Content area
Child maltreatment and substance abuse are both international public health priorities. Research shows that child maltreatment increases the risk for substance use and problems. Thus, recognition of this relationship may have important implications for substance demand reduction strategies, including efforts to prevent and treat substance use and related problems. Latin America and the Caribbean is a rich and diverse region of the world with a large range of social and cultural influences. To date, relatively little work has addressed the link between child maltreatment and substance use in the region. A working group constituted by the Inter-American Drug Abuse Control Commission (CICAD) and the Centre for Addiction and Mental Health (CAMH) in June, 2010 identified this area as a priority area for a multinational research partnership. This paper summarizes existing information on drug use and child maltreatment in six participating countries, Colombia, El Salvador, Jamaica, Nicaragua, Panama and Uruguay, and considers the implications of child maltreatment prevention for demand reduction strategies to address substance use issues. A CICAD/CAMH-sponsored multinational research partnership has been formed, which will involve research on the link between child maltreatment and substance misuse, expertise exchange and resource sharing.
Child maltreatment has emerged as a global public health issue (Kessler et al. 2010; Westby 2007). National and international efforts to address and prevent child maltreatment have been initiated in recent decades, such as the United Nations’ Convention on the Rights of the Child (United Nations General Assembly, 1989). Nevertheless, child maltreatment remains a major concern and international research efforts to understand the impact of child maltreatment have recently been launched (Kessler et al. 2010).
In June 2010, an Inter-American working group, with representatives from Canada, Colombia, El Salvador, Jamaica, Nicaragua, Panama, the United States, and Uruguay, met in Toronto, Canada under the auspices of the Inter-American Drug Abuse Control Commission (CICAD) and the Centre for Addiction and Mental Health (CAMH). CICAD is a Secretariat within the Secretariat for Multidimensional Security (SMS) at the Organization of American States. CICAD’s core mission is to enhance the human and institutional capacities of its member states to reduce the production, trafficking and use of illegal drugs, and to address the health, social and criminal consequences of the drug trade. CAMH is Canada’s largest mental health and addiction teaching hospital, affiliated with the University of Toronto and a PAHO/WHO Collaborating Centre, which combines clinical care, research, education, policy development and health promotion to address mental health and addiction needs.
The working group met with the goal of identifying a priority area for a multi-center research study to be implemented in selected Latin American and Caribbean (LAC) countries. In view of the increasing evidence of the impact of child maltreatment on substance use and abuse and the small number of existing studies on the topic from LAC countries, the working group chose to form a research partnership that would undertake and encourage collaborative multinational research and facilitate expertise exchange and resource linkages.
In this paper, we consider the significance of child maltreatment and substance abuse, and consider how they may be linked. We then consider international information on child maltreatment, followed by an analysis of available data on child maltreatment and drug use in Colombia, El Salvador, Jamaica, Nicaragua, Panama and Uruguay. We then identify the importance of understanding child maltreatment for potential demand-reduction initiatives, and describe the recently formed multinational research partnership with the goal of stimulating research in this important area.
The Link Between Child Maltreatment and Substance Abuse
Child maltreatment “…encompasses any acts of commission or omission by a parent or other caregiver that result in harm, potential for harm, or threat of harm to a child, even if harm is not the intended result” (Gilbert et al. 2009, p.69). Childhood maltreatment will include physical, sexual, psychological or emotional abuse as well as neglect (emotional or physical) experienced by an individual less than 18 years old. Drug use is the use of any psychoactive substance (including alcohol), whether licit or illicit, while drug abuse is the progression of this usage to include adverse physical or psychological outcomes (Tarter and Mezzich 1996).
It has long been considered that adverse experiences in childhood increase the likelihood of problems in adolescence and adulthood (Widom 1999; Kessler et al. 1997; MacMillan et al. 2001; Wekerle and Wall 2002; Wolfe and Wekerle 1993). One adverse outcome that has been linked to traumatic and abusive experiences in childhood is substance abuse (Rogosch et al. 2010; Conroy et al. 2009; Kerr et al. 2009). Rohsenow et al. (1988) reported that clients in substance abuse treatment reported a very high rate of sexual abuse as children. Other studies suggested that other forms of childhood trauma were also associated with higher rates of subsequent substance abuse (Medrano et al. 1999), and many authors have identified that exposure to childhood maltreatment is a risk factor associated with drug use (Leventhal and Smithz 2006; Adlaf and Smart 1985; Hartzler and Fromme 2003; McCarthy et al. 2001; Moeller and Dougherty 2002; Felix-Ortiz and Newcomb 1999; Cloninger et al. 1988; Schuckit 1994; Kilpatrick et al. 2000). In a recent international study, Kessler et al. (2010) examined the impact of childhood adversities on adult psychopathology in middle and high income countries. They observed that childhood adversity increased the likelihood of all forms of adult psychopathology studied, including substance disorders, in all regions of the world examined. In particular, they found that childhood adversity could account for 30% of substance disorders in adolescents, 28.9% in early adulthood, and 34.2% in later adulthood (risk proportions attributable to each population).
