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Impacts of intergenerational substance use and trauma among black women involved in the criminal justice system: A longitudinal analysis

Published:January 09, 2023DOI:https://doi.org/10.1016/j.josat.2023.208952

      Highlights

      • We examined intergenerational substance use and trauma on drug use and CPS cases over time.
      • We use data from N = 443 participants in the Black Women in a Study of Epidemics
      • Increases in number of parents/grandparents with drug problems increased odds of substance use
      • Increases in number of parents/grandparents with drug problems increased odds of open CPS cases.
      • The generational effects of substance use and trauma is pervasive and warrants early intervention

      Abstract

      Introduction

      Intergenerational substance use and trauma disproportionately impact racialized women. Yet, how these factors impact outcomes in women involved in the criminal justice system is understudied.

      Methods

      Using data from 443 participants in the Black Women in a Study of Epidemics, we assessed the impact of intergenerational substance use and trauma on participant drug use and open Child Protective Services (CPS) cases over 18 months. In repeated-measures logistic regression, intergenerational substance and trauma were independent variables, while participants' drug use at each follow-up and any open CPS case (s) served as separate dependent variables. Models were adjusted for criminal justice involvement, age, marital status, education, childhood guardian, number of children, and prior year homelessness.

      Results

      On average, participants were aged 35 years, 64 % had never married, and 44 % were raised by both parents. Two-thirds of women (67 %) reported intergenerational substance use (≥1 parent and/or grandparent with alcohol/drug problems), while only 13 % reported intergenerational trauma. Each increase in the number of parents/grandparents with drug/alcohol problems was associated with 30 % increased odds of participants' drug use (aOR 1.30, 95 % CI: 1.07,1.57) and 40 % increased odds of having an open CPS case (aOR 1.40, 95 % CI: 1.11, 1.78). The association of intergenerational trauma and CPS cases was attenuated with sociodemographic/contextualizing factors.

      Conclusions

      Intergenerational substance use and trauma are associated with negative outcomes. Our findings highlight the need for substance use treatment to address the pervasive generational effects of substance use and trauma faced by racialized women in the criminal justice system.

      Keywords

      1. Introduction

      1.1 Trends in substance use disorders and overdose deaths among women

      Around 5.6 % of women in the United States (7.2 million) have substance use disorders (SUDs), and 15.4 % of US women (19.5 million) report past-year illicit substance use (
      Substance Abuse and Mental Health Services Administration
      Key substance use and mental health indicators in the United States: results from the 2019 National Survey on Drug Use and Health (HHS Publication No. PEP20-07-01-001, NSDUH Series H-55).
      ; ). Currently, the rate of increase in drug overdose deaths among women surpasses men, though overdose deaths are more common in men (
      • Barbosa-Leiker C.
      • Campbell A.N.
      • McHugh R.K.
      • Guille C.
      • Greenfield S.F.
      Opioid use disorder in women and the implications for treatment.
      ;
      • Lynn E.
      • Doyle A.
      • Keane M.
      • Bennett K.
      • Cousins G.
      Drug poisoning deaths among women: A scoping review.
      ). From 1999 to 2017, overdose deaths among women increased by 1643 % for synthetic opioids, 915 % for heroin, 830 % for benzodiazepines, and 280 % for cocaine (
      • VanHouten J.P.
      • Rudd R.A.
      • Ballesteros M.F.
      • Mack K.A.
      Drug overdose deaths among women aged 30–64 years—United States, 1999–2017.
      ). Yet scant literature addresses the intersection between gender, harm reduction, and women-specific experiences of substance use and access to services (
      • Shirley-Beavan S.
      • Roig A.
      • Burke-Shyne N.
      • Daniels C.
      • Csak R.
      Women and barriers to harm reduction services: a literature review and initial findings from a qualitative study in Barcelona, Spain.
      ;
      • Bardwell G.
      • Austin T.
      • Maher L.
      • Boyd J.
      Hoots and harm reduction: A qualitative study identifying gaps in overdose prevention among women who smoke drugs.
      ).

