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Research Article                                                                                                                                        Open Access

## Experiences of victimization among adolescents with Substance Abuse Disorders in Sweden

Mats Anderberg* & Mikael Dahlberg

Linneaus University, Växjö, Sweden

*Corresponding author: mats.anderberg@lnu.se

## Abstract

Background: Adolescents who initiate treatment for substance abuse often have a history of victimization in the form of physical, psychological, or sexual abuse. These experiences can have serious adverse consequences that may affect their lives and social functioning.

Objective: This article describes and analyzes victimization among adolescents who are in outpatient treatment for substance abuse disorders with respect to gender, social circumstances, alcohol and drug abuse, and mental health.

Method: This cross-sectional study is based on structured interviews with 748 adolescents from seven outpatient clinics in Sweden. Chi-squared tests were performed to examine significant differences between gender and victimization (or lack of victimization). The study also included a quantitative content analysis of interview utterances.

Results: The analysis showed that more than half of the adolescents had experienced violence or another type of abuse. There are also significant gender differences: two thirds of the girls and slightly less than half the boys had experienced abuse in some form, and the girls had more severe needs at treatment admission.

Conclusion: This  study  established  that  experiences  of  victimization  and  exposure  to  violence  are  widespread  among adolescents with substance abuse disorders in Sweden. This is an important issue that requires attention and action, with preventive  and  therapeutic  interventions  needed  to  provide  support  for  both  substance  abuse  disorders  and  psychiatric symptoms.

Keywords: Adolescents; victimization; substance abuse; outpatient care

## Introduction

Victimization  during  childhood  is  a  serious  risk factor for future substance abuse disorders (1-4), and adolescents who present for drug and alcohol abuse treatment frequently have a history of exposure to violence  in  the  form  of  physical,  psychological,  or sexual abuse earlier in their lives (5). These experiences can have significant adverse consequences that  may  impact  the  lives  and  social functioning of these individuals.

An American study of 1655 adolescents found that 8% to 45% of those surveyed had been exposed to some  form  of  violence  during  the  past  year  (i.e., school violence, community violence, child abuse, or parental  intimate  partner  violence)  and  that  5%  to 30% had experienced two to three different types of violence,  primarily  exposure  to  violence  outside  of the  home  (6).  Another  American  study  of  a  large national sample estimated that one third of adolescents  reported  exposure  to  multiple  types of victimization (7). It is difficult to get a clear picture of  the  prevalence  of  victimization  or  exposure  to violence  among  adolescents  in  Sweden  in  general, but a report on the living conditions of adolescents showed  that  17%  of  15-  and  16-year-old  students reported having been victims of minor violence and that  5%  reported  being  victims  of  more  serious violence (8). This article sheds light on the relationship  between  adolescent  victimization  and substance abuse disorders on the basis of the findings of interviews with adolescents from several outpatient clinics in Sweden.

Drug  and  alcohol  use  commonly  begin  during adolescence. Nascent substance abuse problems may present and develop during this period, with future health  risks  and  social  problems  as  a  result.  Binge drinking and alcohol use among adolescents seem to have  generally  declined  in  Sweden  during  the  last decade, but there was a minor increase between 2007 and  2013  in  the  percentage  of  upper  secondary school pupils who had tried or used drugs, mostly cannabis. The increase was evident in both genders, with about 14% of boys and 10% of girls reporting drug use during the year prior (9).

During  recent years, there have  been  several national  initiatives  aimed  at  adolescents  who  use drugs and alcohol. A joint project among the cities of Stockholm,  Gothenburg,  and  Malmö  under  the auspices of the national Alcohol, Narcotics, Doping and Tobacco Strategy ran from 2012 to 2015 and had the main objective of reducing cannabis use among adolescents (10). Another research project was aimed at creating models for documentation and follow up in collaboration with the 'Maria clinics,' which are specialized outpatient clinics that target adolescents with various types of substance abuse disorders and their  relatives.  Many  of  these  adolescents  report  a history of various types of violence and abuse (11), and  thus  it  would  be  useful  to  have  a  deeper understanding of the forms of victimization that they have experienced. How are these experiences related to their substance abuse and mental health? Are there differences between girls and boys?

