Using the common factor model of comorbidity, severe victimization experiences were hypothesized to be shared risk factors for ID and ED problems. The study found that indicators of victimization severity predicted co-occurring ID and ED problems, whereas, with the exception of victimization by trusted perpetrators, indicators of victimization severity were not associated with a single type of MH problem (i.e., ID-only or ED-only problem).
For types of severe experiences, frequently victimized adolescents or those victimized for longer duration were more likely to have co-occurring ID and ED problems, than were adolescents without frequent/long duration victimization experiences. These findings are consistent with research that suggests frequent victimization and/or longer duration victimization can place adolescents at risk for both ID and ED problems (Finkelman 1995
; Naar-King et al. 2002
). One explanation for these findings is that longer duration or frequent victimization experiences may place excessive demands on coping or pose a risk for maladaptive coping due to which adolescents may internalize or externalize their responses to these experiences. Additionally, frequent or long duration experiences imply that adolescents may have been experiencing abuse for a long time that has not been reported. Therefore, they may not have received timely mental health services or services to prevent re-victimization.
Adolescents with multiple types of victimization experiences were more likely to have co-occurring ID and ED problems, than were adolescents with a single type of victimization experiences. The findings are in line with research that shows multiple types of victimization relate to a greater number of, and more severe, negative outcomes than do single types of victimization (Finkelhor et al. 2007a
). The traumagenic dynamics involved in multiple types and more frequent victimization experiences (e.g., powerlessness and betrayal) or repeated negative messages that something is wrong with the victim, or he or she is at fault for the abuse, may increase the likelihood of both ID and ED problems.
Adolescents who reported being victimized within the past year were more likely to have co-occurring ID and ED problems than were adolescents who were victimized more than a year ago. Recently victimized adolescents may still be experiencing abuse or be worried about future abuse. Adolescents currently in abusive relationships have more MH and behavioral problems than do those who had been abused in the past (Luster and Small 1997
). Studies on adults also provide support for the negative effects of recent victimization. Recent abuse among adults has been associated with more dysfunctional coping methods and poorer MH than less recent abuse (Dale et al. 2009
Adolescents who were victimized by trusted perpetrators were more likely to have ID problems than were those victimized by a nontrusted abuser. These findings were similar to Trembley et al.’s findings (1999
). They found that children victimized by a close adult had more internalizing symptoms than those victimized by a more distant perpetrator (e.g., stranger or someone outside the family). A betrayal of trust by an emotionally close perpetrator may result in hurtful emotions and internalizing consequences (Leary et al. 1998
; Trembley et al. 1999
). In contrast, victimization by trusted perpetrators was not significantly related to an ED problem. Thus, victimization by trusted perpetrators may not be a shared risk factor for ID and ED problems, as predicted by the common-factors model for comorbidity.
Among the control variables, the study found some evidence for racial/ethnic differences in MH problems, with African Americans more likely to externalize and Hispanics more likely to internalize than other ethnic groups. These findings are consistent with some authors who found racial/ethnic differences in MH symptoms of victimized adolescents (Hatcher et al. 2009
). Cultural variations in values are one possible explanations for these differences. For example, African American culture may place a higher value on confrontation and assertiveness, which may be labeled as an externalizing behavior (McLaughlin et al. 2007
Gender was associated with significant differences in MH problems. Females were more likely to have an ID-only problem than males, and males were more likely to have an ED-only problem than females. Although these findings are consistent with the empirical literature that shows a relationship between gender and types of MH problems, the studies on gender variations among adolescents in internalizing and externalizing problems are mixed. While most studies show males in the general population are more likely to externalize (Darves-Bornoz et al. 1998
; Gallerani et al. 2010
), a national probability study on victims of child maltreatment show female adolescents are more likely to externalize than male adolescents (Wall et al. 2005
). A study on gender differences in psychiatric symptoms among adolescents by Edokpolo et al. (2010)
found that females with substance use disorders had more externalizing and internalizing problems than males. In this research, female adolescents appeared to be at higher risk than males for co-occurring ID and ED problems and ID-only problems.
In this study, age was another characteristic significantly related to MH. Studies show that internalizing and externalizing problems may increase or decrease with age. The change in MH problems with age may occur due to numerous psychological, biological, social, and contextual factors (Compas et al. 1995
). In this study, older adolescents were more likely than younger adolescents to have an ID-only problem. In contrast, younger adolescents were more likely than older adolescents to have an ED-only or co-occurring ID and ED problems. These findings are consistent with research that suggests that internalizing and externalizing symptoms vary markedly across childhood and from early to late adolescence (McLaughlin et al. 2007
Adolescents with substance abuse diagnoses were more likely to have an ED-only problem, versus neither ID nor ED problems, than were adolescents who did not meet the criteria of substance abuse. This is in line with research that shows a link between externalizing problems and substance abuse (see Jester et al. 2008
). In contrast, adolescents with substance dependence diagnoses, in this research, were more likely to have co-occurring ID and ED problems (versus ID-only, ED-only or neither ID nor ED problems) than were adolescents with no substance dependence diagnoses. The high rate of co-occurring ID and ED problems among substance-dependent adolescents in this study is consistent with research by Chan et al. (2008)
. In their study of 4,938 adolescents and 1,958 adults assessed for substance-abuse treatment, they found rates of co-occurring ID and ED problems were higher among respondents with past year dependence than those without. Substance dependence, therefore, appears to be a risk factor for co-occurring ID and ED problems, and substance abuse appears to be a risk factor for ED-only problems among victimized adolescents.