      1.2 Trauma and SUDs among women

      Current literature on women and SUDs highlights the interplay between trauma and victimization on the initiation, trajectory, and severity of substance use and outcomes (
      • Barbosa-Leiker C.
      • Campbell A.N.
      • McHugh R.K.
      • Guille C.
      • Greenfield S.F.
      Opioid use disorder in women and the implications for treatment.
      ;
      • Bardwell G.
      • Austin T.
      • Maher L.
      • Boyd J.
      Hoots and harm reduction: A qualitative study identifying gaps in overdose prevention among women who smoke drugs.
      ;
      • Cross D.
      • Crow T.
      • Powers A.
      • Bradley B.
      Childhood trauma, PTSD, and problematic alcohol and substance use in low-income, african american men and women.
      ;
      • Jones A.A.
      • Gerke T.
      • Striley C.W.
      • Osborne V.
      • Whitehead N.
      • Cottler L.B.
      A longitudinal analysis of the substance abuse, violence, and HIV/AIDS (SAVA) syndemic among women in the criminal justice system.
      ;
      • Roberts N.P.
      • Roberts P.A.
      • Jones N.
      • Bisson J.I.
      Psychological interventions for posttraumatic stress disorder and comorbid substance use disorder: A systematic review and meta-analysis.
      ,
      • Roberts S.C.
      • Zahnd E.
      • Sufrin C.
      • Armstrong M.A.
      Does adopting a prenatal substance use protocol reduce racial disparities in CPS reporting related to maternal drug use? A California case study.
      ). Trauma and victimization can shape how survivors view themselves (e.g., internalized stigma and self-blame) and behaviors (e.g., self-medicating through substance use) (
      • Kennedy A.C.
      • Prock K.A.
      “I still feel like I am not normal”: A review of the role of stigma and stigmatization among female survivors of child sexual abuse, sexual assault, and intimate partner violence.
      ;
      • Weiss N.H.
      • Forkus S.R.
      • Contractor A.A.
      • Dixon-Gordon K.L.
      The interplay of negative and positive emotion dysregulation on mental health outcomes among trauma-exposed community individuals.
      ). Among those in SUD treatment, over 85 % report a lifetime prevalence of trauma, with women five times more likely than men to report trauma in treatment (
      • Cosden M.
      • Larsen J.L.
      • Donahue M.T.
      • Nylund-Gibson K.
      Trauma symptoms for men and women in substance abuse treatment: A latent transition analysis.
      ;
      • Giordano A.L.
      • Prosek E.A.
      • Stamman J.
      • Callahan M.M.
      • Loseu S.
      • Bevly C.M.
      • Cross K.
      • Woehler E.S.
      • Calzada R.M.R.
      • Chadwell K.
      Addressing trauma in substance abuse treatment.
      ;
      • Keyser-Marcus L.
      • Alvanzo A.
      • Rieckmann T.
      • Thacker L.
      • Sepulveda A.
      • Forcehimes A.
      • Islam L.Z.
      • Leisey M.
      • Stitzer M.
      • Svikis D.S.
      Trauma, gender, and mental health symptoms in individuals with substance use disorders.
      ;
      • Sanford A.
      • Donahue M.
      • Cosden M.
      Consumer perceptions of trauma assessment and intervention in substance abuse treatment.
      ). The resulting psychological conditions, such as posttraumatic stress disorder (PTSD), are high and can complicate addiction recovery (
      • Roberts N.P.
      • Roberts P.A.
      • Jones N.
      • Bisson J.I.
      Psychological interventions for posttraumatic stress disorder and comorbid substance use disorder: A systematic review and meta-analysis.
      ,
      • Roberts S.C.
      • Zahnd E.
      • Sufrin C.
      • Armstrong M.A.
      Does adopting a prenatal substance use protocol reduce racial disparities in CPS reporting related to maternal drug use? A California case study.
      ).
      The relationships between trauma and SUDs can be more pronounced in minoritized women, such as Black and Indigenous women, who must also navigate societal oppression and discrimination due to race/ethnicity and sex/gender (
      • Bardwell G.
      • Austin T.
      • Maher L.
      • Boyd J.
      Hoots and harm reduction: A qualitative study identifying gaps in overdose prevention among women who smoke drugs.
      ;
      • Cross D.
      • Crow T.
      • Powers A.
      • Bradley B.
      Childhood trauma, PTSD, and problematic alcohol and substance use in low-income, african american men and women.
      ;
      • Florez I.A.
      • Mekawi Y.
      • Hunnicutt-Ferguson K.
      • Visser K.F.
      • Clunie A.M.
      • Dunn S.E.
      • Kaslow N.J.
      Childhood abuse, posttraumatic stress symptoms, and alcohol misuse among African-American women.
      ;
      • Galán C.A.
      • Auguste E.E.
      • Smith N.A.
      • Meza J.I.
      An intersectional-contextual approach to racial trauma exposure risk and coping among black youth.
      ;
      • Kelly L.C.
      • Spencer C.M.
      • Keilholtz B.
      • McAllister P.
      • Stith S.M.
      Is separate the new equal? A meta-analytic review of correlates of intimate partner violence victimization for Black and White women in the United States.
      ;
      • Skewes M.C.
      • Blume A.W.
      Understanding the link between racial trauma and substance use among american indians.
      ). Evidence suggests that for minoritized women, trauma is associated with higher levels of substance use and other health outcomes, including mental illness, physical illness, and suicide (
      • Galán C.A.
      • Auguste E.E.
      • Smith N.A.
      • Meza J.I.
      An intersectional-contextual approach to racial trauma exposure risk and coping among black youth.
      ;
      • Nutton J.
      • Fast E.
      Historical trauma, substance use, and indigenous peoples: seven generations of harm from a “big event”.
      ). Experiences of structural discrimination have been shown to limit Black women's likelihood of seeking formal sources of help (e.g., mental health treatment, legal help) (
      • Kelly L.C.
      • Spencer C.M.
      • Keilholtz B.
      • McAllister P.
      • Stith S.M.
      Is separate the new equal? A meta-analytic review of correlates of intimate partner violence victimization for Black and White women in the United States.
      ).
      • Hakimi D.
      • Bryant-Davis T.
      • Ullman S.E.
      • Gobin R.L.
      Relationship between negative social reactions to sexual assault disclosure and mental health outcomes of black and white female survivors.
      found that while adverse social reactions increased PTSD severity among women who have experienced trauma, this effect was more pronounced among Black women than White women. Moreover, posttraumatic stress has been shown to have a stronger correlation with IPV in Black women than in White women; Black women are also more likely to experience IPV and severe and fatal injuries (
      • Kelly L.C.
      • Spencer C.M.
      • Keilholtz B.
      • McAllister P.
      • Stith S.M.
      Is separate the new equal? A meta-analytic review of correlates of intimate partner violence victimization for Black and White women in the United States.
      ). Yet, the literature examining the relationship between trauma and SUDs in minoritized women is primarily descriptive (
      • Cross D.
      • Crow T.
      • Powers A.
      • Bradley B.
      Childhood trauma, PTSD, and problematic alcohol and substance use in low-income, african american men and women.
      ;
      • Skewes M.C.
      • Blume A.W.
      Understanding the link between racial trauma and substance use among american indians.
      ), warranting quantitative studies assessing life outcomes over time. Trauma may also lead to a dysregulated stress response system, which, in turn, promotes negative affect and other health and social consequences, particularly in parenting (
      • Cross D.
      • Crow T.
      • Powers A.
      • Bradley B.
      Childhood trauma, PTSD, and problematic alcohol and substance use in low-income, african american men and women.
      ;
      • Edwards L.
      • Jamieson S.K.
      • Bowman J.
      • Chang S.
      • Newton J.
      • Sullivan E.
      A systematic review of post-release programs for women exiting prison with substance-use disorders: Assessing current programs and weighing the evidence.
      ).