Physical abuse has been identified as being related to the use of drugs (Brems et al. 2004) and externalizing behaviour problems (Righthand et al. 2003). Individuals who were physically abused were also found to initiate alcohol use earlier than those who were not physically abused (Brems et al. 2004). The impact of psychological abuse is a challenging area to study because there is no widely accepted definition of psychological abuse. Also psychological abuse tends to co-occur along with other types of maltreatment, which makes it difficult to measure the impact of psychological abuse alone (Righthand et al. 2003). However it has been suggested that psychological abuse is responsible for more adverse outcomes than physical abuse alone (Crittenden 1996; Yates and Wekerle 2009) and may be the main issue underlying all types of abuse (Titus et al. 2003). Psychological abuse tends to affect the child’s sense of self, and has been found to be associated with substance use and abuse (Righthand et al. 2003). These children sometimes demonstrate symptoms of psychological distress (Righthand et al. 2003) which is associated with drug use.
Tonmyr et al. (2010) reported on a comprehensive review of the relationship between childhood maltreatment and adolescent substance use. These investigators concluded that while the magnitude of the relationship varied across type of maltreatment and type of substance considered, there was consistent evidence that maltreatment increased the risk for early initiation of substance use. However, while a link between child maltreatment and substance abuse appears clear, several pathways may underlie that link. Hovdestad et al. (2011) reviewed potential explanations of the link between child maltreatment and adolescent substance abuse. These authors suggested that three types of models have been proposed: 1) PTSD models that emphasize the role of trauma in increasing substance abuse, 2) models that emphasize the role of substance use in relieving negative affect produced by self-dysfunction caused by maltreatment, and 3) models that focus on disruptions in relationships, produced by maltreatment, as causes for later substance abuse.
Child Maltreatment and Substance Abuse—International Data and LAC Information
Child maltreatment is a global problem, but international estimates are few and can provide much variability. In an early review of the prevalence of child sexual abuse, Finkelhor (1994) observed that reported rates of child sexual abuse among women ranged from 7 per 100 in Finland and Ireland to 36 per 100 in Austria, and among men ranged from 3 per 100 in Sweden and Switzerland to 29 per 100 in South Africa. In a more recent international review, Stoltenborgh et al. (2011) confirm important international variability, with lowest rates of self-reported child sexual abuse for both females and males occurring in Asia, highest rates for females occurring in Australia, and highest rates for boys occurring in Africa.
Stoltenborgh et al. (2011) noted that methodological issues can have a large role in determining estimated rates of maltreatment. Self-report measures result in the highest estimates. In the United States, Hussey et al. (2006) found that self-reported child maltreatment was common among respondents to the National Longitudinal Study of Adolescent Health. Possible supervision neglect was reported by 41.5% of the sample, physical assault was reported by 28.4%, physical neglect was reported by 11.8% and contact sexual abuse by 4.5%. However, estimates based on administrative records typically find lower rates of maltreatment. The Public Health Agency of Canada (2010) examined 174,411 suspected cases child abuse and neglect in 2008 investigated by Canadian child welfare agencies. Of these cases, 36% were substantiated by investigation and in an additional 8% there was insufficient evidence to substantiate maltreatment, but suspicion of maltreatment remained at the conclusion of the investigation. In substantiated cases, physical abuse, sexual abuse, neglect, emotional maltreatment and exposure to domestic violence accounted for 20%, 3%, 34%, 9% and 34% of cases, respectively. In general, it is acknowledged that maltreatment is under-reported, and is primarily reported by professionals (such as police, educators and health professionals) in high-income countries. In middle- and low-income countries there may be fewer professionals to report maltreatment, and it is often a hidden issue where family members are the primary perpetrators.
While much less information on child maltreatment is available from Latin America and the Caribbean, it has been estimated that 40 million children under 15 years of age experience violence, abuse and neglect (UN, ECLAC & UNICEF 2009). This maltreatment may play an important role in substance use and problems in the region. However, with some important exceptions (e.g., Belfer and Rohde 2005; Mejia et al. 2006), research from Latin America and the Caribbean has not yet addressed the issue of child maltreatment and its relationship with substance abuse and other problems.
Colombia
Colombia is located in the northwest of South America with territory in both hemispheres, the western Pacific coast and the Atlantic coast, and across the equator. It has a total area of 2,070,408 km2 and it borders on 11 countries. It has a population of approximately 42 million with a per capita income of USD$3,083.
