933–942. http://dx.doi.org/10.1542/peds.2005-2452
Hussong, A. M., & Hicks, R. E. (2003). Affect and peer context interactively impact adolescent substance use. Journal of Abnormal Child Psychology, 31(4),
413–426.
Hussong, A. M., Jones, D. J., Stein, G. L., Baucom, D. H., & Boeding, S. (2011). An internalizing pathway to alcohol use and disorder. Psychology of Addictive
Behavior, 25(3), 390–404. http://dx.doi.org/10.1037/a0024519
Hyucksun Shin, S. (2012). A longitudinal examination of the relationships between childhood maltreatment and patterns of adolescent substance use
among high-risk adolescents. American Journal on Addictions, 21(5), 453–461. http://dx.doi.org/10.1111/j.1521-0391.2012.00255.x
Johnson, D., Pike, J. L., & Chard, K. M. (2001). Factors predicting PTSD, depression, and dissociative severity in female treatment-seeking childhood sexual
abuse survivors. Child Abuse and Neglect, 25(1), 179–198.
Johnson, J., & Leff, M. (1999). Children of substance abusers: Overview of research findings. Pediatrics, 103(5 Pt 2), 1085–1099.
Johnston, L., O’Malley, P. M., Bachman, J. G., & Schulenberg, J. E. (2012). Monitoring the Future National Survey results on drug use, 1975–2011. In Vol. I:
Secondary school students.
Kaplow, J. B., Curran, P. J., Angold, A., & Costello, E. J. (2001). The prospective relation between dimensions of anxiety and the initiation of adolescent alcohol
use. Journal of Clinical Child Psychology, 30(3), 316–326. http://dx.doi.org/10.1207/s15374424jccp3003 4
Kashdan, T. B., Elhai, J. D., & Frueh, B. C. (2006). Anhedonia and emotional numbing in combat veterans with PTSD. Behaviour Research and Therapy, 44(3),
457–467. http://dx.doi.org/10.1016/j.brat.2005.03.001
Kaufman, J., Birmaher, B., Brent, D., Rao, U., Flynn, C., Moreci, P., & Ryan, N. (1997). Schedule for Affective Disorders and Schizophrenia for School-Age Children-
Present and Lifetime Version (K-SADS-PL): Initial reliability and validity data. Journal of the American Academy of Child and Adolescent Psychiatry, 36(7),
980–988. http://dx.doi.org/10.1097/00004583-199707000-00021
Kendler, K. S., Bulik, C. M., Silberg, J., Hettema, J. M., Myers, J., & Prescott, C. A. (2000). Childhood sexual abuse and adult psychiatric and substance use
disorders in women: An epidemiological and cotwin control analysis. Archives of General Psychiatry, 57(10), 953–959.
Keyes, K. M., Hatzenbuehler, M. L., Grant, B. F., & Hasin, D. S. (2012). Stress and alcohol: Epidemiologic evidence. Alcohol Research, 34(4), 391–400.
Kidd, T., Hamer, M., & Steptoe, A. (2011). Examining the association between adult attachment style and cortisol responses to acute stress. Psychoneuroen-
docrinology, 36(6), 771–779. http://dx.doi.org/10.1016/j.psyneuen.2010.10.014
Kilpatrick, D. G., Acierno, R., Saunders, B., Resnick, H. S., Best, C. L., & Schnurr, P. P. (2000). Risk factors for adolescent substance abuse and dependence: Data
from a national sample. Journal of Consulting and Clinical Psychology, 68(1), 19–30.
King, K. M., & Chassin, L. (2004). Mediating and moderated effects of adolescent behavioral undercontrol and parenting in the prediction of drug use
disorders in emerging adulthood. Psychology of Addictive Behavior, 18(3), 239–249. http://dx.doi.org/10.1037/0893-164x.18.3.239
Kovacs, M. (1981). Rating scales to assess depression in school-aged children. Acta Paedopsychiatrica, 46(5–6), 305–315.
Lake, S., Wood, E., Dong, H., Dobrer, S., Montaner, J., & Kerr, T. (2014). The impact of childhood emotional abuse on violence among people who inject drugs.
