Navigation

Drug Abuse Treatment

INTRODUCTION

In her seminal article titled "Where's Poppa?," Phares (1) noted that fathers have not been adequately represented in research examining empirical links between disturbance in the psychosocial adjustment of parents and emotional-behavioral difficulty in children. Building on the work of Caplan and Hall-McCorquodale (2, 3), she outlined a number of reasons for the historical focus on poor mothering as the primary cause of emotional--behavioral difficulty in children, and she refuted a number of myths that have contributed to the underrepresentation of fathers in research examining parenting and risk for poor developmental outcomes in children. Some 10 years later, her comments about the relative neglect of fathers seem particularly relevant for the drug abuse research community.

At this time, there is clear evidence that paternal substance abuse represents global risk for poor developmental outcomes in children, particularly heightened risk for the transmission of substance abuse across generations (4-14). Similarly, paternal substance abuse has been linked with a host of other problems that represent threats to normative child development. In research performed from several different perspectives, paternal substance abuse has been associated with disturbance in personality functioning, poor vocational adjustment, poor marital relationships, disruption of family environments, spousal abuse, child abuse, and parental neglect (15-23). However, with very few exceptions [e.g., Brook et al. (24) and Eiden et al. (25, 26)], fathering has been ignored in the design of research examining the adverse consequences of chronic drug and alcohol abuse (27-30). Although researchers (31-36) have been exploring the nature of maternal drug abuse, parenting, and risk for poor developmental outcomes in children, very little is known about the dynamics of fathering in the context of chronic drug abuse.

Moreover, research on drug abuse and fathering has been hampered by inadequate documentation of parenting responsibilities within samples of drug-abusing men. Although researchers [e.g., McMahon and Luthar (37)] occasionally document parenting status in research done with drug-abusing women, the status of drug-abusing men as fathers is rarely noted in published surveys of either the general population or populations of individuals seeking treatment. Consequently, this study was designed to document the parenting status of men seeking methadone maintenance treatment and clarify ways their status as parents differs from that of women seeking the same treatment.

METHOD

Sample

The sample for this study was drawn from a cohort of 572 opioid-dependent individuals accounting for 606 requests for outpatient treatment during a 12-month period. Complete data were available for 524 individuals. Data for 48 applicants were excluded because information concerning their status as a parent was missing. Data for 33 applicants who made a second or, in one instance, a third request for services during the 12-month period of interest were limited to information collected at the time of their first request.

Characteristics of the final sample are summarized in Table 1. As indicated, it consisted of 362 men and 162 women who were, on average, approximately 36 years of age. A majority of the applicants were of Euro American heritage. Applicants of African American and Hispanic heritage composed approximately 30% of the cohort. Most of the applicants had never been married, many were supporting themselves with some form of public entitlement, and all were living in southcentral Connecticut. On average, the applicants had been using opioids regularly for a period of approximately 13 years, more than half of the cohort was using opioids intravenously, and almost half were also using cocaine.

When the 48 individuals excluded from the sample because of missing data were compared with the 524 individuals retained, there were no significant differences in age, gender, ethnicity, marital status, years of regular opioid use, or secondary use of cocaine. When the men retained in the final sample were compared with the women, there were significant differences in age IF(l, 522)=6.60; p=0.01], marital status ([chi square]=6.55; df=2; N=524; p=0.04), source of financial support ([chi square]=8.12; df=1; N=524; p=0.004), age at time of first opioid use [F(1, 522)=21.11; p<0.0001], and years of regular opioid use [F(1, 522)=32.86; p<0.0001]. As indicated in Table 1, the men were, on average, approximately 2 years older, they were more likely to never have been married, and they were less likely to be supporting themselves with public entitlements, primarily because a greater percentage of women were receiving Temporary Assistance for Needy Families (TANF) benefits. As a group, the men also had begun using opioids approximately 3 years earlier than the women, and because they were older, they had been using approximately 5 years longer.

Procedure

With approval of the local institutional review board, a trained research assistant coded 1) demographic data, 2) information concerning parenting status, and 3) information concerning drug abuse history from records of the 606 clinical screenings completed during the 12-month period of interest. These screenings were all conducted face-to-face by clinical staff working in a central intake unit established to evaluate individuals seeking admission to methadone maintenance treatment and clinical trials exploring the efficacy of pharmacological intervention for opioid dependence.