There  is a lack of general  knowledge  about adolescents who come into contact with outpatient care in Sweden for the treatment of substance abuse disorders (12). There are also no specifically Swedish studies of the link between victimization and substance  abuse  during  adolescence,  and  there  are relatively  few  international  studies  of  the  needs  or post-treatment outcomes  of adolescents with a history  of  victimization  who  begin  treatment  for substance abuse (13).

The  purpose  of  this  article  is  to  describe  and analyze victimization among adolescents who begin outpatient treatment for substance abuse disorders. Specifically,  the  relationships  among  gender,  social circumstances, drug and alcohol abuse, and mental health will be investigated.

There are several definitions of the term victimization as it related to the abuse literature used by  both  researchers  and  practitioners.  The  term  is usually linked to individuals' experiences of physical, sexual, and psychological abuse and serious neglect during childhood (14), but exposure to family violence or community violence is sometimes included  in  the  definition  (6).  The  following  more comprehensive  definition  of victimization has  been suggested by Finkelhor:

…harms that occur to individuals because of other human actors behaving in  ways  that violate  social  norms .  The human  agency and norm violation components give victimizations a special  potential  for  traumatic  impact. It  is  different  from  other stresses  and traumas,  such  as  accidents,  illnesses, bereavements, and natural disasters [emphasis….] (15; p. 10).

A  distinction  is  commonly  made  between  the concepts of direct victimization and indirect victimization. This concerns the idea of whether someone has been the target of direct violence versus whether he or she has witnessed violence between or involving people close to him or her. Another term that is sometimes used is poly -victimization, which means that an individual  has  been  exposed  to  multiple  types  of victimization (16). In this article, the term exposure to violence is used interchangeably with victimization.

## Victimization in relation to drug and alcohol use

Individuals with a history of abuse, exploitation, or neglect  during  childhood  have  an  elevated  risk  for developing addictive disorders later in life as compared with individuals who lack such experience (2,4,7,17-19).  Several  studies  have  shown  that  the exposure of children and adolescents to violence or experiences of victimization has a significant correlation with drug abuse later in life (6,20). This group commonly initiates substance use earlier, uses multiple substances more frequently and at a higher rate  (18,19),  and  develops  substance-abuse-related problems more often (19).

The results are mixed with regard to alcohol use, with some studies establishing a connection between victimization  during  childhood  and  high  alcohol consumption  among  older  teenagers  and  young adults  (17,21);  other  studies  have  not  been  able  to find these correlations (6,22).

There  are  also  some  differences  concerning  the form of violence to which the individual has been exposed.  Experiences  of  both  direct  and  indirect victimization  have  been  shown  to  influence  later drug  abuse  among  adolescents  (22-24),  although psychological abuse has a somewhat lower correlation with drug abuse as compared  with physical and sexual abuse (1). The cumulative effect of poly-victimization is also related to more severe drug abuse (6,7,23), and adolescents who have been exposed  to  both  physical  and  sexual  abuse  are  at particularly high risk for drug abuse (1,7). Adolescents who witnessed community violence also exhibit higher rates of tobacco, alcohol, and drug use later in life (6,24).

A strong connection has been established between a  history  of  victimization  and  elevated  substance abuse; there is high consensus among the results of various studies, despite varying samples and methods (2). However, the causal direction is both bidirectional and complex. For example, adolescents who  are  involved  in  drug  use  early  on  are  also  at higher risk of later exposure to violence (25,26), and there may be other factors that affect the association: '[T]he  relationship  between  childhood  abuse  and SUPs  is  not  likely  to  be  direct.  Several  different conditions or disorders have been found to mediate or moderate this relationship, including  PTSD, depression, general anxiety symptoms, and conduct problems (2; p. 52).'

Because  the  causal  connection  is  unclear,  some researchers argue that victimization primarily results in various psychiatric symptoms (e.g., anxiety, depression,  post-traumatic  stress  disorder,  conduct disorder, risk taking of various kinds), which in turn may lead to both experimental drug use and later to addictive disorders of a more serious nature (3,7,22,27).  The  degree  of  victimization  is  often related to  the  degree  of  psychiatric  disorder  (2,28). Serious substance abuse problems among adolescents  are  seen  as  these  individuals'  way  of coping with the stress and painful emotions that arise from  traumatic  events  (2,6,17,21,23,29).  Alongside victimization, elevated substance abuse can probably also  be  explained  by  other  factors,  such  as  peer pressure  and  changed  individual  attitudes  toward drugs (23,26).  Other  possible  explanations  are  that contextual factors during childhood influence future substance abuse; for example, many of the victimized children  and  adolescents  also  suffer  from  other problems,  such  as  growing  up  in  a  socially  and economically disadvantaged neighborhood (19).