Drug and Alcohol Review, http://dx.doi.org/10.1111/dar.12133
Lammers, J., Kuntsche, E., Engels, R. C., Wiers, R. W., & Kleinjan, M. (2013). Mediational relations of substance use risk profiles, alcohol-
related outcomes, and drinking motives among young adolescents in the Netherlands. Drug and Alcohol Dependence, 133(2), 571–579.
http://dx.doi.org/10.1016/j.drugalcdep.2013.07.030
Laslett, A. M., Room, R., Dietze, P., & Ferris, J. (2012). Alcohol’s involvement in recurrent child abuse and neglect cases. Addiction, 107(10), 1786–1793.
http://dx.doi.org/10.1111/j.1360-0443.2012.03917.x
Lo, C. C., & Cheng, T. C. (2007). The impact of childhood maltreatment on young adults’ substance abuse. American Journal of Drug and Alcohol Abuse, 33(1),
139–146. http://dx.doi.org/10.1080/00952990601091119
March, J. S., Parker, J. D., Sullivan, K., Stallings, P., & Conners, C. K. (1997). The Multidimensional Anxiety Scale for Children (MASC): Factor structure, reliability,
and validity. Journal of the American Academy of Child and Adolescent Psychiatry, 36(4), 554–565. http://dx.doi.org/10.1097/00004583-199704000-00019
Molnar, B. E., Buka, S. L., & Kessler, R. C. (2001). Child sexual abuse and subsequent psychopathology: Results from the National Comorbidity Survey.
American Journal of Public Health, 91(5), 753–760.
Moncrieff, J., & Farmer, R. (1998). Sexual abuse and the subsequent development of alcohol problems. Alcohol and Alcoholism, 33(6), 592–601.
Moran, P., Vuchinich, S., & Hall, N. (2004). Associations between types of maltreatment and substance use during adolescence. Child Abuse and Neglect,
28(5), 565–574. http://dx.doi.org/10.1016/j.chiabu.2003.12.002
Nelson, B. S., & Wampler, K. S. (2002). Further understanding the systemic effects of childhood sexual abuse: A comparison of two groups of clinical couples.
Journal of Child Sexual Abuse, 11(3), 85–106.
Nelson, E., Heath, A. C., Madden, P. A., Cooper, M. L., Dinwiddie, S. H., Bucholz, K. K., & Martin, N. G. (2002). Association between self-reported childhood
sexual abuse and adverse psychosocial outcomes: Results from a twin study. Archives of General Psychiatry, 59(2), 139–145.
Pardini, D., Lochman, J., & Wells, K. (2004). Negative emotions and alcohol use initiation in high-risk boys: The moderating effect of good inhibitory control.
Journal of Abnormal Child Psychology, 32(5), 505–518.
Pilowsky, D. J., Keyes, K. M., & Hasin, D. S. (2009). Adverse childhood events and lifetime alcohol dependence. American Journal of Public Health, 99(2),
258–263. http://dx.doi.org/10.2105/ajph.2008.139006
Romano, E., & De Luca, R. (2001). Male sexual abuse: A review of effects, abuse characteristics, and links with later psychological functioning. Aggression
and Violent Behavior, 6, 55–78.
 M.J. Alvarez-Alonso et al. / Child Abuse & Neglect 51 (2016) 379–389 389

Rothman, E. F., Edwards, E. M., Heeren, T., & Hingson, R. W. (2008). Adverse childhood experiences predict earlier age of drinking onset: Results from a
representative US sample of current or former drinkers. Pediatrics, 122(2), e298–e304. http://dx.doi.org/10.1542/peds.2007-3412
Rubio, G., Bermejo Vicedo, J., & Santo-Domingo Carrasco, C. S.-S. M. J. (1998). Validación de la Prueba para la Identificación de Transtornos por Uso de Alcohol
(AUDIT) en Atención Primaria. Revista Clínica Española, 198(1), 11–14.
Ruggiero, K. J., McLeer, S. V., & Dixon, J. F. (2000). Sexual abuse characteristics associated with survivor psychopathology. Child Abuse and Neglect, 24(7),
951–964.