Measurement

Data used in this study were systematically coded from a structured clinical interview designed to establish eligibility for methadone maintenance treatment. In addition to the demographic and drug abuse characteristics listed in Table 1, data coded from this structured interview were used to define three dimensions of parenting status: 1) categorical status as the parent of at least one biological child, 2) number of biological children, and 3) number of minor biological children. Five dimensions of parenting status were also defined for each applicant who reported having at least one biological child: 1) age of youngest child, 2) age of oldest child, 3) residence with at least one biological child, 4) age at birth of oldest child, and 5) drug abuse status at birth of oldest child. Data collected from the 33 individuals who sought assistance a second time during the 12-month period of interest reflected nearly perfect agreement in the coding of information collected by different clinicians over an average of 143 (SD=82) days. In addition, the few inconsistencies present in the data all represented plausible changes in marital, parenting, or drug abuse status.

Data Analysis

Descriptive statistics were used to characterize the parenting status of men and women. Chi-square tests of association were then used to test for significant relationships between gender and the categorical variables. Analyses of variance were used to test for significant gender differences in continuous variables. The relationship between categorical status as a biological parent and gender was tested by using the full cohort. All other tests were performed by using the subset of biological parents within the cohort. To hold the Type I error rate for the study at no more than 0.05, only statistics with p values less than 0.006 were considered statistically significant.

RESULTS

Within this cohort, 328 (63%) of the 524 applicants were the biological parent of at least one child. As expected, women were more likely than men to be the biological parent of at least one child ([chi square]=35.72; df=1; N=524; p<0.001). As indicated in Table 2, 81% of the women and 54% of the men were biological parents. However, data presented in Table 2 indicate that there were actually more fathers than mothers in the cohort because men seeking treatment outnumbered women more than 2 to 1. Fathers also accounted for a majority of the parents seeking admission, and men with children comprised the largest subgroup of individuals seeking treatment.

When fathers were compared with mothers, the men were significantly older when they first became a parent [F(1,326)=19.04; p<0.0001], and they were more likely to have already been using opioids regularly when their first child was born ([chi square]=27.32; df=1; N=328; p<0.0001). As indicated in Table 3, the men were, on average, almost 3 years older than the women when they first became a parent. Moreover, as noted in Table 4, 63% of the fathers versus only 33% of the mothers were already using opioids regularly when their first child was born. Fathers also accounted for 74% of the parents using at the time their first child was born, and men using when their first child was born accounted for the largest subgroup of parents entering treatment.

Despite these differences associated with the onset of parenthood, there were no significant gender differences in the number of children [F(1, 326)=1.91; p=0.17], the number of minor children [F(1, 326)=2.15; p=0.14], age of youngest child [F(1, 326)=0.14; p=0.70], or age of oldest child [F(1, 695)=0.21; p=0.65]. As indicated in Table 3, both fathers and mothers averaged approximately two children each, and they averaged approximately 1.5 minor children. The youngest child of both men and women was, on average, approximately 10 years of age, whereas the oldest child was, on average, approximately 14 years of age.

Finally, 100 (30.5%) of the 328 parents were living with at least one biological child at the time they sought treatment. Mothers were more likely than fathers to be living with a biological child ([chi square]=23.35; df=1; p<0.0001). As noted in Table 5, 45% of the mothers versus 20% of the fathers were living with at least one biological child. Furthermore, even though fathers outnumbered mothers within the cohort, data presented in Table 5 indicate that there were actually more mothers than fathers living with a biological child. However, nonresident fathers defined, by far, the largest group of parents seeking treatment.

DISCUSSION

When considered within the existing literature on drug abuse and parenting, the results of this study highlight a number of important issues concerning the parenting status of men within this local cohort of individuals seeking methadone maintenance treatment. When parenting status was examined by gender, there was a sizable group of fathers within the cohort, there were actually more fathers than mothers, and men with children defined the largest group of individuals seeking treatment. Moreover, when fathers were compared with mothers, there were no significant differences in the number of children nor the average age of their children. When compared with mothers, fathers were, however, more likely to have already been abusing opioids when they first became a parent. Although few parents of either gender were living with any of their biological children, fathers were also more likely to be living away from all their children, and nonresident fathers defined the largest group of parents seeking treatment.

Careful review of data that can sometimes be extracted from large-scale surveys of the general population highlight similar patterns in the relationship between gender, drug use. and parenting status. For example, in a secondary analysis of the National Household Survey on Drug Abuse, the U.S. Department of Health and Human Services (38) summarized data indicating that, within the general population, there are probably more fathers than mothers using illicit drugs. Those data also suggest that, among parents who use illicit drugs, fathers are more likely than mothers to be living away from their minor biological children. However, the percentage of drug-abusing men living with at least some of their biological children appears to be much higher in the general population.