Drug Use
Colombia is the world’s leading producer of cocaine (Ford 2003) and the National Narcotics Directorate is responsible for the planning, monitoring and evaluation of drug prevention programs. The Directorate has determined that the use of psychoactive substances is growing and is a serious public health concern for Colombia, and in 2008 reported that 9.1% of the population had used illicit drugs such as marijuana, cocaine, bazuco, ecstasy, heroin, LSD and mushrooms (Ministry of Social Protection and National Directorate of Narcotic Drugs 2008). Marijuana was found to be the most widely consumed illegal substance with a lifetime prevalence of use of 8% (see Table 1). Young adults between the ages of 18–24 years had the highest level of alcohol consumption, at 46%, followed by individuals aged 25–34 years, at 43%. Alcohol consumption was lower in older age groups. Risky alcohol consumption was most common among individuals between the ages of 18–24 years. This is the age group of most university students and it also has the highest prevalence of use of illicit substances (Direccion Nacional de Estupefacientes 2009).
Table 1. Prevalence of lifetime consumption of licit and illicit drugs: Colombia, 2008
Study | Sample | Results | Source & Year | |
|---|---|---|---|---|
Licit | Illicit | |||
National study of psychoactive substance use in Colombia, 2008 | 29,164 Persons (12–65 years) | Lifetime use: | Lifetime use: | Ministry of Social Protection and National Directorate of Narcotic Drugs (2008) |
Cigarette: 45% | Marijuana: 8% | |||
Alcohol: 68% | Cocaine: 2.5% | |||
Basuco: 1.1% | ||||
Ecstasy: 0.9% | ||||
Inhalants: 0.8% | ||||
Heroin: 0.2% | ||||
Source: Estudio Nacional Consumo de Drogas 2008
In 2009, the Andean Epidemiologic Survey on Synthetic Drug Use in the University Population was conducted with the assistance of the Inter-American Commission for Drug Abuse Control and CICAD/OAS. It identified a substantial involvement with synthetic drugs in this population. Synthetic drugs are widely used by college students; 23.2% using mainly ecstasy, 20% using LSD and approximately 7% using amphetamines (Comunidad Andina 2009).
Childhood Maltreatment
In 2000, 68,585 cases of violence within the family were registered, of which 10,900 involved child maltreatment, 43,210 involved spousal maltreatment, and the rest involved both. Two million children are mistreated per year in their homes, and of these cases 850,000 are considered to involve severe maltreatment. An estimated 361 children per 1,000 experience maltreatment. On average, seven children per day are victims of homicide (Instituto de Medicina Legal y Ciencias Forenses 2000; Defensoría del Pueblo 2001).
In 2001 the Instituto de Medicina Legal y Ciencias Forenses (Legal Medical Institute and Forensic Sciences) diagnosed 13,352 abuse cases involving sexual abuse or violence. Of all diagnoses, 86% involved minors under 18. In cases of abuse involving minors, in 78% the perpetrator was well-known by the child, particularly fathers, fathers-in-law or other relatives. These cases may be increasing in recent years, rising from a total of 10,716 in 1997 to 12,485 in 1999 and 13,352 in 2001 (Instituto de Medicina Legal y Ciencias Forenses 2000; Defensoría del Pueblo 2001). Cases of child abuse by age are presented in Table 2.
Table 2. Child abuse cases by age and sex: Colombia, 2008
Age (years) | Females | Males | Total |
|---|---|---|---|
0–4 | 827 | 1,009 | 1,836 |
5–9 | 1,273 | 1,477 | 2,750 |
10–14 | 1,992 | 1,675 | 3,667 |
15–17 | 1,725 | 908 | 2,633 |
Not stated | 7 | 8 | 15 |
Indirect | 1,304 | 1,318 | 2,622 |
Total | 7,128 | 6,395 | 13,523 |
Source: The Institute of Legal Medicine and Forensic Sciences 2008
An estimated 35,000 children are involved in sex work in Colombia. The number of children involved in prostitution has increased in the past decade, including younger children under the age of 10. The majority of children involved in child prostitution have been victims of violence in the home, abandonment, sexual abuse or expulsion from school (UNICEF 2001).
Another form of child abuse that exists in Colombia is the participation of children in armed conflict. It is estimated that between 6,000 and 7,000 children are involved with irregular guerilla forces and insurrectionists, with the majority between 15 and 17 years of age. The CRAF guerrillas are believed to have the largest number of children involved, followed by the ELN (Oficina del Alto Comisionado para la Paz 2002).
