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Adverse Childhood Experiences and Subsequent Substance Abuse

in a Sample of Sexual Offenders: Implications for Treatment and

Prevention

Article  in  Victims and Offenders · January 2015

DOI: 10.1080/15564886.2014.971478

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Barry University

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Adverse Childhood Experiences and
Subsequent Substance Abuse in a Sample
of Sexual Offenders: Implications for
Treatment and Prevention
Jill Levensona
a School of Social Work, Barry University, Miami Shores, Florida, USA
Published online: 09 Jan 2015.

To cite this article: Jill Levenson (2015): Adverse Childhood Experiences and Subsequent Substance
Abuse in a Sample of Sexual Offenders: Implications for Treatment and Prevention, Victims
& Offenders: An International Journal of Evidence-based Research, Policy, and Practice, DOI:
10.1080/15564886.2014.971478

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Victims & Offenders, 00:1–26, 2015
Copyright © Taylor & Francis Group, LLC
ISSN: 1556-4886 print/1556-4991 online
DOI: 10.1080/15564886.2014.971478

Adverse Childhood
Experiences and Subsequent
Substance Abuse in a Sample
of Sexual Offenders:
Implications for Treatment
and Prevention

Jill Levenson

School of Social Work, Barry University, Miami Shores, Florida, USA

Abstract: The purpose of this study was to explore the prevalence of substance abuse
indicators in a sample of male sexual offenders (N = 679) and to examine the influence
of adverse childhood experiences (ACE) on the likelihood of substance abuse outcomes.
Half of these sex offenders reported a history of drug or alcohol abuse, and nearly
one in five reported a substance-related arrest. Higher ACE scores were associated
with endorsement of a greater number of substance-abuse-related problems, suggesting
that accumulation of early trauma may increase the likelihood for substance misuse.
By enhancing our understanding of the frequency and antecedents of dynamic risk fac-
tors such as substance abuse, we can better devise clinical interventions that respond
to the comprehensive needs of sexually abusive individuals and reduce risk for sexual
reoffense. As well, early interventions for at-risk families and maltreated youth may
interrupt their trajectory toward adulthood substance abuse and criminal behavior,
including sex offending.

Keywords: addiction, sex offenders, treatment, trauma

Substance abuse is associated with childhood trauma, and individuals who
grew up in homes where child maltreatment and household dysfunction were
common are at increased risk for substance-related disorders in adulthood
(Dube et al., 2001; Dube, Anda, Felitti, Edwards, & Croft, 2002; Dube et al.,

Address correspondence to Jill Levenson, School of Social Work, Barry University,
11300 NE 2nd Avenue, Miami Shores, FL 33161. E-mail: jlevenson@barry.edu

Color versions of one or more figures in the article can be found online at www.
tandfonline.com/uvao.

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2 J. Levenson

2003). Sex offenders have higher rates of adverse childhood experiences (ACE)
than males in the general population (Jespersen, Lalumière, & Seto, 2009;
Levenson, Willis, & Prescott, 2014; Reavis, Looman, Franco, & Rojas, 2013),
which can contribute to increased risks for drug and alcohol abuse. The current
study investigated the prevalence of substance abuse indicators in a sample
of male sexual offenders, and examined the influence of early adverse expe-
riences on the likelihood of substance abuse outcomes. It is expected that the
study can inform treatment protocols designed to reduce the risk of reoffending
for identified sexual abusers by better understanding the variables contribut-
ing to this empirically derived dynamic risk factor (Abracen & Looman, 2004;
Hanson & Harris, 1998; Långström, Sjöstedt, & Grann, 2004). As well, the
link between early adversity and substance abuse has implications for early
interventions that can reduce the risk of future criminality for child victims of
maltreatment.