Similar trends have also been noted in data extracted from large-scale surveys of individuals seeking substance abuse treatment. For example, in a secondary analysis of the California Drug and Alcohol Treatment Assessment (CALDATA), Gerstein et al. (39) found that, when compared with men, a greater percentage of women seeking substance abuse treatment in California had minor children living in their household at the time of their admission. However, because men outnumbered women, approximately equal numbers of men and women were entering treatment with a child living in their home. Likewise, Wechsberg et al. (40) found that, compared with men, a greater percentage of women participating in the Drug Abuse Treatment Outcome Study (DATOS) was entering drug abuse treatment with minor children living in their household, but because men also outnumbered women within that cohort, approximately equal numbers of men and women were living with minor children when they entered treatment.

Similar trends in the relationship between gender and parenting status have also been briefly noted in smaller, less representative samples of drug-abusing adults. For example. Chatham et al. (41) found that men entering methadone maintenance were less likely than women to be living with children. Again, because men outnumbered women, there were actually more men than women living with children at the time of admission, and there was no significant gender difference in the average number of children in the home. Freeman et al. (42) found a similar relationship between gender and residence with children in a representative sample of intravenous drug users not enrolled in treatment. In a recent examination of patterns of residence with biological children within a community sample of intravenous drug users, Pilowsky et al. (43) found that fathers were less likely than mothers to be living with at least one biological child under 14 years of age, but the correlates of residential status for fathers did not differ significantly from those for mothers.

Review of this literature also highlights a number of conceptual and methodological issues that complicate clear documentation of parenting status among drug-abusing men. First, parenting status is rarely documented in studies of drug-abusing adults. Review of the literature suggests that researchers do not typically document the parenting status of drug-abusing adults unless there is interest in comparing the psychosocial adjustment of drug-abusing men and women (40-42). Researchers [e.g., McMahon and Luthar (37)] also document parenting status in research done exclusively with women.

Moreover, when the parenting status of men is documented, it is often documented in a way that deemphasizes the actual number of fathers. For example, in the secondary analyses of the National Household Survey on Drug Abuse done by the U.S. Department of Health and Human Services (38), the secondary analysis of CALDATA done by Gerstein et al. (39), and several investigations of gender differences in the nature of drug abuse (41, 42), the focus tends to be on simple coding of residence with a minor child. Presentations of these data often do not differentiate nonresident parents from individuals with no biological children (38), despite the fact that the results of this study and others (43) suggest that nonresident parents, particularly nonresident fathers, represent the largest group of parents with drug abuse problems.

Almost all research examining the parenting status of drug-abusing individuals has involved secondary analysis of existing data (38, 39) or limited coding of parenting status within investigations being done for other reasons (42). Consequently, key variables are often not available, or they are not clearly defined. For example, simple coding of residence with minor children does not offer important information about the number of children present, the age of the children, the nature of the adult-child relationship, and the whereabouts of other children with whom the adult may have a biological or social relationship. Likewise, as in this study, coding of information about biological children ignores the fact that drug-abusing fathers may be living with children they did not conceive. Furthermore, existing data concerning parenting status are often not readily available in peer-reviewed journals (39, 40), and in research reports prepared for peer-reviewed journals (40-43), a focus on statistical differences in the proportion of mothers versus fathers rather than the absolute number of fathers versus mothers may be contributing to misperceptions that there are relatively few drug-abusing fathers within clinical samples.

Assuming the results of this study accurately reflect the presence of fathers within populations of individuals seeking drug abuse treatment, they highlight the need for additional information about the dynamics of fathering as it occurs in the context of chronic drug abuse (27-30). The results suggest that, after a clear accounting of drug-abusing fathers, there is need to better document ways the parenting behavior of drug-abusing men differs from that of both drug-abusing women and men with no history of alcohol or drug abuse. Assuming chronic drug abuse compromises ability to function effectively as a father, there is also need to better document how that occurs over time and how failure to function as a parent affects the psychological state of drug-abusing men. Given evidence (4-14) that paternal drug abuse represents global risk for compromise of normative child development, there is also need to better document ways the parenting behavior of drug-abusing fathers affects the cognitive, emotional, and social development of their children.