In a recent 4 year period the Colombian Institute of Familial Well-being (ICBF) reported sheltering 752 children aged 9–17 years (512 males and 240 females) who have broken ties with the rebel groups. Of these, 92 fled on their own and 660 were captured. Ejercito Nacional has reported that in 2001, 101 children between 9 and 17 years of age (33 females and 68 males) were reportedly killed in the guerilla conflict, or fled the guerilla groups. Of the total combatants demobilised in Colombia in 2000, 48% were under 18 years of age (Oficina del Alto Comisionado para la Paz 2002).
In Colombia there are more than 2.5 million working children. Of this total, 1.7 million are adolescents between 12 and 17 and 800,000 are children between 6 and 11 years. Eighty percent work in the informal sector and 323,000 children are working as domestic servants in homes of others. In 1996 the National Household Survey and the Survey of Children and Adolescents established that, of the population between 7 and 11 years working in eight major cities in Colombia, 49.3% of boys and 64.9% of girls worked in trade and sales. In rural areas 87% of boys and 50% of girls aged 10–11 years are agricultural workers, who work on average 12–15 h per day. Between 20% and 25% of working children are involved in high-risk occupations. This percentage rises to 70% in the agricultural sector (DANE 2002).
El Salvador
The Republic of El Salvador is located in Central America, and is surrounded by Honduras, Nicaragua and Guatemala. It is approximately 21,040 km2 in size, and has a population of 6,122,413 inhabitants, with a density of 291 inhabitants/km2. El Salvador has a republican, democratic and representative government and has the third largest economy in Central America with a per capita income of approximately $7,100. Its gross domestic product in 2008 was $22.12 million with an inflation rate 7.3%.
Drug Use
The consumption of drugs has been and continues to be a serious concern. El Salvador’s National Antidrug Plan 2002–2008 was approved in June 2002. The plan involves monitoring, evaluation, recommendations and enforcement activities to control the supply and demand of drugs, including control measures, identifying ongoing initiatives, and developing and evaluating programs. In 2002, the Observatorio Salvadoreño de Drogas (OSD) was created as a research center for the acquisition of statistics on drugs.
In El Salvador, drug consumption is more common among males than females (Rivas 2006). Reported reasons for drug consumption included the need to feel accepted within a group, to satisfy curiosity, to get feelings of well-being and security, lack of family communication, and the lack of parental involvement in children’s education.
A prevalence study carried out by the Comisión Nacional Anti-Drogas (CNA) in 2004 found that the typical age of initiating drug consumption is between 11 and 12 years (CNA 2006). Approximately 4% of the general population has consumed marijuana at some time in their life and 8% consider marijuana consumption not a serious concern (CNA 2006).
A study of the consumption of psychoactive substances within 131 public and private schools, with a sample of 3,147 students, found that most students experimented with cigarettes before the age of 14 (Fundación Antidrogas de El Salvador (FUNDASALVA) 2004). Drug consumption was found to increase with age. Alcohol was the most commonly consumed substance, but consumption of stimulants and tranquilizers among young people aged 18–24 was also common, with the highest level of consumption occurring among women (FUNDSALVA 2004).
Child Maltreatment
During the period 2004–2007, reported cases of child abuse increased from 1,818 cases in 2004 to 4,403 in 2007. Consequently, on March 26, 2009 the new Law of Integral Protection of Childhood and Adolescence (LAW LEPINA) was passed and became effective April 16, 2010. This law was designed to guarantee rights for all children and adolescents in El Salvador (Asamblea Legislativa de El Salvador 2009). Children, particularly girls, are vulnerable to becoming victims of abuse at the hands of family members, relatives or close family friends. The Center of Police Intelligence, of the Policia Nacional Civil (PNC), in 2008 reported a total of 128 cases of child abuse; 46% involved male victims while 54% involved female victims. The 10–12 year old age group was found to be the most vulnerable, accounting for 22% of all cases (see Table 3)(Observatorio Centroamericano sobre la Violencia 2009).
Table 3. Age groups and reported child maltreatment: El Salvador, 2008
Age | Percent of reported abuse cases |
|---|---|
10–12 years | 22% |
16–18 years | 3% |
13–15 years | 18% |
7–9 years | 16% |
4–6 years | 13% |
0–3 years | 12% |
Age unknown | 16% |
Source: Statistics from the 2008 Policia Nacional Civil (PNC) Report
The Instituto Salvadoreño para el Desarrollo de la Mujer (ISDEMU 2007) reported in August 2007 a total of 2,607 cases of child abuse over the preceding 8 months. Child abuse has been recognized as a significant concern in El Salvador and its impact needs further investigation (OCAVI 2009). However, the level of child abuse may be associated with the level of violence in the country, as every day an average of nine people die from violent causes, and many of these deaths are associated with drug use (Diario Granma 2010).