Shin, S. H., Edwards, E. M., & Heeren, T. (2009). Child abuse and neglect: Relations to adolescent binge drinking in the national longitudinal study of
Adolescent Health (AddHealth) Study. Addictive Behaviors, 34(3), 277–280. http://dx.doi.org/10.1016/j.addbeh.2008.10.023
Shin, S. H., Hong, H. G., & Hazen, A. L. (2010). Childhood sexual abuse and adolescent substance use: A latent class analysis. Drug and Alcohol Dependence,
109(1–3), 226–235. http://dx.doi.org/10.1016/j.drugalcdep.2010.01.013
Shin, S. H., Hong, H. G., & Wills, T. A. (2012). An examination of pathways from childhood maltreatment to adolescent binge drinking. American Journal on
Addictions, 21(3), 202–209. http://dx.doi.org/10.1111/j.1521-0391.2012.00227.x
Shin, S. H., Miller, D. P., & Teicher, M. H. (2013). Exposure to childhood neglect and physical abuse and developmental trajectories of heavy episodic drinking
from early adolescence into young adulthood. Drug and Alcohol Dependence, 127(1–3), 31–38. http://dx.doi.org/10.1016/j.drugalcdep.2012.06.005
Simpson, T. L., & Miller, W. R. (2002). Concomitance between childhood sexual and physical abuse and substance use problems. A review. Clinical Psychology
Review, 22(1), 27–77.
Wekerle, C., Leung, E., Goldstein, A., Thornton, T., & Tonmyr, L. (2009). Substance use among adolescents in child welfare versus adolescents in the general
population: A comparison of the Maltreatment and Adolescent Pathways (MAP) longitudinal study and the Ontario Student Drug Use Survey (OSDUS) datasets.
White, H. R., & Widom, C. S. (2008). Three potential mediators of the effects of child abuse and neglect on adulthood substance use among women. Journal
of Studies on Alcohol and Drugs, 69(3), 337–347.
WHO. (2009). Global health risks: Mortality and burden of disease attributable to selected major risks. World Health Organization. Retrieved from
http://www.who.int/healthinfo/global burden disease/GlobalHealthRisks report full.pdf
WHO. (2014). Alcohol. Media centre: Fact sheet. Retrieved from http://www.who.int/mediacentre/factsheets/fs349/en/
Widom, C., DuMont, K., & Czaja, S. J. (2007). A prospective investigation of major depressive disorder and comorbidity in abused and neglected children
grown up. Archives of General Psychiatry, 64(1), 49–56. http://dx.doi.org/10.1001/archpsyc.64.1.49
Widom, C., Ireland, T., & Glynn, P. J. (1995). Alcohol abuse in abused and neglected children followed-up: Are they at increased risk? Journal of Studies on
Alcohol, 56(2), 207–217.
Widom, C. S., White, H. R., Czaja, S. J., & Marmorstein, N. R. (2007). Long-term effects of child abuse and neglect on alcohol use and excessive drinking in
middle adulthood. Journal of Studies on Alcohol and Drugs, 68(3), 317–326.
Williams, J. G., & Smith, J. P. (1993). Alcohol and other drug use among adolescents: Family and peer influences. Journal of Substance Abuse, 5(3), 289–294.
Wills, T. A., Sandy, J. M., & Shinar, O. (1999). Cloninger’s constructs related to substance use level and problems in late adolescence: A mediational model
based on self-control and coping motives. Experimental and Clinical Psychopharmacology, 7(2), 122–134.
Wills, T. A., Sandy, J. M., Yaeger, A. M., Cleary, S. D., & Shinar, O. (2001). Coping dimensions, life stress, and adolescent substance use: A latent growth analysis.
Journal of Abnormal Psychology, 110(2), 309–323.
Winters, K. C., & Henly, G. A. (1989). Personal Experience Inventory test and manual. Los Angeles.
Winters, K. C., Latimer, W. W., & Stinchfield, R. (2002). Clinical issues in the assessment of adolescent alcohol and other drug use. Behaviour Research and
Therapy, 40(12), 1443–1456.
Wisdom, J. P., & Green, C. A. (2004). “Being in a funk”: Teens’ efforts to understand their depressive experiences. Qualitative Health Research, 14(9), 1227–1238.
http://dx.doi.org/10.1177/1049732304268657
Young-Wolff, K. C., Kendler, K. S., Ericson, M. L., & Prescott, C. A. (2011). Accounting for the association between childhood maltreatment and alcohol-use
disorders in males: A twin study. Psychological Medicine, 41(1), 59–70. http://dx.doi.org/10.1017/s0033291710000425