Finally, given indications that drug-abusing men typically begin fathering children after the onset of serious drug abuse, the results of this study highlight the need for clinical intervention that specifically targets the sexual behavior of drug-abusing men who may not be prepared to fulfill the social obligations they would incur with the birth of a child (27). Assuming at least some drug-abusing men are interested in being more effective parents, there is need for clinical intervention to support them in their role as fathers, particularly as nonresidential fathers (27). Moreover, even if most drug-abusing men are not interested in being more effective parents, there is still need for clinical intervention designed to support the mothers of their children and targeted prevention designed to minimize whatever risk for poor developmental outcomes their children incur (27).

Table 1. Characteristics of men and women
seeking treatment for opioid dependence

Variable                       Full sample     Men         Women

Age                             36.3 (7.6)   36.8 (8)     35.0 (6.7)
Ethnicity
  Euro American                 68.3 (358)   67.1 (243)   71.0 (115)
  African American              17.9 (94)    17.7 (64)    18.5 (30)
  Hispanic                      12.0 (63)    14.1 (51)     7.4 (12)
  Other                          1.7 (9)      1.1 (4)      3.1 (5.0)
Marital status
  Never married                 57.8 (303)   61.4 (222)   49.7 (80)
  Currently married             22.3 (117)   20.3 (74)    26.7 (43)
  Previously married            19.9 (104)   18.3 (66)    23.6 (38)
Receiving public entitlement    50.6 (265)   46.4 (168)   59.9 (97)
Age of first opioid use         23.3 (7.2)   25.5 (7)     22.4 (7.2)
Years of regular opioid use     12.9 (9.1)   14.4 (10)     9.5 (7.2)
Intravenous use of opioids      55.0 (288)   57.5 (208)   49.4 (80)
Secondary use of cocaine        43.2 (226)   41.5 (150)   46.8 (76)

N=524; 362 men and 162 women. Values represent M (SD)
for the continuous variables (age, age of first opioid
use, and years of regular opioid use), and % (n) for
the categorical variables (ethnicity, marital status,
receiving public entitlement, intravenous use of opioids,
and secondary use of cocaine).

Table 2. Parenting status of men and women seeking treatment for
opioid dependence
                         Men    Women
Biological parent
  Yes
    Count (n)           196     132
    Percent of row       59.8    40.2
    Percent of column    54.1    81.5
    Percent of sample    37.4    25.2
  No
    Count (n)           166      30
    Percent of row       84.7    15.3
    Percent of column    45.9    18.5
    Percent of sample    31.7     5.7

N=524; 362 men and 162 women.

Table 3. Characteristics of fathers and mothers seeking treatment for
opioid dependence

                             Fathers        Mothers

Number of children         2.05 (1.07)    2.23 (1.21)
Number of minor children   1.55 (1.12)    1.74 (1.21)
Age of youngest child      9.75 (7.27)    10.05 (6.67)
Age of oldest child        13.72 (8.39)   14.12 (6.69)
Age became parent          24.41 (5.92)   21.72 (4.76)

n=328 parents; 196 fathers and 132 mothers. Values represent M (SD).

Table 4. Drug abuse status of fathers and mothers at birth of oldest
child

                           Fathers     Mothers

Drug abuse status
  Using
    Count (n)               123         44
    Percent of row           73.6       26.3
    Percent of column        62.8       33.3
    Percent of sample        37.5       13.4
  Not using
    Count (n)                73         88
    Percent of row           45.3       54.7
    Percent of column        37.2       66.7
    Percent of sample        22.3       26.8

n=328 Parents: 196 fathers and 132 mothers.

Table 5. Residential status of fathers and mothers seeking
treatment for opioid dependence

                                            Fathers     Mothers

Living with at least one biological child
  Yes
    Count (n)                                 40          60
    Percent of row                            40.0        60.0
    Percent of column                         20.4        45.5
    Percent of sample                         12.2        18.3
  No
    Count (n)                                156          72
    Percent of row                            68.4        31.6
    Percent of column                         79.6        54.5
    Percent of sample                         47.6        21.9

n=328 parents; 196 fathers and 132 mothers.

ACKNOWLEDGEMENTS

This research was supported by the National Institute on Drug Abuse (Grants P50 DA09241 and R03 DA11988) and the Weltner Research Fellowship administered by the Connecticut Mental Health Center Foundation, New Haven, Connecticut. The authors thank Rajita Sinha for her support of this project.