ACE SCORES AND SUBSTANCE ABUSE

In one of the largest surveys examining childhood trauma in the general pop-
ulation, the Centers for Disease Control (CDC) studied 17,337 patients of a
health insurance program in the United States who completed the 10-item
Adverse Childhood Experiences (ACE) scale (Felitti et al., 1998). Among males,
the ACE study found substantial prevalence rates of child maltreatment,
defined as abuse (emotional = 8%, physical = 30%, and sexual = 16%) or
neglect (emotional = 12%, physical = 11%). The scale also measured rates
of household dysfunction (domestic violence = 12%, parents not married =
22%, or the presence of substance abuse [24%], mental illness [15%], or an
incarcerated member of the household [4%]). The ACE study provided com-
pelling evidence that child maltreatment and family dysfunction in American
households are common.

One’s ACE score reflects the number of different types of adverse child-
hood experiences experienced by the individual, and a higher score signifies
the accumulation of trauma. Multiple forms of child abuse and household
dysfunction often co-occur, and having experienced one adverse event sig-
nificantly increases the odds of reporting additional adverse events (Dong
et al., 2004). Numerous studies have consistently demonstrated the negative
impact of cumulative childhood trauma on behavioral, medical, and psychoso-
cial well-being in adulthood (Anda, Butchart, Felitti, & Brown, 2010; Briere
& Elliot, 2003; Felitti et al., 1998; Maschi, Baer, Morrissey, & Moreno, 2013).
As ACE scores increase, so does the risk for myriad adult troubles, includ-
ing chemical dependency, injection drug use, suicide attempts, depression,
smoking, heart and pulmonary diseases, fetal death, obesity, liver disease,
and intimate partner violence (Felitti et al., 1998). As well, ACE scores
are related to risky sexual behavior, including early initiation of sexual

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Adverse Childhood Experiences 3

activity, promiscuity, sexually transmitted diseases, and unintended preg-
nancies (Centers for Disease Control and Prevention, 2013a; Felitti et al.,
1998).

The ACE study had some important limitations, including the retro-
spective data collection and the inclusion of a relatively small domain of
maltreatment and family dysfunction variables. The ACE study may actu-
ally underestimate the prevalence of childhood trauma, since the sample was
highly educated and had health insurance—so impoverished and minority pop-
ulations were underrepresented. A nationally representative sample of over
4,000 children and their parents, conducted via a randomized household tele-
phone survey, revealed even higher rates of cumulative childhood trauma:
two-thirds of the children had been exposed to more than one type of vic-
timization and 30% experienced five or more (Finkelhor, Turner, Hamby, &
Ormrod, 2011). The deleterious consequences of polyvictimization were evident
in higher endorsements of trauma symptoms. Finkelhor, Shattuck, Turner,
and Hamby (2013) made attempts to improve the ACE scale by modifying
some items and adding additional domains of adversity (e.g., peer victimiza-
tion, community violence, illnesses and injuries, socioeconomic status) utilizing
nationally representative samples. They found that these modifications led to
more robust effects when measuring distress by trauma scores, but confirmed
that the child maltreatment items in the original ACE scale remained impor-
tant contributors to the cumulative stress of childhood adversity (Finkelhor
et al., 2013).

Chief among the sequelae of childhood trauma are substance abuse disor-
ders. ACE scores showed a strong graded relationship to younger initiation
of illicit drug use, any lifetime drug use, and drug addiction (Dube et al.,
2003). Moreover, having a parent who abused alcohol is highly associated
with other ACEs (Dube et al., 2001) and in turn heightens the risk for
having problematic drinking behaviors oneself in adulthood (Dube et al.,
2002). Alcohol and drug abuse is a significant problem in the United States
and is exacerbated by a history of trauma. In 2012, over 9% of individ-
uals over the age of 12 reported using an illicit drug at least once in
the past month, and 6.5% reporting heavy drinking at least five times in
the past month—with 23% revealing binge drinking (Substance Abuse and
Mental Health Services Administration, 2012b). According to the National
Epidemiologic Survey on Alcohol and Related Conditions, about 8.5% of
American adults meet criteria for an alcohol disorder, and 2% meet criteria for
a drug abuse disorder (National Institute on Alcohol Abuse and Alcoholism,
2006). Post-traumatic stress disorder (PTSD), which can result from child
maltreatment experiences, has been found to be associated with having a co-
occurring substance abuse diagnosis (Pietrzak, Goldstein, Southwick, & Grant,
2011).