      1.3 Intergenerational substance use and trauma among women

      SUDs can both facilitate and exacerbate intergenerational trauma, trauma transmitted from parents to children, by increasing the odds of poverty and through disruptions in parental functioning and parent-child attachments (
      • Isobel S.
      • Goodyear M.
      • Furness T.
      • Foster K.
      Preventing intergenerational trauma transmission: A critical interpretive synthesis.
      ;
      • Meulewaeter F.
      • De Pauw S.S.
      • Vanderplasschen W.
      Mothering, substance use disorders and intergenerational trauma transmission: An attachment-based perspective.
      ). In a meta-analysis of IPV among Black and White women,
      • Kelly L.C.
      • Spencer C.M.
      • Keilholtz B.
      • McAllister P.
      • Stith S.M.
      Is separate the new equal? A meta-analytic review of correlates of intimate partner violence victimization for Black and White women in the United States.
      found that abuse in the family of origin was a leading predictor of IPV among Black women. Women experiencing poverty, compared to women who are not, are more likely to be reported to Child Protective Services (CPS), suggesting an additional burden on minoritized women in poverty (
      • Cross D.
      • Crow T.
      • Powers A.
      • Bradley B.
      Childhood trauma, PTSD, and problematic alcohol and substance use in low-income, african american men and women.
      ). Specific to minoritized women, Black women are twice as likely to be caregivers of children than Black men and are around ten times more likely to be referred to CPS than White women (
      • Cross D.
      • Crow T.
      • Powers A.
      • Bradley B.
      Childhood trauma, PTSD, and problematic alcohol and substance use in low-income, african american men and women.
      ). At the intersection of racism, substance use, and child welfare, research has found that while Black pregnant women are as likely to use substances as White pregnant women, Black newborns were four to five times more likely than White newborns to be referred to CPS at delivery (
      • Roberts N.P.
      • Roberts P.A.
      • Jones N.
      • Bisson J.I.
      Psychological interventions for posttraumatic stress disorder and comorbid substance use disorder: A systematic review and meta-analysis.
      ,
      • Roberts S.C.
      • Zahnd E.
      • Sufrin C.
      • Armstrong M.A.
      Does adopting a prenatal substance use protocol reduce racial disparities in CPS reporting related to maternal drug use? A California case study.
      ;
      • Roberts S.
      • Nuru-Jeter A.
      Universal screening for alcohol and drug use and racial disparities in child protective services reporting.
      ). This Black/White disparity remains even as Black pregnant women who use substances have a higher likelihood than expected to enter treatment (
      • Roberts S.
      • Nuru-Jeter A.
      Universal screening for alcohol and drug use and racial disparities in child protective services reporting.
      ). The legal ramifications of having a SUD and, subsequently, poverty, coupled with increased odds of social service involvement among minoritized individuals, contribute to an increased likelihood of criminal justice involvement (
      • Jones A.A.
      • Gerke T.
      • Striley C.W.
      • Osborne V.
      • Whitehead N.
      • Cottler L.B.
      A longitudinal analysis of the substance abuse, violence, and HIV/AIDS (SAVA) syndemic among women in the criminal justice system.
      ).

      1.4 Substance use and trauma among women involved in the criminal justice system

      Women involved in the criminal justice system are especially vulnerable to the cyclical and mutually reinforcing issues of social disadvantage (
      • Jones A.A.
      • Gerke T.
      • Striley C.W.
      • Osborne V.
      • Whitehead N.
      • Cottler L.B.
      A longitudinal analysis of the substance abuse, violence, and HIV/AIDS (SAVA) syndemic among women in the criminal justice system.
      ). The extreme forms of social disadvantage, trauma, and substance use are often the same factors that lead to criminal justice involvement and can continue both across the life course and intergenerationally (
      • Edwards L.
      • Jamieson S.K.
      • Bowman J.
      • Chang S.
      • Newton J.
      • Sullivan E.
      A systematic review of post-release programs for women exiting prison with substance-use disorders: Assessing current programs and weighing the evidence.
      ;
      • Jones A.A.
      • Gerke T.
      • Striley C.W.
      • Osborne V.
      • Whitehead N.
      • Cottler L.B.
      A longitudinal analysis of the substance abuse, violence, and HIV/AIDS (SAVA) syndemic among women in the criminal justice system.
      ;
      • Latuskie K.A.
      • Andrews N.C.
      • Motz M.
      • Leibson T.
      • Austin Z.
      • Ito S.
      • Pepler D.J.
      Reasons for substance use continuation and discontinuation during pregnancy: A qualitative study.
      ). Among those involved in the criminal justice system, women have been shown to have higher rates of SUDs and lifetime and current victimization than men (
      • Edwards L.
      • Jamieson S.K.
      • Bowman J.
      • Chang S.
      • Newton J.
      • Sullivan E.
      A systematic review of post-release programs for women exiting prison with substance-use disorders: Assessing current programs and weighing the evidence.
      ;
      • Jones A.A.
      • Gerke T.
      • Striley C.W.
      • Osborne V.
      • Whitehead N.
      • Cottler L.B.
      A longitudinal analysis of the substance abuse, violence, and HIV/AIDS (SAVA) syndemic among women in the criminal justice system.
      ). Research examining the presence and quality of programs for minoritized women who use substances and are justice-involved highlights the need for trauma-informed care for optimum benefit (
      • Henderson A.
      • Kroese B.S.
      Group interventions for trauma and substance misuse available for women in criminal justice services: A systematic review of the literature.
      ;
      • Jones A.A.
      • O’Leary C.C.
      • Striley C.W.
      • Gerke T.
      • Crecelius R.
      • Sullivan J.
      • Cottler L.B.
      Substance use, victimization, HIV/AIDS risk, and recidivism among females in a therapeutic justice program.
      ;
      • Saxena P.
      • Grella C.E.
      • Messina N.P.
      Continuing care and trauma in women offenders’ substance use, psychiatric status, and self-efficacy outcomes.
      ).