REFERENCES

(1.) Phares V. Where's poppa? The relative lack of attention to the role of fathers in child and adolescent psychopathology. Am Psychol 1992; 47:656-664.

(2.) Caplan PJ, Hall-McCorquodale I. Mother-blaming in major clinical journals. Am J Orthopsychiatry 1985; 55:345-353.

(3.) Caplan PJ, Hall-McCorquodale I. The scapegoating of mothers: a call for change. Am J Orthopsychiatry 1985; 55:610-613.

(4.) Chassin L, Pitts SC, Prost J. Binge drinking trajectories from adolescence to emerging adulthood in a high-risk sample: predictors and substance abuse outcomes. J Consult Clin Psychol 2002; 70:67-78.

(5.) Clark DB, Moss HB, Kirisci L, Mezzich AC, Miles R, Ott P. Psychopathology in preadolescent sons of fathers with substance use disorders. J Am Acad Child Adolesc Psychiatry 1997; 36:495-502.

(6.) Clark DB, Parker AM, Lynch KG. Psychopathology and substance-related problems during early adolescence: a survival analysis. J Clin Child Psychol 1999; 28:333-341.

(7.) Hill SY, Locke J, Lowers L, Connolly J. Psychopathology and achievement in children at high risk for developing alcoholism. J Am Acad Child Adolesc Psychiatry 1999; 38:883-891.

(8.) Hill SY, Muka D. Childhood psychopathology in children from families of alcoholic female probands. J Am Acad Child Adolesc Psychiatry 1996; 35:725-733.

(9.) Loukas A, Fitzgerald HE, Zucker RA, von Eye A. Parental alcoholism and co-occurring antisocial behavior: prospective relationships to externalizing behavior problems in their young sons. J Abnorm Child Psychol 2001; 29:91-106.

(10.) Merikangas KR, Dierker LC, Szatmari P. Psychopathology among offspring of parents with substance abuse and/or anxiety disorders: a high-risk study. J Child Psychol Psychiatry 1998; 39:711-720.

(11.) Moss HB, Lynch KG, Hardie TL, Baron DA. Family functioning and peer affiliation in children of fathers with antisocial personality disorder and substance dependence: associations with problem behaviors. Am J Psychiatry 2002; 159:607-614.

(12.) Schuckit MA, Smith TL. An 8-year follow-up of 450 sons of alcoholic and control subjects. Arch Gen Psychiatry 1996; 53:202-210.

(13.) Schuckit MA, Smith TL, Radziminski S, Heyneman EK. Behavioral symptoms and psychiatric diagnoses among 162 children in nonalcoholic or alcoholic families. Am J Psychiatry 2000; 157:1881-1883.

(14.) Sher KJ, Walitzer KS, Wood PK, Brent EE. Characteristics of children of alcoholics: putative risk factors, substance use and abuse, and psychopathology. J Abnorm Psychol 1991; 100:427-448.

(15.) Corbisiero JP, Reznikoff M. The relationship between personality type and style of alcohol use. J Clin Psychol 1991; 47:291-298.

(16.) Dion MR, Braver SL, Wolchik S, Sandler IN. Alcohol abuse and psychopathic deviance in noncustodial parents as predictors of child-support payment and visitation. Am J Orthopsychiatry 1997; 67:70-79.

(17.) Dumka LE, Roosa MW. The role of stress and family relationships in mediating problem drinking and fathers' personal adjustment. J Stud Alcohol 1991; 56:528-537.

(18.) Egami Y, Ford DE, Greenfield SF, Crum RM. Psychiatric profile and sociodemographic characteristics of adults who report physically abusing or neglecting children. Am J Psychiatry 1996; 153:921-928.

(19.) Ichiyama MA, Zucker RA, Fitzgerald HE, Bingham CR. Articulating subtypes differences in self and relational experience among alcoholic men using structural analysis of social behavior. J Consult Clin Psychol 1996: 64:1245-1254.

(20.) Jacob T, Krahn GL, Leonard K. Parent--child interactions in families with alcoholic fathers. J Consult Clin Psychol 1991; 59:176-181.

(21.) Leonard KE, Senchak M. Prospective prediction of husband aggression within newly wed couples. J Abnorm Psychol 1996; 105:369-380.

(22.) Reich W, Earls F, Powell J. A comparison of the home and social environments of children of alcoholic and non-alcoholic fathers. Br J Addict 1988; 83:831-839.

