...1995). One frequently observed outcome is adolescent or adult substance use. Using household probability sample of adolescents, Kilpatrick and colleagues found that young people who reported sexual assault in the year prior to the study were 2.4 times more likely to report alcohol abuse, 1.6 times more likely to report marijuana use, and 2.6 times more likely to report hard drug use than other youth after controlling age, sex, ethnicity, familial drug and alcohol problems, and physical assault (Kilpatrick et al., 2000). Other researchers have reported similar associations between sexual abuse and substance use (e.g., Luster & Small, 1997; Miller & Downs, 1993; Saunders, Kilpatrick, Hanson, Resnick, & Walker, 1999). In addition, existing research reveals that the relationship between sexual abuse and substance use persists even when controlling demographic variables (Kilpatrick et al., 2000), familial drug and alcohol abuse (Kilpatrick et al., 2000; Spak, Spak, & Allebeck, 1998), psychopathology (Spak et al., 1998), physical child abuse, parental absence, and family involvement in crime (Dembo et al., 1992a, 1992b).

It remains a matter of speculation as to why childhood sexual abuse is associated with substance use later in life. A clear understanding of the mechanisms by which sexual abuse results in substance use is necessary to guide efforts at treatment for those who have been victimized.

Potential Pathways from Sexual Abuse to Substance Use

The literature on the effects of sexual abuse offers some clues as to mechanisms that may link childhood victimization and later substance use. Finkelhor and Kendall-Tackett (1997) suggest that trauma and stress resulting from childhood sexual victimization can alter the normative course of cognitive and social development for children. Their assertion converges with a wealth of data tying sexual abuse to problems with fundamental developmental tasks such as the formation of identity and self-concept (e.g., Briere & Elliott, 1994; Feiring, Taska, & Lewis, 1996) and behavioral self-control (e.g., Brodsky et al., 2001; Herrera & McCloskey, 2001; Katz, 2000). Negative self-concept (Harter, 1999) and deficient self-control have been identified, in turn, as risks for adolescent substance use (Hawkins, Catalano, & Miller, 1992; Neumark-Sztainer, Story, French, & Resnick, 1997). Therefore, it is possible that negative self-concept and behavioral under-control (BUC) constitute pathways from child sexual abuse to adolescent substance use.

Depressive Self-Concept

A large body of theoretical work supports the notion that child abuse in general and sexual abuse in particular are damaging to victims' identity formation and positive sense of self (e.g., Briere & Elliott, 1994; Harter, 1999). In a review of literature linking abuse and self-concept. Harter and colleagues conclude that childhood abuse leads to feelings of inner "badness" among victims (Harter, 1999; Harter, Bresnick, Bouchey, & Whitesell, 1997). They note especially "the sense of profound negativity that female adolescent sexual abuse victims experience with regard to their core self" (Harter et al., 1997, p. 849). Damage to sexual abuse victims' self-worth is thought to occur in two main ways: internalization of blame and feelings of stigmatization. Westen (1994) suggests that self-blame for abuse among children (especially younger ones) originates in two developmentally driven tendencies. First, children tend to think in egocentric ways, and are unlikely to assign blame externally. Second, because they are concerned with security, children are loath to assume that they are unable to protect themselves; self-blame allows them a sense of control over their bodies and environment. Finkelhor and Browne (1985) propose that stigmatization is one of the main traumatogenic dynamics of sexual abuse. These authors argue that feelings of stigmatization result from guilt, shame, and a sense of isolation in terms of victim status that often accompany sexual abuse.

Empirical evidence tying childhood sexual abuse and poor self-concept is accumulating. In a meta-analysis of existing literature, Jumper (1995) found a significant but small relationship between child sexual abuse and low self-esteem among women (r = .24). Using a sample of agency-identified maltreated children and nonmaltreated controls, Bolger, Patterson, and Kupersmidt (1998) found that sexual abuse predicted both initial level of self-esteem (r = -.19) and rate of change in self-esteem over time when other types of maltreatment were controlled. In another study using data from an agency sample, girls reported more shame about sexual abuse events than boys (d [approximately equal to] .4). Adolescent girls and boys reported both more depressive symptoms (d [approximately equal to] .4) and lower self-worth (d [approximately equal to] .5) than younger children (Feiring, Taska, & Lewis, 1999). In summary, low self-esteem accompanies sexual abuse, especially among girls, and especially during adolescence.