Jamaica
Jamaica is the third largest island in the Caribbean with an area of 4,411 km2 and has a population of approximately 2.7 million persons, who are mainly of African descent. Jamaica is a developing country, with considerable economic concerns, with the average individual having an income of USD$4633. This type of economic climate makes the island vulnerable to illegal activity. Jamaica acts as a transshipment point for drugs coming from Colombia to the United States and therefore drug use and abuse is a serious concern within the island.
Drug Use
In 2001, approximately 12% of the Jamaican population aged 12–55 years were reported as abusing or being dependent on drugs (National Council on Drug Abuse 2002). Alcohol was the most frequently used substance, while marijuana users represented 99% of all illicit substance users. Drug use was also found to increase significantly with age (Jamaican Reproductive Adolescent Project 2004). Drug use and abuse has been found to greatly affect the quality of Jamaican family life, health costs and also mortality rates.
Child Maltreatment
Corporal punishment is widely used in Jamaica and this type of disciplining technique is believed to be associated with later drug use by the child (Lau et al. 2005). In 2004, Jamaica enacted the Child Care and Protection Act, which stated that persons under 18 years old should be protected from abuse, neglect, harm or even threat of harm. This Act also appointed a Children’s Advocate who is responsible for protecting and enforcing the rights of all Jamaican children. Nevertheless, the rate of reported child maltreatment in Jamaica is consistently increasing (see Table 4).
Table 4. Number of cases of child abuse reported to the Office of the Children’s registry: Jamaica, 2007–2010
Type of abuse | 2007 | 2008 | 2009 | 2010a |
|---|---|---|---|---|
Physical abuse | 122 | 992 | 1,574 | 890 |
Sexual abuse | 114 | 825 | 1,468 | 859 |
Emotional abuse | 36 | 232 | 735 | 302 |
Neglect | 81 | 1,607 | 3,001 | 1,570 |
Total | 353 | 3,656 | 6,778 | 3621a |
Source: adapted from Selected Statistics on Child Abuse and Neglect in Jamaica, 2007–2010 (Office of the Children’s Registry 2010)
The incidents of sexual abuse may be greater than reported as some reports of sexual abuse were classified by their type (e.g., rape, carnal incest) rather than sexual abuse against children
aFigures shown for 2010 refer to reports from January–June 2010
Jamaican culture is one wherein marriage is not the norm and children are usually born within common law or visiting unions (Leo-Rhynie 1993; Samms-Vaughan 2006). Typical Jamaican families tend to be matriarchal with fathers being psychologically and sometimes physically absent (Leo-Rhynie 1993). This results in the mother being the disciplinarian and the ‘breadwinner’. However, the mother’s work to support her family may affect care for her children. These children are sometimes cared for by their extended family, neighbours or friends. This makes the child vulnerable to abuse or neglect from many adults within the society.
The parenting style employed by Jamaican parents or caregivers tends to be authoritarian with the consequences for any type of disobedience being usually a flogging (Smith and Mosby 2003). The hitting of children is culturally sanctioned within Jamaica. Parents, caregivers and teachers carry out this type of punishment, which sometimes leads to severe abuse and neglect (Smith and Mosby 2003).
Children are brought up to believe that they are flogged because they are loved. Unlike flogging by the father, flogging by a mother is usually tempered by affection afterwards (Leo-Rhynie 1997). This usually results in a close bond between mothers and their children, even in light of harsh punishments. However discipline is gender dependent; boys tend to be flogged more than girls, but girls are more likely to be verbally abused (Leo-Rhynie 1997).
Nicaragua
Nicaragua is made up of 17 departments in three macro-regions, the Pacific, Central and Atlantic regions, with a population of about 6 million people. The Pacific region is an area of high ecological risk with a high population density (nationally there are 45.8 inhabitants/km2 while Managua has 398 inhabitants/km2). The Central region is a predominantly rural area with an agricultural economy and very little road development. The Atlantic region covers 46% of the country, and is mostly a rural jungle area with low population density (5.9 inhabitants/km2), large Indigenous population, low indices of schooling, limited access by road, and few links with the rest of the country. Despite a decline in the poverty rate, the absolute numbers in poverty have been rising, with poverty concentrated in rural and peri-urban areas. Nicaragua is one of the poorest countries in the region, in terms of macroeconomic indicators, import/export, and income/expenditure figures.