      1.5 Current study

      The literature examining intergenerational substance use and trauma among women involved in the criminal justice system and their children is limited. While there are studies examining the relationship between trauma and substance use in Black women, these are primarily descriptive, qualitative, limited to parent-child only, and thus limited regarding the magnitude of the effects (
      • Cross D.
      • Crow T.
      • Powers A.
      • Bradley B.
      Childhood trauma, PTSD, and problematic alcohol and substance use in low-income, african american men and women.
      ;
      • Skewes M.C.
      • Blume A.W.
      Understanding the link between racial trauma and substance use among american indians.
      ). Research examining interactions of trauma and abuse, interpersonal relationships, parenting, the context of health, and social disadvantage experienced by women across the spectrum of criminal justice involvement, particularly those of minoritized women, is needed (
      • El-Bassel N.
      • Mukherjee T.I.
      • Stoicescu C.
      • Starbird L.E.
      • Stockman J.K.
      • Frye V.
      • Gilbert L.
      Intertwined epidemics: progress, gaps, and opportunities to address intimate partner violence and HIV among key populations of women.
      ;
      • Jones A.A.
      • Gerke T.
      • Striley C.W.
      • Osborne V.
      • Whitehead N.
      • Cottler L.B.
      A longitudinal analysis of the substance abuse, violence, and HIV/AIDS (SAVA) syndemic among women in the criminal justice system.
      ;
      • Meyer J.P.
      • Isaacs K.
      • El-Shahawy O.
      • Burlew A.K.
      • Wechsberg W.
      Research on women with substance use disorders: Reviewing progress and developing a research and implementation roadmap.
      ). Addressing this gap, we quantify the association between intergenerational substance use (among paternal and maternal grandparents and parents) and trauma on life outcomes (continual substance use, child maltreatment charges) among Black women involved in the criminal justice system.

      2. Methods

      2.1 Study and sample overview

      We utilized data on 643 participants of the Black Women in a Study of Epidemics (B-WISE), a study aimed to understand how the interrelated social issues of race, class, and gender influence substance use, criminal justice involvement, and health disparities among Black women (
      • McLouth C.J.
      • Oser C.B.
      • Stevens-Watkins D.
      Concordance between self-reported drug use and urinalysis in a sample of Black American women.
      ;
      • Oser C.B.
      • Harp K.
      • Pullen E.
      • Bunting A.M.
      • Stevens-Watkins D.
      • Staton M.
      African-american women’s tobacco and marijuana use: The effects of social context and substance use perceptions.
      ;
      • Harp K.L.
      • Oser C.B.
      A longitudinal analysis of the impact of child custody loss on drug use and crime among a sample of african american mothers.
      ). The sample included Black women recruited from 3 settings: prison, probation offices, and communities (not involved in the criminal justice system). The study was a prospective longitudinal cohort study with data collected at baseline, six-, 12-, and 18 months by trained Black female research staff. Women in the prison sample were followed-up after their release into the community. To be eligible for this study, participants had to self-identify as Black, female, an English speaker, and be over the age of 18 years. To collect follow-up data, women recruited from prison had to be released within 60 days of their baseline interview, either through parole or completion of their sentence. Those recruited in the probation group had to self-disclose their status to be eligible, and those recruited in the community could not currently be involved with the criminal justice system.
      Participant recruitment occurred in Kentucky and varied by criminal justice and drug use status. To balance substance use across the sample, for every participant enrolled in each recruitment group (prison, probation, and community) reporting past-year substance use (or past-year use before incarceration), an additional woman belonging to the same recruitment group was enrolled who had no past-year substance use. Overall, the participants varied on whether they were incarcerated at baseline, were on probation or parole at baseline, or were women recruited from the general population of the study area. Recruitment occurred in Lexington, Kentucky, for women in the community, and flyers with study information were distributed in public areas such as public transit, beauty shops, and grocery stores. Women in the probation group were recruited from probation offices known to serve large populations of Black women in Kentucky, and women in the prison sample were recruited from 3 women's prisons. Participants received remuneration of $20 for completing the baseline survey, $25 for completing each follow-up visit, $10 for completing urine drug screens, and $5 for updating their contact information at each follow-up visit. An additional $10 remuneration was given to participants who completed the baseline survey and every follow-up visit. Retention rates were 94 % (6 months), 92 % (12 months), and 90 % (18 months). This study was approved by the University of Kentucky's Institutional Review Board, and participants were protected by a Certificate of Confidentiality.