The  relationship  between  victimization  and  drug and  alcohol  abuse  is  also  characterized  by  clear gender differences. Several studies have established that girls with a history of victimization develop more severe  addictive  disorders  as  compared  with  boys (19,26,30). In addition, a history of sexual abuse is more predictive  of  alcohol  and  drug  abuse  among girls  than  among  boys  (17,25).  However,  some studies have shown that a history of childhood sexual abuse is strongly related to high alcohol consumption among boys (21,29).

Victimization  among  adolescents  in  treatment  for  substance abuse disorders

A  significant  proportion  of  adolescents  who  enter substance abuse treatment have experienced victimization  earlier  in  their  lives  (13,20,28,30-32). Histories  of  multiple  types  of  abuse  are  relatively common in this group, with between 40% and 90%

of these patients having such backgrounds (5). There seems to be a relationship between the severity of victimization and the seriousness of substance abuse; in other words, those who experience more severe forms and a higher frequency of victimization go on to  use  heavier  drugs  (13,20,26).  It  also  seems  that adolescents who have been exposed to more severe forms of abuse and violence are more likely to be found in  inpatient  care  rather  than  outpatient  care (13,30,31).

Girls  in  substance  abuse  treatment  have  been shown  to  have  a  history of multiple types of victimization to a significantly higher extent (39% to 68%)  than  boys  (2%  to  29%)  (20,30,32).  Other studies  have  shown  that  girls  have  more  often experienced sexual abuse, whereas it is more common  for  boys  to  have  experienced  physical violence  (13,32,33).  Girls  in  both  inpatient  and outpatient care generally report more extensive drug use as compared with boys (30).

A history of abuse also has strong connections with psychiatric  symptoms  or  having  experienced  other types of trauma: '…victimization is common among adolescents presenting for substance abuse treatment, often involving multiple types of trauma, and  that  there  are  major  gender  differences  in  the patterns of victimization, as well as differences in the extent  to  which  people  were  'traumatized'  by  the victimization (5; p. 5).'

Other studies have investigated how victimization can  influence  treatment  outcomes  and  how  the severity of victimization may  predict treatment results. A history of various forms of abuse may have a  negative  impact  on  adolescents'  commitment  to treatment;  these  individuals  tend  to  have  a  higher dropout rate (2,3). Some studies show that treatment outcomes of adolescents with a history of victimization do not generally differ from the outcomes of those who do not have such a history (13). In addition, the severity of victimization does not  seem  to  have  any  impact  on  treatment,  but adolescents who are placed in residential treatment appear to be more successful as compared with those who undergo outpatient treatment (30,31). Nevertheless, in general, high levels of alcohol and drug  use  seem  to  linger  for  a  longer  time  among those who have been more severely victimized (30).

## Method

Sample

This cross-sectional study is based on data material collected by outpatient clinics in seven Swedish cities: Gothenburg, Helsingborg, Hässleholm, Kungsbacka,  Linköping,  Malmö,  and  Stockholm.  The clinics provide various forms of treatment for alcohol  and  drug  abuse  as  well  as  counseling  and support  for  adolescents  and  their  families.  The average  treatment  duration  is  4  to  6  months.  The clinics  offer  psychosocial  and  medical  assessment related  to  the  abuse  of  alcohol  and  drugs,  drug testing,  individual  and  family  therapy,  and  manualbased treatment programs. The staff members include  social  workers,  nurses,  psychologists,  and doctors.

Structured interviews were transferred to a database via the clinics that participate in the documentation system. In 2014, information about 788 adolescents from the seven different cities was reported  to  the  database.  Of  these,  there  were  40 individuals for whom information was incomplete or missing. Ultimately, there remained 748 adolescents who  had  begun  some  form  of  treatment  at  the participating clinics. The gender distribution among the  adolescents  was  29%  girls  and  71%  boys;  the average age was 17 years (range, 12 to 25 years).