(23.) Tarter RE, Blackson TC, Martin CS, Seilhamer R, Loeber R, Moss HB. Characteristics and correlates of child discipline practices in substance abuse and normal families. Am J Addict 1993; 2:18-25.

(24.) Brook DW, Brook JS, Whiteman M, Arencibia-Mireles O, Pressman MA, Rubenstone E. Coping in adolescent children of HIV-positive and HIV-negative substance-abusing fathers. J Genet Psychol 2002; 163:5-23.

(25.) Eiden RD, Chavez F, Leonard KE. Parent-infant interaction among families with alcoholic fathers. Dev Psychopathol 1999; 11:745-762.

(26.) Eiden RD, Leonard KE. Paternal alcoholism, parental psychopathology, and aggravation with infants. J Subst Abuse 2000; 11:17-29.

(27.) McMahon TJ, Rounsaville BJ. Substance abuse and fathering: adding poppa to the research agenda. Addiction 2002; 97:1109-1115.

(28.) Parke RD. Substance-abusing fathers: descriptive, process and methodological perspectives. Addiction 2002: 97:1118-1119.

(29.) Phares V. Finding poppa in substance abuse research. Addiction 2002; 97:1119-1120.

(30.) McMahon TJ, Rounsaville BJ. Substance abuse and fathering: some final comments on context and process. Addiction 2002; 97:120-122.

(31.) Bernstein VJ, Hans SL. Predicting the developmental outcome of two-year-old children born exposed to methadone: impact of social-environmental risk factors. J Clin Child Psychol 1994; 23:349-359.

(32.) Goodman G, Hans SL, Cox SM. Attachment behavior and its antecedents in offspring born to methadone-maintained women. J Clin Child Psychol 1999; 28:58-69.

(33.) Hans SL, Bernstein VJ, Henson LG. The role of psychopathology in the parenting of drug-dependent women. Dev Psychopathol 1999; 11:957-977.

(34.) Luthar SS, Cushing G, Merikangas K, Rounsaville BJ. Multiple jeopardy: risk and protective factors among addicted mothers' offspring. Dev Psychopathol 1998; 10:117-136.

(35.) Suchman NE, Luthar SS. The mediating role of parenting stress in methadone-maintained mothers' parenting. Parenting Sci Pract 2001; 1:285-315.

(36.) Suchman NE, Luthar SS. Maternal addiction, child maladjustment, and sociodemographic context: implications for parenting behaviors. Addiction 2000; 95:1417-1428.

(37.) McMahon TJ, Luthar SS. Women in treatment: within-gender differences in the psychosocial adjustment of opioid-dependent women. J Nerv Ment Dis 2000; 188:679-687.

(38.) U.S. Department of Health and Human Services. Substance Abuse Among Women and Parents. Rockville, MD: U.S. Department of Health and Human Services, 1994.

(39.) Gerstein DR, Johnson RA, Larison CL, Harwood HJ, Fountain D. Alcohol and Other Drug Treatment for Parents and Welfare Recipients: Outcomes, Costs, and Benefits. Rockville, MD: U.S. Department of Health and Human Services, 1994.

(40.) Wechsberg WM, Craddock SG, Hubbard RL. How are women who enter substance abuse treatment different than men? A gender comparison from the drug abuse treatment outcome study. Drugs Soc 1998; 13:97-115.

(41.) Chatham LR, Hiller ML, Rowan-Szal GA, Joe GW, Simpson DD. Gender differences at admission and follow-up in a sample of methadone maintenance clients. Subst Use Misuse 1999; 34:1137-1165.

(42.) Freeman RC, Rodriquez GM, French JF. A comparison of male and female intravenous drug users' risk behaviors for HIV infection. Am J Drug Alcohol Abuse 1994; 20:129-157.

(43.) Pilowsky DJ, Lyles CM, Cross SI, Celentano D, Nelson KE, Vlahov D. Characteristics of injection drug using parents who retain their children. Drug Alcohol Depend 2001; 61:113-122.

Thomas J. McMahon

Division of Substance Abuse, Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA

Justin D. Winkel

Department of Psychology, University of Tennessee, Knoxville, Tennessee, USA Suniya S. Luthar

Department of Human Development, Teachers College, Columbia University, New York, New York, USA

Bruce J. Rounsaville

Division of Substance Abuse, Department of Psychiatry, Yale University School of Medicine, West Haven, Connecticut, USA

COPYRIGHT 2005 Taylor & Francis Ltd.
COPYRIGHT 2005 Gale Group