      2.2 Exposures

      2.2.1 Intergenerational substance use (Primary exposure)

      Women were asked if their biological parents and/or maternal and paternal grandparents had known problems with alcohol or drugs using items from the Addiction Severity Index (ASI) (
      • McLellan A.T.
      • Kushner H.
      • Metzger D.
      • Peters R.
      • Smith I.
      • Grissom G.
      • Pettinati H.
      • Argeriou M.
      The fifth edition of the Addiction Severity Index.
      ). Intergenerational substance use was defined as the sum of the number of parents and grandparents participants reported as having drug or alcohol use problems.

      2.2.2 Intergenerational trauma (Secondary exposure)

      Similar to intergenerational substance use, intergenerational trauma was assessed by asking women if their biological parents and biological grandparents were known to have PTSD. Intergenerational trauma was infrequent in the sample and thus dichotomized (present/absent) based on if any parent or grandparent had a history of PTSD.

      2.3 Outcomes

      2.3.1 Participant drug use

      At baseline and each follow-up assessment, women were asked whether they had used drugs in the past 6-months. We use self-report substance use as this item was collected at every time interval and allows women to report on all possible drug use.

      2.3.2 History of an open CPS case

      Regarding potential child maltreatment, women reported on any prior (baseline) or current open case(s) with CPS at each follow-up interview.

      2.4 Additional variables

      Women reported their age, marital status (married/living as married, widowed, divorced, or separated, or single/never married), education (number of completed years), number of children living with them (biological, stepchildren, and adopted), ethnicity (Hispanic vs. Non-Hispanic), past year homelessness (yes vs. no), generation of African-American (1st, 2nd, or 3rd generation or greater), who raised them in their childhood (both parents, single parent, non-parents), agreement with the statement “I feel shame” about themselves as a proxy measure of self-esteem (strongly disagree, disagree, agree, strongly agree), number of physically abusive events in their childhood, and number of physically violent episodes in their households.

      2.5 Missing data

      The majority of the missing data was among 194 women who did not report parent/grandparent substance use and PTSD, our exposures of interest. However, we observed that these variables were missing most commonly among individuals raised by a single parent (1 % missing maternal substance use or trauma, 29 % missing paternal substance use or trauma, 14 % missing grandparental substance use or trauma) or non-parents (10 % missing maternal substance use or trauma, 30 % missing paternal substance use or trauma, 19 % missing grandparental substance use or trauma) compared to women raised by both parents (0 % missing maternal substance use or trauma, 1 % missing paternal substance use or trauma, 15 % missing grandparental substance use or trauma). Thus, it is likely that these data are missing not at random; i.e., the reason for the missingness is related to the missing value itself. Specifically, parental/grandparental absenteeism could be a result of the parent/grandparent's substance use or PTSD, and because of this absenteeism, participants were unable to report whether their absent parent/grandparent had a history of substance use or trauma. Recent simulation studies suggest that a complete-case analysis is unbiased when data are missing not at random and the missingness is unrelated to the outcome under study (
      • Bartlett J.W.
      • Harel O.
      • Carpenter J.R.
      Asymptotically unbiased estimation of exposure odds ratios in complete records logistic regression.
      ;
      • Hughes R.A.
      • Heron J.
      • Sterne J.A.
      • Tilling K.
      Accounting for missing data in statistical analyses: Multiple imputation is not always the answer.
      ), which is likely in the present data. For this reason, we opted to perform a complete-case analysis in the current study. We excluded 6 women (1 %) who were missing data on covariates to facilitate our complete-case analysis further.

      2.6 Statistical analyses

      Sample characteristics were calculated by criminal justice involvement (prison, probation, or community member) and overall. Continuous variables were reported as mean and standard deviation, while categorical variables were reported as frequency and percent in each category. We used repeated-measures logistic regression analyses to assess the association of intergenerational substance use and intergenerational trauma with participant drug use and the presence of an open CPS case (separate models for each outcome). Minimally adjusted models included criminal justice involvement as a covariate. Multivariable adjusted models additionally included age, marital status, education, childhood guardian, number of children, and prior year homelessness as covariates. We accounted for correlation among multiple observations per person using generalized estimating equations with an autoregressive-1 (AR-1) correlation structure.
      All analyses were completed in SAS 9.4 (Cary, NC), and a two-sided p-value<0.05 was considered statistically significant.