## Instrument and procedures

UngDOK, an abbreviation of the Swedish words for Youth  and  Dokumentation,  is  a  semi-structured interview  that  has  been  specifically  developed  for adolescents and young adults with substance abuse disorders (11). The purpose of this tool is to assess the  young  person's  problems,  needs,  and  current situation to enable the relevant assessment, planning, and delivery of treatment. The intake form associated with this interview covers the following life domains: housing and financial support, employment, alcohol and drugs, treatment history, criminality, childhood history, exposure to violence, family and relationships,  and  physical  and  mental  health.  The interview method  is  currently  the subject of a validation study.

When  the  treatment  intervention  begins,  data  is collected through admission interviews using UngDOK; interviews may also be conducted at the end of treatment and in connection with follow-up assessments. Only the intake data were used in this study. The main variable from the UngDOK that was assessed  was  the  following:  'Have  you  ever  been exposed to violence/abuse - physical, psychological and sexual?' This question is intended to identify the adolescent's subjective perceptions about his or her personal  experiences.  This  question  was  answered either  as  'No'  (0)  or  'Yes'  (1).  As  a result  of  the close  connection  that  exists  between  victimization and traumatic experiences, another variable was used: 'Have you experienced a traumatic  event  that  still affects you psychologically?' This may involve past violence,  accidents,  or  disasters  that  still  affect  the adolescent's well-being in the form of such experiences  as  nightmares,  hypervigilance,  or  the avoidance of situations that bring the traumatic event to mind. The question is answered as either 'No' (0) or 'Yes' (1). If the answer is 'Yes,' this question is followed  by  an  open-ended  question  in  which  the adolescent is asked to specify the traumatic event.

The interviews were conducted by therapists at each clinic  after  informed  consent  had  been  obtained from  the  adolescent  and  in  accordance  with  a manual. Only de-identified data, with no connection to personal data, was used in this study.

## Analysis

The analysis was performed in three stages. During the  first  stage,  the  three  main  variables  physical, psychological  and  sexual  violence  were  compiled individually and in the aggregate and were related to girls and boys. A chi-squared test was performed to more closely examine whether there were significant gender differences among various forms of exposure.

During  the  second  stage,  on  the  basis  of  the literature review, the relationships among victimization and several variables that describe the characteristics  of  the  study  group  with  regard  to social  circumstances,  drug  and  alcohol  use,  and mental  health  were  also  analyzed  with  chi-squared testing. A victimization index (see Table 2) was also constructed, and it included exposure to any of the three forms of violence.

The  third  stage  involved  a  quantitative  content analysis.  In  this  type  of  analysis,  various  forms  of large text material, e.g., from documents or interviews, are compiled and categorized. Unambiguous and exclusive categories are created to the  greatest  possible  extent  (34).  To  do  this  the participating  researchers  independently  categorized all 188 utterances from the study subjects regarding the  types  of  traumatic  events  that  affect  mental health. There was agreement at this stage about 91% of the utterances. The researchers jointly created the presented compilation, which includes 98 utterances that can be specifically linked to victimization. The other  90  answers  mainly  concerned  accidents  and diseases and were therefore excluded.

## Results

Table 1 presents the various forms of exposure of violence included in the index. It was constructed to illustrate the occurrence of victimization by gender.

A total of 54% of the adolescents who presented for  outpatient  treatment  reported  that  they  had  at some time been exposed to some form of physical, psychological, or sexual violence/abuse. Girls reported this to a considerably higher extent, at 67%, than boys, at 48%. Of the adolescents, 45% reported having  at  some  time  been  exposed  to  physical violence; 36% made reports of psychological violence,  and  11%  said  that  they  had  experienced sexual  violence.  Girls  were  exposed  to  physical, psychological, and sexual violence to a greater extent than boys, but there were no significant differences between  girls  and  boys  with  regard  to  physical violence.

TABLE 1. Occurrence of various forms of violence and abuse included in a victimization index for the total study group

|                               | Total (N = 748)   | Girls (n = 217)   | Boys (n = 531)   | p Value   |   N |
|-------------------------------|-------------------|-------------------|------------------|-----------|-----|
| Victimization index           | 54%               | 67%               | 48%              | *         | 723 |
| Physical violence             | 45%               | 50%               | 43%              | NS        | 722 |
| Psychological violence        | 36%               | 57%               | 27%              | *         | 719 |
| Sexual violence               | 11%               | 34%               | 2%               | *         | 714 |
| One form of violence/abuse †  | 24%               | 20%               | 26%              | NS        | 723 |
| Two forms of violence/abuse   | 21%               | 24%               | 21%              | NS        | 723 |
| Three forms of violence/abuse | 8%                | 24%               | 1%               | *         | 723 |