Negative feelings about the self, in turn, relate to substance use in adolescence and adulthood. From a theoretical standpoint, low self-esteem, depression, and hopelessness may result in attempts to dissociate from or escape the pain of low self-regard by engaging in self-destructive and escapist behaviors such as drug use (Harter, 1999). In other words, adolescents who feel badly about themselves may self-medicate in order to feel better, at least temporarily. In the Christchurch Health and Development Study, multiproblem (i.e., delinquent, substance using, etc.) youth were more often in the lowest decile of self-esteem and reported higher rates of suicidal ideation (29.6%) compared to other youth (10.3%, Fergusson, Horwood, & Lynskey, 1994). Data from the Minnesota Student Survey suggest that high self-esteem is negatively correlated with suicide risk and substance abuse (r = -.49, r = -.26, respectively) among girls (Neumark-Sztainer et al., 1997). Finally, Gutierres and Todd (1997) concluded that existing research consistently suggests that drug users as a group have lower self-esteem than nonusers.

A small body of research provides support for the notion that low self-worth may mediate the effects of sexual abuse on later substance use. Dembo and colleagues have conducted a series of studies examining the mediating role of self-derogation (i.e., low global self-esteem) between physical and sexual victimization in childhood and later substance use (Dembo et al., 1987; Dembo et al., 1989). Using data from detainees in a juvenile detention center, they found that self-derogation partially mediated the effects of physical and sexual abuse on substance use; both types of abuse continued to have direct effects on substance use as well.

Behavioral Under-Control

Behavioral under-control encompasses sensation- or risk-seeking, aggression, impulsivity, hyperactivity, and inattention (e.g., Colder & Stice, 1998; Dawes, Tarter, & Kirsci, 1997). Some authors have proposed physiological mechanisms to account for the link between aspects of behavioral self-regulation. Brodsky et al. (2001) review evidence indicating that low serotonin may reflect a common biological substrate for aggression and impulsivity. A growing body of research suggests that exposure to stress in childhood can affect brain structure and chemistry, including levels of stress hormones and serotonin (Bremner, 1999). Thus, stress associated with childhood sexual abuse may lead to lowered serotonin levels and blunted responses to stress that are associated with BUC.

The literature on sexual abuse reveals some support for this constellation of behaviors among victims. For example, in one sample of substance abusing adolescent girls, a composite measure of physical and sexual victimization in childhood was correlated significantly with a BUC factor incorporating measures of hyperactivity, impulsivity, and inattention (Mezzich et al., 1997). Data from a sample of adult inpatients indicated that a history of physical or sexual abuse in childhood was associated with higher levels of self-reported impulsivity (d = .5) and aggression (d = .5) (Brodsky et al., 2001).

Behavioral under-control has been investigated as a catalyst in the adolescent risk-behavior literature (e.g., Dawes et al., 1997; Solof, Lunch, & Moss, 2000). Data from the Minnesota Twin Family Study revealed that girls and boys who reported drinking before age 14 scored between .2 and .5 standard deviations above nondrinkers on teacher-rated measures of opposition, hyperactivity, impulsivity, and inattention (McGue, Iacono, Legrand, Malone, & Elkins, 2001). Findings from a sample of alcohol-abusing or alcohol dependent and comparison adolescents revealed significantly higher levels of self-reported impulsivity and aggression among both male and female problem drinkers (Solof et al., 2000). Colder and Stice (1998) focused on impulsivity as a key indicator of disinhibition in their 9-month longitudinal study of high school seniors, and found that it predicted substance use both concurrently and prospectively when controlling for initial levels of use. Finally, data from the Minnesota Student Survey revealed that risk-taking disposition predicted drug use among 6th, 9th, and 12th grade girls (Neumark-Sztainer et al., 1997).

Aims and Hypotheses

The present study aims to extend past research in two ways. The first goal is to compare the risk of substance use among girls who were sexually abused in childhood to girls who reported no sexual abuse history, using a 9-year longitudinal design and instituting controls for potentially confounding variables. Many researchers have relied exclusively on retrospective designs using adult samples, and some have neglected to include control groups, or a sufficient number of plausible control variables that might otherwise account for substance use.

We expect that childhood sexual abuse will predict drug and alcohol use in adolescence independently of witnessing interparental violence and experiencing physical child abuse. We also include controls for parenting practices, maternal illicit drug use, and childhood maladjustment. Past multivariate analyses indicate that ethnicity, family income, family mobility, isolation from extended family members, biological relatedness of the mother's partner to her child, maternal drinking, maternal employment,...

NOTE: All illustrations and photos have been removed from this article.



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