      3. Results

      3.1 Overall sample characteristics

      Our sample included 443 women with complete data; 148 were recruited from the community, 139 were recruited while on probation, and 156 were recruited in prison. The average age of women in our sample was 35 years; 64 % were single/never married, and the average years of education was 12, equivalent to a high school diploma (Table 1). Fewer than 1 % of participants identified as Hispanic, and 98 % were 3rd or greater generation African-American, meaning they, their parents, grandparents, or greater were born in the United States. In terms of family structure, participants, on average, had two children living with them, and 18 % reported past-year homelessness. Thirty-nine percent of women were raised by a single parent, and 18 % were raised by non-parents. Physical abuse during childhood was reported by 21 % of women, and 52 % reported witnessing violence in their childhood homes. When asked whether they feel ashamed of themselves as a proxy for poor self-esteem, 30 % of the women “agreed” or “strongly agreed.”
      Table 1Baseline characteristics stratified by criminal justice status.
      Characteristic
      Statistics are presented as mean (standard deviation) for continuous variables and no. (%) for categorical variables.
      Criminal justice statusTotal (N = 443)
      Community (N = 148)Probation (N = 139)Prison (N = 156)
      Age, years36.5 (14.2)34.0 (10.1)35.3 (9.4)35.3 (11.4)
      Marital Status
       Married/Living as Married20 (13.5 %)17 (12.2 %)24 (15.4 %)61 (13.8 %)
       Widowed, Divorced, or Separated34 (23.0 %)30 (21.6 %)34 (21.8 %)98 (22.1 %)
       Single, Never Married94 (63.5 %)92 (66.2 %)98 (62.8 %)284 (64.1 %)
      Education Completed, years12.9 (2.3)11.9 (2.0)11.8 (2.3)12.2 (2.3)
      Number of Children1.9 (1.7)2.4 (1.7)2.7 (2.1)2.3 (1.9)
      Hispanic Ethnicity1 (0.7 %)1 (0.7 %)0 (0.0 %)2 (0.5 %)
      Homeless in last year15 (10.1 %)98 (29.5 %)24 (15.4 %)80 (18.1 %)
      Generation African American
      Two women refused to answer this question.
       1st Generation0 (0.0 %)1 (0.7 %)0 (0.0 %)1 (0.2 %)
       2nd Generation2 (1.4 %)5 (3.6 %)1 (0.6 %)8 (1.8 %)
       3rd or Greater Generation145 (98.0 %)132 (95.0 %)155 (99.4 %)432 (97.5 %)
      Raised By
       Both Parents78 (52.7 %)53 (38.1 %)63 (40.4 %)194 (43.8 %)
       Single Parent54 (36.5 %)56 (40.3 %)61 (39.1 %)171 (38.6 %)
       Non-Parents16 (10.8 %)30 (21.6 %)32 (20.5 %)78 (17.6 %)
      I feel shame
       Strongly Disagree53 (35.8 %)46 (33.1 %)39 (25.0 %)138 (31.2 %)
       Disagree57 (38.5 %)57 (41.0 %)58 (37.2 %)172 (38.8 %)
       Agree32 (21.6 %)29 (20.9 %)44 (28.2 %)105 (23.7 %)
       Strongly Agree6 (4.1 %)7 (5.0 %)15 (9.6 %)28 (6.3 %)
      Physically Abused in Childhood
       Never124 (83.8 %)106 (76.3 %)120 (76.9 %)350 (79.0 %)
       Once6 (4.1 %)5 (3.6 %)10 (6.4 %)21 (4.7 %)
       Twice4 (2.7 %)5 (3.6 %)3 (1.9 %)12 (2.7 %)
       Three Times1 (0.7 %)2 (1.4 %)2 (1.3 %)5 (1.1 %)
       Four Times0 (0.0 %)0 (0.0 %)1 (0.6 %)1 (0.2 %)
       Five Times0 (0.0 %)1 (0.7 %)2 (1.3 %)3 (0.7 %)
       More than Five times13 (8.8 %)20 (14.4 %)18 (11.5 %)51 (11.5 %)
      Physical Violence in Household
       Never72 (48.7 %)62 (44.6 %)78 (50.0 %)212 (47.9 %)
       Once13 (8.8 %)11 (7.9 %)11 (7.1 %)35 (7.9 %)
       Twice14 (9.5 %)11 (7.9 %)10 (6.4 %)35 (7.9 %)
       Three Times7 (4.7 %)3 (2.2 %)7 (4.5 %)17 (3.8 %)
       Four Times0 (0.0 %)3 (2.2 %)1 (0.6 %)4 (0.9 %)
       Five Times0 (0.0 %)1 (0.7 %)3 (1.9 %)4 (0.9 %)
       More than Five times42 (28.4 %)48 (34.5 %)46 (29.5 %)136 (30.7 %)
      Intergenerational Substance Use
       None58 (39.2 %)42 (30.2 %)46 (29.5 %)146 (33.0 %)
       Grandparents6 (4.1 %)10 (7.2 %)2 (1.3 %)18 (4.1 %)
       One Parent37 (25.0 %)38 (27.3 %)40 (25.6 %)115 (26.0 %)
       Grandparent and One Parent22 (14.9 %)15 (10.8 %)20 (12.8 %)57 (12.9 %)
       Both Parents12 (8.1 %)12 (8.6 %)27 (17.3 %)51 (11.5 %)
       Both Parents and Grandparents13 (8.8 %)22 (15.8 %)21 (13.5 %)56 (12.6 %)
      Intergenerational Trauma
       None131 (88.5 %)119 (85.6 %)136 (87.2 %)386 (87.1 %)
       Grandparents4 (2.7 %)2 (1.4 %)3 (1.9 %)9 (2.0 %)
       One Parent8 (5.4 %)14 (10.1 %)13 (8.3 %)35 (7.9 %)
       Grandparent and One Parent2 (1.4 %)4 (2.9 %)2 (1.3 %)8 (1.8 %)
       Both Parents3 (2.0 %)0 (0.0 %)1 (0.6 %)4 (0.9 %)
       Both Parents and Grandparents0 (0.0 %)0 (0.0 %)1 (0.6 %)1 (0.2 %)
      a Statistics are presented as mean (standard deviation) for continuous variables and no. (%) for categorical variables.
      b Two women refused to answer this question.
      Intergenerational substance use was prevalent in 67 % of our sample. Over one-third of participants reported 2 or more parents/grandparents with alcohol/drug problems; 13 % reported one parent and one grandparent, 12 % reported both parents, and an additional 12 % reported both parents and grandparents with drug and alcohol problems. Overall, 13 % of women reported familial PTSD, with most reporting that they had one parent with PTSD. Regarding participant drug use, 60 % reported past-year use at baseline, 54 % at the 6-month follow-up, 55 % during the 12-month follow-up, and 54 % at the 18-month follow-up. Open CPS cases were assessed among women with children (n = 355); of these women, 41 % had an open CPS case in their lifetime.