TABLE 2. Social circumstances, drug and alcohol use, and mental health in relation to victimized and non-victimized adolescents

|                                              | Total (N = 748)   | Victimized Adolescents (n = 389)   | Non-Victimized Adolescents (n = 334)   | p Value   |   N |
|----------------------------------------------|-------------------|------------------------------------|----------------------------------------|-----------|-----|
| Lack of occupation                           | 20%               | 26%                                | 12%                                    | *         | 721 |
| School problems                              | 64%               | 72%                                | 54%                                    | *         | 711 |
| Convicted of a crime                         | 37%               | 38%                                | 34%                                    | NS        | 697 |
| Association with criminal peers              | 31%               | 40%                                | 22%                                    | *         | 709 |
| Association with drug-abusing peers          | 65%               | 72%                                | 57%                                    | *         | 712 |
| Problems in the childhood environment †      | 53%               | 68%                                | 35%                                    | *         | 720 |
| Placement in foster care/residential home    | 18%               | 22%                                | 11%                                    | *         | 719 |
| Risky alcohol consumption per AUDIT-C ‡      | 48%               | 56%                                | 37%                                    | *         | 710 |
| Primary drug: alcohol §                      | 13%               | 14%                                | 11%                                    | NS        | 711 |
| Primary drug: cannabis                       | 76%               | 71%                                | 82%                                    | *         | 711 |
| Other primary drug                           | 12%               | 15%                                | 7%                                     | *         | 711 |
| Frequency of use 2-3 days/week or more       | 44%               | 51%                                | 36%                                    | *         | 705 |
| Polydrug use                                 | 28%               | 40%                                | 15%                                    | *         | 686 |
| Previous substance abuse treatment           | 29%               | 37%                                | 20%                                    | *         | 718 |
| Depression                                   | 35%               | 47%                                | 21%                                    | *         | 677 |
| Anxiety                                      | 46%               | 61%                                | 28%                                    | *         | 683 |
| Concentration difficulties                   | 56%               | 69%                                | 42%                                    | *         | 688 |
| Difficulties controlling aggressive behavior | 21%               | 28%                                | 13%                                    | *         | 660 |
| Suicidal thoughts                            | 13%               | 19%                                | 5%                                     | *         | 644 |
| Eating disorders                             | 7%                | 12%                                | 2%                                     | *         | 636 |
| Self-harming behavior                        | 8%                | 14%                                | 2%                                     | *         | 652 |
| Neuropsychiatric diagnosis                   | 20%               | 21%                                | 17%                                    | NS        | 708 |
| Prescription drugs for psychiatric disorders | 19%               | 27%                                | 9%                                     | *         | 654 |
| Previous psychiatric care                    | 39%               | 50%                                | 12%                                    | *         | 718 |

§The term primary drug refers to the drug that causes the adolescent the most problems at the start of treatment (36)

A total  of  21%  of  the  adolescents  reported  that they  had  been  exposed  to  two  different  forms  of violence  or  abuse,  and  8%  reported  three  forms. Gender differences are apparent here, with 24% of girls  having  been  exposed  to  all  three  forms  of violence or abuse as compared with only 1% of boys.

Table 2 presents the relationship between victimization  and  the  variables  that  describe  the affected adolescents with regard to social circumstances,  drug  and  alcohol  use,  and  mental health.

This table shows that victimization is related to all three life domains and almost all study variables. The group  of  adolescents  who  have  been  exposed  to violence  in  some  form  have  a  significantly  higher level of problems than the non-victimized group in relation to social circumstances. These include a lack of  occupation  for  the  last  three  months;  past  or present problems in school; association with criminal and/or  drug-abusing  peers;  previous  placement  in foster care or a residential home; and the occurrence of problems in the childhood environment related to substance abuse, mental health, and violence/assault. However,  no  significant  differences  were  found between the groups with regard to criminal convictions.

A corresponding picture emerges concerning drug and alcohol use. Victimization is related to generally higher  rates  of  the  risky  consumption  of  alcohol, cannabis, or other primary drugs; a high frequency of use  of  the  primary  drug  in  the  last  three  months; polydrug use; and the occurrence of previous substance abuse treatment. However, no differences were  found  between  the  groups  with  regard  to alcohol as the primary drug.