Drug Use
According to the World Health Organization, the lifetime prevalence of alcohol drinking in young people in Nicaragua is 41.1% (World Health Organization 2006) and the per capita recorded alcohol consumption (liters of pure alcohol) among adults (>= 15 years) in 2003 was 2.5 l (World Health Organization 2006). Sanchez (2003) examined substance use among high school students and found that alcohol and tobacco use was common. Marijuana was the illicit drug most commonly consumed, followed by cocaine, solvents-inhalants and crack. Consumption also tended to increase with age and education, with higher prevalence of drug use being found in private schools (Sanchez 2003).
A recent study (Silva Garcia 2008) of students from the Faculty of Medicine in two universities in Nicaragua found that the prevalence of tobacco consumption in the last 12 months ranged between 36.8% and 50.7%. The prevalence of alcohol consumption for the last 12 months ranged between 53.6% and 77.6% (Silva Garcia 2008).
Child Maltreatment
The main risk factors associated with child abuse in Nicaragua are poverty, low educational level and a culture of violence. Poverty, the culture of violence and the macho mentality are not only risk factors associated with cases of child maltreatment, but also are serious barriers to the prosecution of offenders and to tracking and monitoring cases of abuse. According to the Legal Medicine Institute, among cases of domestic violence, 4.54% were classified as Child Abuse in 2006 and 2.9% involved girls under 10 years old (Saavedra and Suarez 2006). In cases of sexual abuse, the perpetrators are typically men between 18 and 30 years old, and are most commonly a father, step-father, neighbour, uncle, cousin, or brother (Diagnóstico sobre la situación de violencia 2004). Only 10% of the perpetrators are unknown to the victim (Saavedra and Suarez 2006).
Panama
The Republic of Panama has a total surface area of 75,517 km2. It is bordered on the North by the Caribbean Sea, on the East by the Republic of Colombia, on the South by the Ocean Pacific and on the West by the Republic of Costa Rica. It has total population of 3,322,576 inhabitants. The population is composed of Hispanic groups, afrocolonials, African-American-Antilleans, and ethnic groups such as Chinese, South Asians, Hebrews, Central Europeans, Central Americans, and 7 Indigenous groups (Kunas and others), with large transcultural diversity. The country is politically divided into nine provinces, 75 districts, three Indigenous districts at the provincial level, and 620 communities.
Drug Use
Panama’s geographical position makes the country easily accessible and a strategically ideal route for trafficking licit and illicit drugs from drug producers in South America to consumers in North America and Europe. The 1996, National Youth Survey found that over 40% of school-attending adolescents had started to drink alcohol, while a much smaller proportion had used marijuana and inhalant drugs; the use of cocaine (crack/coca paste) and heroin was quite rare. Dormitzer et al. (2004) estimated the association between drug exposure opportunity and drug use, finding that the most frequently used was alcohol (exposure 4.82, use: 5.01), followed by marijuana (exposure 1.14; use:1.33), tobacco (exposure 1.07, use:1.15), and inhalants (exposure 0.98, use: 1.01). A 2009 survey of students in Kuna found evidence for the initiation of drug use as early as age 13 (CONAPRED, MEDUCA (Ministry of Education) MIDES (Ministry of Social Development), Kunayala Congress 2009).
Child Maltreatment
The Committee of Children’s Rights in Panama identified many types of child abuse in the country, such as physical abuse, abandonment, sexual abuse, verbal abuse, and neglect (Committee of Children’s Rights, Panama 2004). However, all the cases were not gathered by one institution, and also child maltreatment tends to be under reported. In 2001, Hospital del Niño (Children Hospital) reported 65 cases of physical abuse, 79 cases of sexual abuse, 11 cases of neglect, and 10 cases of abandonment. In 2002, of the reported cases of child maltreatment it was found that children less than 1 year old most frequently experienced physical abuse (30.5%) and neglect or abandonment (30%). Boys aged 1–4 years most frequently experienced physical abuse (39%), and sexual abuse (36%), while girls of the same age most frequently experienced sexual abuse (55%), and physical abuse (19%). Children 5 to 14 years old were most likely to experience sexual abuse and neglect (Red Nacional contra la Violencia 2002). The Government Child Care Protection Program, that reports statistics on the various types of child maltreatment, provided evidence that the rate of reported child maltreatment may be increasing (see Table 5).