      3.2 Sample characteristics by justice involvement

      Community-recruited women reported an additional year of education, an increased likelihood of being raised by both parents, and a reduced prevalence of past-year homelessness compared to women involved in the criminal justice system. Women recruited from prison reported an increased likelihood of feeling shame versus women on probation or those not involved in the criminal justice system. Regardless of criminal justice involvement, women reported a similar prevalence of witnessing physical violence in their childhood homes. Intergenerational substance use and a history of a CPS case were more prevalent among women involved with the criminal justice system than in community-recruited women.

      3.3 Multivariable logistic regression assessing correlates of substance use

      Correlates of continual substance use among the participants are displayed in Table 2. In a minimally adjusted regression model, each increase in the number of parents/grandparents with drug/alcohol problems was associated with a 30 % increase in odds of women's continual substance use (aOR 1.30, 95 % CI: 1.08,1.57), controlling for criminal justice status and intergenerational trauma. In this same model, intergenerational trauma was marginally associated with participant substance use (aOR 1.64, 95 % CI: 0.94, 2.95), and women recruited from prison, compared to community-recruited women, were nearly four times more likely to use substances (aOR 3.94, 95 % CI: 2.43, 6.40). In the fully adjusted model, intergenerational substance use (aOR 1.28, 95 % CI: 1.05, 1.55) and being recruited from prison vs. the community (aOR 3.84, 95 % CI: 2.31, 6.38) were associated with women's substance use.
      Table 2Association of parent/grandparent alcohol and drug use with participant substance use.
      Minimally adjusted model
      VariableNot adjusted for familial traumaAdjusted for familial trauma
      Odds ratio [95 % CI]p-valueOdds ratio [95 % CI]p-value
      Intergenerational Substance Use
      An ordinal variable defined as the sum of the number of parents and grandparents participants reported to have drug or alcohol use disorders.
      1.33 [1.11, 1.60]0.00231.30 [1.08, 1.57]0.0065
      Intergenerational Trauma
      Present (at least one parent or grandparent with a history of PTSD) or absent (no parents or grandparents with a history of PTSD).
      1.64 [0.91, 2.95]0.1007
      Criminal Justice Involvement
       Probation vs. Community0.95 [0.61, 1.47]0.80740.94 [0.60, 1.46]0.7766
       Prison vs. Community3.91 [2.41, 6.35]< 0.00013.94 [2.43, 6.40]<0.0001
      Multivariable adjusted model
      VariableNot adjusted for familial traumaAdjusted for familial trauma
      Odds ratio [95 % CI]p-valueOdds ratio [95 % CI]p-value
      Intergenerational Substance Use
      An ordinal variable defined as the sum of the number of parents and grandparents participants reported to have drug or alcohol use disorders.
      1.30 [1.07, 1.57]0.00711.28 [1.05, 1.55]0.0138
      Intergenerational Trauma
      Present (at least one parent or grandparent with a history of PTSD) or absent (no parents or grandparents with a history of PTSD).
      1.55 [0.85, 2.81]0.1545
      Criminal Justice Involvement
       Probation vs. Community0.88 [0.56, 1.38]0.57460.88 [0.56, 1.39]0.5881
       Prison vs. Community3.75 [2.25, 6.24]<0.00013.84 [2.31, 6.38]<0.0001
      Age, per 5 years0.94 [0.86, 1.03]0.16930.95 [0.87, 1.04]0.2481
      Marital Status
       Married/Living as Married vs. Single0.77 [0.60, 1.00]0.05120.77 [0.60, 1.00]0.0501
       Previously Married vs. Single0.92 [0.73, 1.16]0.48300.92 [0.73, 1.16]0.4898
      Education, per additional year0.97 [0.89, 1.05]0.40380.97 [0.89, 1.05]0.4684
      Raised By
       Single Parent vs. Both Parents1.13 [0.74, 1.74]0.56891.15 [0.75, 1.77]0.5274
       Non-Parents vs. Both Parents0.90 [0.51, 1.59]0.71220.88 [0.50, 1.56]0.6680
      Kids, per additional child1.01 [0.91, 1.12]0.85791.00 [0.90, 1.11]0.9753
      Homeless in prior year1.13 [0.82, 1.56]0.43971.13 [0.82, 1.56]0.4490
      a An ordinal variable defined as the sum of the number of parents and grandparents participants reported to have drug or alcohol use disorders.
      b Present (at least one parent or grandparent with a history of PTSD) or absent (no parents or grandparents with a history of PTSD).