Corresponding differences can also be noted in the area of mental health. The adolescents who had been exposed to violence report various forms of psychiatric  symptoms  in  the  last  30  days  to  a significantly  higher  extent  than  the  non-victimized group. These symptoms include depression, anxiety, concentration difficulties, trouble controlling aggressive behaviors, suicidal thoughts, eating disorders, self-harming behaviors, taking prescription  drugs  for  psychiatric  symptoms,  and having previously received psychiatric care. Victimization does not, however, seem to be related to the occurrence of a neuropsychiatric diagnosis.

The empirical material also contains questions that are intended to identify various forms of trauma or traumatic events that affect the adolescent's mental health.  A  total  of  29% of  the  adolescents reported this kind of problem at admission.

A total of 188 adolescents specified the event in response to an open-ended question. Four categories of  violence  exposure  were  created  in  the  content analysis of the adolescents' utterances: physical, psychological, sexual, and witnessed violence. Answers having to do with other traumatic  events that  can  be  linked  to  accidents  or  diseases,  for example, were placed in a fifth category.

A total of 98 utterances (52%) can be traced to the four  different  forms  of  victimization.  Twenty-two percent  of  the  utterances  fell into the  physical violence category: 16% for the girls and 26% for the boys. A few illustrative examples are provided here:

TABLE 3. Utterances  concerning  traumatic  events  that  affect  mental health in relation to gender

|                        | Total (N = 188)   | Girls (n = 81)   | Boys (n = 107)   |
|------------------------|-------------------|------------------|------------------|
| Physical violence      | 22%               | 16%              | 26%              |
| Psychological violence | 7%                | 5%               | 8%               |
| Sexual violence        | 14%               | 31%              | 2%               |
| Witnessed violence     | 9%                | 2%               | 14%              |
| Other traumatic events | 48%               | 46%              | 50%              |
| Total                  | 100%              | 100%             | 100%             |

- 'Gunfire in a gang fight'
- 'Assaulted by a boyfriend'
- 'Hit by my father'

A total  of  7%  of  the  utterances  had  to  do  with psychological violence: 8% for girls and 5% for boys. Here are some illustrative examples:

- 'Threats that have led to recurring violent nightmares'
- 'Psychological abuse'
- 'Fear that someone is going to hurt me'

There are clear differences between boys and girls when it comes to expressions of sexual violence: 2% for boys and 31% for girls. A few sample utterances follow:

- 'I was raped'
- 'I have been sexual abused'
- 'A man who exposed himself'

A total of 9% of the utterances provide information about the witnessing of various forms of violence. Boys reported this at a rate of 14%, which was  higher  than  the  2%  among  girls.  Examples include the following:

- 'I have seen violence and threats from my father against my mother'
- 'I saw a friend stab a guy'
- 'I have witnessed violence'

## Discussion

The findings established that more than half of the adolescents  who  initiate  outpatient  treatment  for substance abuse disorders have a history of victimization  and  various  types  of  abuse.  These results  agree  with  the  results  that  have  emerged  in previous studies (13,20,28,30-32). The prevalence of various types of exposure to violence is also generally high among the target group and varies from 11% to 45%.

As presented in the Results section of this article, there are also tangible gender differences: two thirds of the girls and slightly less than half of the boys had experienced violence or abuse in some form, which is consistent with previous studies of adolescents in substance  abuse  treatment  (13,20,30,32,33).  These differences are also found in relation to the various forms  of  victimization  and  particularly  correlated with  psychological  and  sexual  violence,  which  are considerably  more common  among  girls. It is remarkable that one out of three girls who seek care at  outpatient  clinics  report  that  they  have  been victims of some form of sexual abuse. The prevalence of sexual abuse among boys is low, but it is possibly under-reported on the basis of what has been  discovered  by  previous  research  (2).  In  this study,  the  percentage  of  girls  exposed  to  physical violence is slightly higher than that seen among boys, although this difference is not statistically significant. This result deviates from other studies, in which boys have been found to have experienced a higher rate of physical abuse as compared with girls (13,32,33).

The  results  also  shed  light  on  the  strong  link between victimization and other central domains in the  lives  of  adolescents.  Victimization  appears  to have a profound impact on the social situation, drug and  alcohol  use,  and  mental  health  of  affected individuals.