Table 5. Victims of child maltreatment reported by the child care protection program: Panama, 2001–2009
Type of abuse | 2001 | 2002 | 2006 | 2009 |
|---|---|---|---|---|
Physical abuse | 132 | 155 | 410 | 466 |
Sexual abuse | 348 | 482 | 456 | 564 |
Emotional abuse | 106 | 153 | 130 | 94 |
Physical abuse and emotional abuse | 59 | 64 | 43 | 92 |
Familial neglect | – | – | – | 549 |
Neglect (abandonment) | – | – | – | 92 |
Generic abuse | 1,209 | 952 | 1,120 | 868 |
Total | 1,854 | 1,806 | 2,159 | 2,725 |
Source: Juzgado de Niñez y Adolescencia. Centro de Estadísticas Judiciales. Órgano Judicial. 2009
Uruguay
Uruguay is located in South America with coastlines on the Rio de la Plata and the Atlantic Ocean. Its land area is 177,508 km2. It has its borders with Brazil and Argentina. According to the 2009 census there were 3,334,052 inhabitants, and 86.9% were Caucasian, 9.1% were of African descent, and 3.8% were of Indigenous background. Life expectancy is approximately 76 years with an infant mortality rate of 12 per 1,000 live births. Uruguay’s literacy rate is 96.8%.
Drug Use
The National Drug Observatory (Observatorio Uruguayo de Drogas, OUD) has reported that alcohol is the drug most frequently consumed by the young population, with a majority of young people reporting that they have used alcohol at least once in their lifetime. One out of every three secondary school students displays high risk patterns of use, reporting an episode of abusive consumption within the past 15 days. However the perception of risk associated with alcohol consumption was very low (Junta Nacional de Drogas 2006). The average prevalence of alcohol use among secondary school students is 52.7%; however the prevalence increases with age to 72% by the time students reach 17 years.
High rates of tobacco consumption among young people are also seen, but the age for the initiation of smoking has been gradually increasing due to laws recently implemented as a result of anti-tobacco campaigns. This has resulted in the prevalence of habitual tobacco consumption by young people decreasing from 30.2% in 2003 to 18.4% in 2009 (Junta Nacional de Drogas 2010).
The prevalence of use of illegal drugs, such as marijuana, cocaine and pasta base (a form of cocaine that is smoked), has tended to increase over the years, but in the most recent data (2009) statistically significant decreases in the use of these drugs were reported (Junta Nacional de Drogas 2010). The lifetime prevalence for cocaine use by secondary school students was 3.9%, and 3% of students experimented with other illegal drugs. The prevalence of lifetime use of pasta base has remained at the same rate since 2007, at 1.3% of students. The lifetime rate of cannabis use in the 2009 data was 16.2%. This reflects a statistically significant decrease from 2007 (Junta Nacional de Drogas 2007) where lifetime use was 19.7%.
Child Maltreatment
Little data on the prevalence of child maltreatment in the general population are available. In the 2008 report on cases requiring family conflict resolution, the Ministry of Social Development reported a high prevalence of maltreatment in cases involving children aged 0–17 years (Ministerio de Desarrollo Social 2008). Practices involving psychological or physical abuse were reported by 80% of those interviewed and negligent behaviors by adults in charge were reported by 86%. Physical abuse in its various forms was reported by 55% of respondents; 37.5% of respondents reported chronic physical abuse and 63% reported that at least one act or behavior involving psychological or physical abuse towards a child occurred more than once.
Drug Use and Child Maltreatment in Latin America—Implications for Demand Reduction
The economic, political and social infrastructure in Latin America and the Caribbean make these regions ideal for drug production and distribution (Thoumi 2005). These regions are not simply producers but are also consumers of legal and illegal drugs. Drug-related problems in LAC impact not only individuals, by causing serious individual health problems, but also society, by contributing to violence, social disintegration, family and financial problems.
It is widely recognized that the consumption of alcohol and other licit and illicit drugs is an international public health problem (Babor et al. 2003, 2010). The prevention of alcohol and other drug problems are approached from two differing but complementary perspectives: the reduction of drug supply and the reduction of drug demand. Strategies to reduce demand should be evidence-based (Babor et al. 2010), and one important facet of an evidence-based approach is to identify factors that increase the likelihood or the risk of drug use. As noted above, substantial evidence demonstrates that child maltreatment increases risk for substance use and related problems. Thus, recognition of this relationship may have very important implications for demand reduction strategies.
In the last decade, these regions have made great efforts to confront the drug issue. Millions of dollars have been spent on anti-drug strategies to eradicate the production and distribution of illicit drugs. Many of these strategies are aimed at drug supply reduction in the region and progress has been made in the development of legal and institutional frameworks and the implementation of anti-drug programs. Supply reduction strategies have included aerial monitoring and eradication, encouraging alternative development, anti-drug task forces, dismantling criminal organizations, improving extradition procedures, tightening anti-narcotics and money laundering laws. However, there will always be illicit drugs available for those who want to use them (Rexed 1978) and there has been no net decrease in drug production in LAC countries (Reiss 2010). Therefore demand reduction strategies may hold the key to reducing the use and consequently the production of illicit drugs in this region.