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4 J. Levenson

ACE, Substance Abuse, and Criminal Offenders
Childhood trauma is frequently found in the histories of criminal offend-

ers. In a national study of inmates and probationers in the United States,
12% of males and 25% of females reported child physical abuse, while 5%
of males and 26% of females reported sexual molestation (Harlow, 1999).
Prisoners frequently report witnessing violence in their families of origin and
many experienced the death of a family member, parental separation or aban-
donment, foster care placement, or parental substance abuse (Courtney &
Maschi, 2013; Haugebrook, Zgoba, Maschi, Morgen, & Brown, 2010; Maschi,
Gibson, Zgoba, & Morgen, 2011). Prospectively collected data from the Chicago
Longitudinal Study (N = 1,539 low-income minority children) highlighted
child maltreatment as a predictor of criminal behavior for both boys and girls
(Mersky, Topitzes, & Reynolds, 2012). A study of over 64,000 youth involved
with the juvenile justice system in Florida revealed significantly higher preva-
lence of all ACEs compared to the general population (Baglivio et al., 2014).
These juveniles had significantly greater cumulative exposure (higher ACE
scores) which were correlated with increased risk of reoffending (Baglivio
et al., 2014). Childhood adversity is clearly associated with delinquency and
criminality, and greater exposure to adverse events significantly increases the
likelihood of mental health problems and serious involvement with drugs and
crime (Harlow, 1999; Messina, Grella, Burdon, & Prendergast, 2007).

Substance misuse is among the most pervasive of mental health disor-
ders for criminal offenders (Substance Abuse and Mental Health Services
Administration, 2012a). According to the U.S. Substance Abuse and Mental
Health Services Administration (SAMHSA), in 2012 about 4 million men were
on probation or parole, many of whom had a variety of behavioral health
problems. Among offenders under community supervision, substance misuse
is widespread; in 2012, about 30% of male probationers aged 18 to 49 had
an alcohol use disorder, 19% had an illicit drug use disorder, and 40% had
either an alcohol or illicit drug use disorder (Substance Abuse and Mental
Health Services Administration, 2012a). In any given year, almost half of
male offenders on probation or parole need substance abuse treatment; how-
ever, only about a quarter receive intervention (Substance Abuse and Mental
Health Services Administration, 2012a). Male and female drug-dependent
prisoners with greater exposure to childhood adversity entered the criminal
justice system and initiated substance use at earlier ages (Messina et al.,
2007). In particular, early physical abuse, domestic violence, and traumatic
neglect have been associated with increased substance abuse for delinquent
youth (Ford, Hartman, Hawke, & Chapman, 2008).

It is unsurprising that early adversity is associated with both criminal
behavior and addictive disorders. Chronic exposure to harsh or threatening
conditions as a child produces anxiety, anger, and depression, along with
a sense of helplessness which can lead to neurobiological changes such as

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Adverse Childhood Experiences 5

hyperarousal (Beech & Mitchell, 2005; Creeden, 2009; Felitti, 2002; Felitti
et al., 1998; Whitfield, 1998). High-risk behaviors such as smoking, drug and
alcohol abuse, sexual behaviors, and aggression can become self-medication
mechanisms because they provide pharmacological and psychological relief
from emotional distress. Nicotine and other drugs, as well as sexual or aggres-
sive activity, can provide an antidote to anxiety and thus potentiate the
addictive nature of these substances and high-risk behaviors (Anda et al.,
2006; Felitti et al., 1998; Ford, Fraleigh, Albert, & Connor, 2010; Whitfield,
1998). On the other hand, individuals vary in their responses to trauma and
many people demonstrate resilience following adverse circumstances.