Stressors were significantly related to ID and ED problems among victimized adolescents. Adolescents who experienced a larger number of stressors were more likely to have co-occurring ID and ED problems (versus ED-only, versus ID-only or neither ID nor ED problems) than were adolescents with a smaller number of stressors. Additionally, adolescents with a large number of stressors were more likely to have an ID-only problem (versus ED-only) than adolescents with small number of stressors. Thus, stressors appear to be a risk factor for co-occurring ID and ED problems and ID-only problems among victimized adolescents.
Research shows stressors activate neurobiological responses necessary for individuals’ survival. If they occur frequently, these responses increase the risk of psychopathology in childhood and adolescence. Stressors may particularly trigger the onset of internalizing or externalizing symptoms in adolescents with certain types of genes and environmental experiences (Gunnar and Quevodo 2007
). Moreover, stressors, perceived as uncontrollable events have also been associated with severity of substance misuse (King and Chassin 2008
) and mental health (Scheniderman et al. 2005
; Turner et al. 2006
; Turner and Lloyd 1995
). Thus, life stressors are important factors that must be considered in future research and in substance abuse treatment with adolescents who have ID and ED issues.
Limitations of the present study include cross-sectional design and use of self-report data. The findings of the study might differ if multiple informants had been included and any inconsistencies between reports from adolescents and other sources had been evaluated. The sample included adolescents who were assessed at the time of intake for substance- abuse treatment, and, therefore, is not representative of the nonclinical population. The results on severe victimization experiences may have been influenced by the timing of the adolescents’ assessments. Due to limited time at intake assessment, the clinical staffs were unable to develop rapport with their clients. A good rapport is necessary to discuss sensitive issues such as severe victimization experiences (Perron et al. 2008
). Nevertheless, the findings are significantly strong to warrant attention to the role of severe victimization experiences in explaining comorbidity of ID and EDs among substance using adolescents.
Implications for Practice
The findings of the study have implications for prevention, assessment, and interventions. In this study, severe victimization histories were related to co-occurring ID and ED problems among adolescents. Co-occurring ID and ED problems among substance-using adolescents have been associated with other problems, such as crime involvement and poor treatment response (Chan et al. 2008
). Therefore, a quality treatment plan for substance using adolescents may require addressing other issues besides substance problems such as victimization experiences and MH needs. Integrated, trauma-informed treatment services (Clark 2002
; Finkelstein et al. 2004
; Harris 1998
; Hawkins 2009
) for substance using adolescents could be useful, as well as providing SA, MH and victim services in the same program. Trauma-sensitive treatment “refers to incorporating an awareness of trauma and abuse into all aspects of treatment and the treatment environment” (Clark 2002
, p. 1). Trauma-sensitivity needs to be incorporated in assessments, placement decisions, and prevention and intervention programs.
Given that severe victimization experiences appear to contribute to the risk of co-morbidity, assessment of adolescents presenting for substance abuse treatment must include not only a general assessment of a possible victimization history but an in-depth evaluation of severity of victimization. This additional depth would encompass specific dimensions of the experience (such as single versus multiple experiences, ongoing victimization, and so on) and questions about what happened, how it happened, why it happened, and what is to be done (Wall and Levy 2005
). A mixed-method instrument including quantitative and qualitative questions may be useful to examine the range of severe victimization experiences among these adolescents. For example, qualitative questions focusing on adolescents’ stories of victimization experiences in their own words may be useful to explore context and severity of victimization and the impact on adolescents.
For treatment planning and interventions, focusing on treating MH outcomes of specific types of victimization may not cover the full-range of adolescents’ treatment needs. It is crucial to address severe victimization experiences that may put them at risk or have harmful effects. According to Cohen et al. (2006)
, “effective treatment models may target specific symptoms clusters, developmental level, and/or level of severity/chronicity more than specific types of maltreatment/trauma experiences” (p. 739). This study found negative MH consequences associated with recent victimization, multiple types of victimization, frequent victimization experiences and for longer duration and, victimization by trusted perpetrators. As a large proportion of adolescents are less likely to have experienced single event victimization, one type of victimization or victimization only by a stranger, it is important for practitioners to understand their complex experiences in developing treatment plans. For instance, this study found that experiences of multiple types of victimization increased the risk for both internalizing and externalizing problems among adolescents. As adolescents often experience multiple types of victimization, interventions must be designed targeting the effects of multiple types of victimizations.
In their review of studies on the treatment of MH consequences of victimization, Cohen et al. (2006)
argued that interventions which effectively reduce MH problems in children exposed to one type of victimization are also effective for other types of victimization or for multiple types. For instance, trauma-focused cognitive behavioral therapy (TF-CBT), originally developed for sexual abuse victims, has been tested and shown to be effective for multiply victimized children.
The findings that severe victimization experiences are risk factors for co-occurring MH problems have key implications for prevention. They underscore the need for early identification of at-risk children and adolescents to prevent the onset of MH or behavioral problems. Early identification of risk can be done in multiple settings, such as schools, foster care, or juvenile justice residential facilities. Professionals working with children and adolescents in these settings must be made aware of the negative effects of victimization experiences on mental and behavioral health of children and adolescents. They must be trained in identifying at-risk children or adolescents and connecting them to appropriate resources. Timely mental health services can help promote adaptive coping among victimized adolescents and reduce their risk for developing substance abuse or MH problems.
Prevention efforts must also focus on reducing the risk for re-victimization. Adolescents with severe victimization histories and those in current abusive relationships are more likely to be revictimized. As recommended by Perron et al. (2008)
, prevention efforts in the form of psycho-education and cognitive-behavioral therapy groups included as part of the substance abuse treatment may help reduce the risk of victimization. Prevention efforts may promote use of resources that may prevent the onset of mental and behavioral health problems among victimized adolescents.