Demand reduction strategies in LAC countries include education, prevention and drug treatment programs. These strategies involve educating people about the dangers of drug use, training anti-drug counselors and practitioners, creating substance abuse treatment programs and other social interventions. However, these programs tend to be underfinanced. As well, the demand reduction strategy of reducing childhood maltreatment has not yet been given serious consideration.
Many studies have identified a link between childhood maltreatment and later drug abuse or risk for drug abuse (Gallego Gómez et al. 2008; Gantiva et al. 2009). The use of physical force as a means of solving problems and disciplining children (Berk 2001) may be culturally accepted within some groups in the LAC region. This approach to disciplining children is legally defined as a form of childhood maltreatment in all these countries, but it remains culturally acceptable in some groups. Other forms of child maltreatment identified in the selected LAC countries considered here included sexual, physical, and psychological abuse and neglect. These different types of child maltreatment may have varying levels of impact on the child. Child sexual abuse is considered to be a severe form of maltreatment and internationally was found to be positively related to many psychological disorders, with alcohol and substance dependence displaying one of the strongest relationships. It was also found that the most severe forms of sexual abuse were associated with the strongest likelihood of substance dependence (Kendler et al. 2000). Additionally, physical abuse and psychological abuse are also implicated in drug use (Brems et al. 2004).
The evidence is strong that the experience of child maltreatment creates risk, possibly through several pathways, for subsequent substance use and abuse. Addressing child maltreatment through effective prevention initiatives may also have a very important influence on later substance use and substance problems. Strategies including effective measures to address or prevent child maltreatment may thus be a very significant component of effective demand reduction strategies in this region and elsewhere.
The Research Partnership
Although childhood maltreatment has consistently been related to adverse developmental outcomes including a relationship with the use and abuse of psychoactive substances, there is a paucity of research relating to childhood maltreatment and later drug use within Latin America and the Caribbean. Therefore the working group, with the support of the Centre for Addiction and Mental Health, the Canadian Government and the Organisation of American States (OAS), Secretariat for Multidimensional Security (SMS), International Drug Control Commission (CICAD) initiated a research partnership to collaborate on research on the issue of child maltreatment and drug use in selected Latin and Caribbean countries, to exchange expertise, and to share resources.
The first collaborative research project planned is a multi-country study, now underway, exploring the relationship between childhood maltreatment and later drug use among university students from selected universities in Colombia, El Salvador, Jamaica, Nicaragua, Panama and Uruguay. Working group members selected this study as the first research initiative because of the access to the university population, support for the initiative from home institutions, and the likelihood that the results from this initiative would serve to stimulate further interest and effort on child maltreatment and drug use in the region. This study will provide important preliminary information as to whether childhood maltreatment in the selected countries, where physical discipline may be culturally acceptable among some groups, is associated with later drug use and problems. The role of potential mediators and moderators, such as family history of substance abuse, psychological distress, and resiliency, will be examined. This study was seen as an essential first step to assessing the demand reduction potential of effectively addressing child maltreatment, and to stimulating further efforts in this area.
Final Considerations
Child maltreatment is a global public health concern and appears to be a precursor to major difficulties later in life. One of these problems is an increased risk for drug use and resulting problems. Further identification of the role that child maltreatment can play in drug use and problems may provide important insights for prevention and amelioration of drug problems through demand reduction. Latin America and the Caribbean contain a rich and diverse group of countries, with a wide range of cultures. As yet, research on the potential role of child maltreatment in creating risk for drug use and problems in the region is very limited. An understanding of this relationship could create important opportunities for demand reduction initiatives to control substance-related problems.
The multinational CICAD/CAMH research partnership described here will stimulate research on child maltreatment and substance use in LAC, and facilitate the exchange of expertise and sharing of resources. We hope not only to identify risks, but also to identify protective factors that may intervene in pathogenic processes. The results of the research program may also have implications for strengthening drug treatment approaches for people who have suffered maltreatment during their childhood. Nevertheless, we recognize that this initiative is a preliminary one, and our most important goal is to stimulate more research in LAC countries and beyond on these issues.
Acknowledgements
The authors are grateful for valuable input, support and encouragement from Drs. D.A. Wolf, B. Brands, N. Giesbrecht, C. Strike, L. Simich, Mr. A. Khenti, Ms. K. Lo, Mr. R. Chung and Ms. G. Stoduto. The Inter-American Drug Abuse Control Commission, the Centre for Addiction and Mental Health, and the Department of Foreign Affairs and International Trade of Canada supported the work reported here. The authors acknowledge the support of their home institutions for this initiative, and Drs. Hamilton, Erickson and Mann also acknowledge ongoing funding support from the Ontario Ministry of Health and Long-Term Care.
Conflict of Interest Statement
None.
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