ACE, Substance Abuse, and Sex Offenders
Sexual offenders have significantly higher ACE scores than males in the

general population (Levenson, Willis, & Prescott, 2014; Reavis et al., 2013).
A study of male sexual offenders (N = 679) compared ACE scores to those
of males in the CDC sample, finding that sex offenders had more than three
times the odds of child sexual abuse, nearly twice the odds of physical abuse,
thirteen times the odds of verbal abuse, and more than four times the odds of
emotional neglect or coming from a broken home (Levenson, Willis, & Prescott,
2014). Less than 16% of the sex offenders reported no adverse experiences
and almost half endorsed four or more. Various maltreatments often coexisted
with other types of household dysfunction, suggesting that many sex offend-
ers were raised in a disordered social environment by caretakers who were
ill-equipped to protect their children from harm. In another study, 9% of inter-
personal violence offenders (male child abusers, domestic violence assaulters,
sex offenders, and stalkers) reported no adverse events in childhood (com-
pared to 38% of males in the original ACE study) and 48% reported four or
more adverse experiences (compared to 9% of the males in the ACE study)
(Reavis et al., 2013). Weeks and Widom (1998) also found higher rates of early
maltreatment for sex offenders, with 26% reporting sexual abuse in childhood,
18% reporting neglect, and two-thirds revealing childhood physical abuse.

Child abuse and neglect occur in a pathogenic environment that can
impede healthy functioning across the life span (Cicchetti & Banny, 2014;
Rutter, Kim-Cohen, & Maughan, 2006). Developmental psychopathology theo-
rists postulate that relational and behavioral patterns result from a dynamic
interaction of affective and cognitive processing by which individuals attach
meaning to their experiences (Rutter & Sroufe, 2000). Abusive or neglect-
ful parenting is characterized by betrayal and invalidation, which contribute
to distorted expectations of oneself, others, and relationships, cultivating the
formation of maladaptive schema, disorganized attachment styles, and poor
affect regulation (Beech & Mitchell, 2005; Chakhssi, Ruiter, & Bernstein, 2013;
Loper, Mahmoodzadegan, & Warren, 2008; Young, Klosko, & Weishaar, 2003).

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6 J. Levenson

Developmental theories of antisocial behavior further suggest that incom-
petent parenting, harsh punishment, poor supervision, and limited positive
family involvement pave the way for conduct problems and delinquent activ-
ities (Cicchetti & Banny, 2014; Ford, Chapman, Connor, & Cruise, 2012;
Kohlberg, Lacrosse, Ricks, & Wolman, 1972; Patterson, DeBaryshe, & Ramsey,
1990; Rutter et al., 2006). The detrimental effects of complex trauma on
biopsychosocial development and attachment increase risk for a range of self-
regulation problems including aggression and substance abuse (Ford et al.,
2012). Early maltreatment and family dysfunction can lead to mistrust and
hostility, which can elicit social rejection and lead to loneliness, negative
peer associations, and delinquent behavior. This intricate trajectory is further
impacted by cumulating cascade effects, by which an early disadvantage in
one domain subsequently impairs functioning and mastery in other developing
areas (Masten & Cicchetti, 2010; Rutter et al., 2006).

Insecure attachments can contribute to problematic and coercive interper-
sonal styles, which play a role in sexual abuse (Beech & Mitchell, 2005; Grady,
Swett, & Shields, 2014; Smallbone, 2006). Such intimacy deficits are related
to reoffense risk for convicted sex offenders (Hanson & Morton-Bourgon, 2005;
Smallbone, 2006). Molestation in childhood can make a unique contribution
to sexually abusive behavior through a number of avenues: compensation for
feelings of powerlessness, social learning by which individuals model their own
abuser’s behavior and distorted thinking, or through the association of sex-
ual arousal with adult-child sexual situations (Seto, 2008). A lack of healthy
emotional intimacy in a childhood environment can contribute to subsequent
impersonal, selfish, or adversarial relational patterns, and tolerant attitudes
toward nonconsensual sex can develop through an individual’s attempt to rec-
oncile their own experiences or by adopting the mind-set of abusers in one’s life
(Hanson & Morton-Bourgon, 2005). A link found between sex offenders’ ACE
scores and risk factors for sexual recidivism suggests that the role of early
adversity in the development of sexual aggression is a relevant consideration
in treatment (Levenson, Willis, & Prescott, 2014).