Adolescents with a history of exposure to violence are over-represented in relation to all studied variables except criminality. As compared with nonvictimized adolescents, they are more likely to lack an occupation, to have more problems in school, and to be  associated  with  friends  who  are  involved  in criminal activity and drugs. In addition, they are twice as likely to have had difficult childhood conditions or to  have  been  placed  in  foster  care  or  residential treatment centers.

The prevalence of exposure to violence is strongly related to more serious drug and alcohol use, which is reflected in essentially all variables in this area, such as risky alcohol consumption, the choice of primary drug, the extent of drug use, the concurrent use of two or more substances, and a history of previous treatment for substance abuse disorders. This strong link  is  also  supported  by  previous  research  (1719,21).

A history of victimization is also strongly tied to current psychiatric symptoms of various kinds among  adolescents,  including  depression,  anxiety, difficulty  concentrating,  violent  behavior,  suicidal ideation, eating disorders, and self-harming behaviors; this finding is consistent with the results of earlier studies (2,3,7,22,27). Nearly one third of the study  population  had  taken  prescription  drugs  for these  or  other  psychiatric  disorders.  Half  of  the adolescents  with  a  history  of  exposure  to  violence have also been the recipients of previous psychiatric care.

Many adolescents also report having experienced various traumatic events that are still having negative effects  on  them.  These  are  usually  the  result  of various types of  violence  or  abuse  toward  the adolescents  themselves  or  toward  people  close  to them. This link has also been confirmed by several previous studies (2,3,5,7,13,22,27,28). These experiences  may  cause  adolescents  to  begin  to  use alcohol  or  drugs  as  a  way  of  coping  with  painful memories and the psychological consequences of the events in which they have been involved (2,6,17,21,23,29). In this type of cross-sectional study, however, it is difficult to determine what the 'chicken'  is  and  what  the  'egg'  is.  Because  it  is difficult to draw such causal conclusions, it can be suggested that there may also be a risk that adolescent substance  use  can  lead  to  contact  with  violent individuals, which may in turn lead the adolescent to being assaulted.

Some of the limitations of the study are due to the fact  that  the  empirical  material  is  based  on  selfreported information  collected with the use of structured interviews. This requires the therapist to carefully  document  the  adolescents'  answers  and utterances  related  to  their  experiences  of  violence and traumatic events. The construction of categories and the categorization of utterances in the  content analysis  may,  of  course,  also  be  done  on  other methodological  grounds.  Nevertheless,  the  analysis provides a deeper understanding of the circumstances and living conditions that need to be considered  within  the  framework  of  the  treatment intervention.

## Clinical Significance

This study has several implications for clinical practice, education, and research. The generally high prevalence of victimization among adolescents who begin outpatient treatment for substance abuse problems  imposes  specific  demands  upon  these clinics  and  similar  organizations.  It  is  obvious  that questions about exposure to violence and abuse need to be included in the intake assessment and that an adolescent's reporting of any such occurrence should give result in the planning and delivery of treatment interventions  (20).  If  treatment  focuses  only  on alcohol  or drug  abuse,  there  is risk  of  poorer outcomes for adolescents with a history of victimization  (30).  It  may  instead  be  relevant  to provide some form of supplementary trauma therapy,  either  integrated  or  in  parallel  with  the treatment of the substance use; a research review has shown that both forms reduce both trauma symptoms and substance abuse (37). If adolescents are provided with support in relation to both their substance abuse disorders and their psychiatric symptoms, the need for drugs and alcohol for selfmedication  is  likely  to  diminish.  Moreover,  it  is urgent that therapists in adolescent substance abuse treatment settings should have some form of fundamental  competence  concerning  victimization and access to relevant supervision.

In future research, it would be valuable to conduct longitudinal studies to conduct long-term follow-up with adolescents who have a history of victimization. It  would  be  useful  to  examine  how  their  social inclusion,  mental  health,  and  drug  and  alcohol  use develop throughout adulthood.

In conclusion, we have established that experiences of victimization and exposure to violence are widespread among adolescents with substance abuse disorders in Sweden. This is an important issue that requires  attention  and  action  in  the  form  of  both preventive and therapeutic interventions from various actors in the community.

## Conflicts of Interest

The authors declare no conflict of interest.

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