As Seto (2008) described, some men who abuse children may have the dis-
order of pedophilia while others do not. Ward (2014) described the need for
“integrative pluralism” (p. 3) as a way to amalgamate multiple theories of sex-
ual offending in a way that recognizes the multidimensionality of the problem.
For instance, four distinct but related constructs seem to contribute to sexual
offending to a greater or lesser extent for each individual: emotional regu-
lation problems, deviant sexual attractions, intimacy and social deficiencies,
and offense-tolerant belief systems (Ward, 2014). A challenge for researchers
and clinicians is to conceptualize offending patterns according to the complex
and interacting biopsychosocial factors that help explain behavior, includ-
ing the ways that developmental adversity contributes to the neurobiology of
attachment and intimacy (Beech & Mitchell, 2005).

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Adverse Childhood Experiences 7

Sexually abusive behavior and substance misuse may be among the mal-
adaptive coping responses that emerge from early traumatic experiences. It is
not unusual for sexual offenders to have substance abuse problems; in fact,
a recent meta-analysis estimated that about half of sex offenders had a his-
tory of substance abuse (Kraanen & Emmelkamp, 2011). Because intoxication
can be a significant disinhibitor, several scholars have described substance
abuse as an important dynamic (fluctuating and changeable) risk factor for sex
offense recidivism (Hanson & Harris, 1998, 2001; Hanson, Morton, & Harris,
2003) and therefore as a relevant treatment target (Andrews & Bonta, 2007,
2010). Drug and alcohol problems are thought to be broadly related to inti-
macy deficits and general self-regulation problems for sex offenders (Abracen
& Looman, 2004), and substance disorders are a common co-morbid condition
with paraphilias and hypersexuality (Kafka & Hennen, 2002). A meta-analysis
of 42 studies assessing drug and alcohol misuse among sex offenders found
that about half were diagnosed with some sort of substance abuse problem in
their lifetime, with alcohol abuse more prominent than drug abuse (Kraanen
& Emmelkamp, 2011). Though a history of substance abuse was unrelated to
recidivism in an early meta-analysis (Hanson & Bussiere, 1998), other stud-
ies have found alcohol and drug abuse to be dynamic predictors of recidivism
(Abracen & Looman, 2004; Hanson & Harris, 1998, 2000; Långström et al.,
2004). Moreover, measures of alcohol abuse added to the prediction of violent
and sexual recidivism as measured by an actuarial instrument (Looman &
Abracen, 2011). Thus, substance abuse and its relationship to early adversity is
a topic relevant to sex offender treatment and preventing the intergenerational
cycle of maltreatment.

Investigations of the effectiveness of sex offender treatment continue to
produce mixed results (Hanson, Bourgon, Helmus, & Hodgson, 2009; Hanson
et al., 2002; Marques, Wiederanders, Day, Nelson, & van Ommeren, 2005), and
meta-analytic researchers have highlighted central weaknesses in research
designs that preclude drawing conclusions about the effectiveness of treatment
(Långström et al., 2013). While researchers strive to better identify the vari-
ables that contribute to reduced recidivism, clinicians are challenged to imple-
ment evidence-based methods aimed at preventing victimization and helping
offenders build more functional and satisfying lives (Hanson et al., 2009; Ward,
Yates, & Willis, 2012; Yates, Prescott, & Ward, 2010). Several scholars have
emphasized a need for the field to move toward tailoring treatment plans to
individualized risks and needs (Hanson et al., 2009), recognizing the impor-
tance of therapeutic engagement and therapist characteristics (Levenson &
Macgowan, 2004; Levenson, Macgowan, Morin, & Cotter, 2009; M

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