      3.4 Multivariate logistic regression assessing correlates of having a history of a CPS case

      Correlates of having a lifetime history of an open CPS case prior to the end of the study period are displayed in Table 3. In the minimally adjusted model, each increase in the number of parents/grandparents with drug/alcohol problems was associated with a 41 % increase in the odds of a woman having a history of an open CPS case (aOR 1.41, 95 % CI: 1.11, 1.79). In this same model, intergenerational trauma was associated with over twice the odds of a history of an open CPS case (aOR 2.28, 95 % CI: 1.13, 4.59) and both prison-recruited women (aOR 1.94, 95 % CI: 1.11, 3.39) and women on probation (aOR 2.63, 95 % CI: 1.50, 4.61) were more likely to have a history of an open CPS case compared to community-recruited women. In the fully adjusted multivariable model, intergenerational substance use (aOR 1.35, 95 % CI: 1.06, 1.72) and women on probation (aOR 2.19, 95 % CI: 1.22, 3.91) remained significantly more likely to have a history of an open CPS case; the effects of intergenerational trauma and recruitment group (prison versus community) were attenuated to non-significance. Additionally, older age (aOR per 5 years 0.88, 95 % CI: 0.79, 0.99) and increasing education (aOR per additional year 0.84, 95 % CI: 0.75, 0.94) decreased the odds of having a history of an open CPS case, while each additional child a woman had (aOR 1.11, 95 % CI: 1.05, 1.17), and prior-year homelessness (aOR 1.01, 95 % CI: 1.01, 1.02) increased the odds of having a history of an open CPS case.
      Table 3Association of parent/grandparent alcohol and drug use with history of a CPS case.
      Minimally adjusted model
      VariableNot adjusted for familial traumaAdjusted for familial trauma
      Odds ratio [95 % CI]p-valueOdds ratio [95 % CI]p-value
      Intergenerational substance use
      An ordinal variable defined as the sum of the number of parents and grandparents participants reported to have drug or alcohol use disorders.
      1.50 [1.20, 1.89]0.00051.41 [1.11, 1.79]0.0046
      Intergenerational trauma
      Present (at least one parent or grandparent with a history of PTSD) or absent (no parents or grandparents with a history of PTSD).
      2.28 [1.13, 4.59]0.0208
      Group
       Probation vs. Community2.58 [1.47, 4.53]0.00092.63 [1.50, 4.61]0.0008
       Prison vs. Community1.90 [1.09, 3.31]0.02321.94 [1.11, 3.39]0.0192
      Multivariable adjusted model
      VariableNot adjusted for familial traumaAdjusted for familial trauma
      Odds ratio [95 % CI]p-valueOdds ratio [95 % CI]p-value
      Intergenerational Substance Use
      An ordinal variable defined as the sum of the number of parents and grandparents participants reported to have drug or alcohol use disorders.
      1.40 [1.11, 1.78]0.00501.35 [1.06, 1.72]0.0139
      Intergenerational Trauma
      Present (at least one parent or grandparent with a history of PTSD) or absent (no parents or grandparents with a history of PTSD).
      1.83 [0.89, 3.76]0.1004
      Criminal Justice Involvement
       Probation vs. Community2.13 [1.19, 3.81]0.01092.19 [1.22, 3.91]0.0082
       Prison vs. Community1.52 [0.87, 2.65]0.14061.54 [0.88, 2.69]0.1266
      Age, per 5 years0.87 [0.78, 0.98]0.02220.88 [0.79, 0.99]0.0349
      Marital Status
       Married/Living as Married vs. Single0.99 [0.98, 1.00]0.06030.98 [0.97, 1.00]0.0555
       Previously Married vs. Single1.00 [0.98, 1.01]0.40890.99 [0.98, 1.01]0.4145
      Education, per additional year0.83 [0.75, 0.93]0.00100.84 [0.75, 0.94]0.0016
      Raised By
       Single Parent vs. Both Parents0.99 [0.59, 1.67]0.97141.00 [0.59, 1.70]0.9878
       Non-Parents vs. Both Parents0.96 [0.51, 1.81]0.89310.92 [0.48, 1.76]0.7986
      Kids, per additional child1.08 [1.04, 1.13]0.00031.11 [1.05, 1.17]0.0003
      Homeless in prior year1.01 [1.00, 1.02]0.00111.01 [1.01, 1.02]0.0014
      a An ordinal variable defined as the sum of the number of parents and grandparents participants reported to have drug or alcohol use disorders.
      b Present (at least one parent or grandparent with a history of PTSD) or absent (no parents or grandparents with a history of PTSD).

      4. Discussion

      4.1 Contextualizing study results

      This study examined the impacts of intergenerational substance use and trauma issues on life outcomes (continual substance use, child maltreatment charges) among Black women with varying levels of involvement in the criminal justice system. Our study revealed high levels of intergenerational substance use, with 60–70 % of women, regardless of recruitment setting, reporting at least one parent or grandparent having an issue with alcohol or drugs. Furthermore, 38 % reported two or more biological parents/grandparents with alcohol/drug problems. Regarding intergenerational trauma, we found that approximately 13 % of the women reported familial PTSD, most of which reported that they had one parent having issues with PTSD. Regarding childhood trauma, about 20 % of the sample reported being physically abused, and 52 % witnessed violence in their childhood homes.
      The pervasiveness of intergenerational substance use and trauma and experienced childhood trauma in our study samples underscore the importance of understanding the prevalence and impacts of these issues among Black women and other minoritized and indigenous populations. Findings also call for multiple community-level interventions specific to carceral settings and the need to expand understanding of life course to account for intergenerational impacts. These interventions may include strengthening self-esteem in romantic and non-romantic interpersonal relationships. Women have identified that strength of interpersonal relationships, self-efficacy, and self-esteem as essential factors in recovery from SUDs (
      • Latuskie K.A.
      • Andrews N.C.
      • Motz M.
      • Leibson T.
      • Austin Z.
      • Ito S.
      • Pepler D.J.
      Reasons for substance use continuation and discontinuation during pregnancy: A qualitative study.
      ). Black women are more likely to use informal resources like family and friends, which may buffer against racial discrimination and costs (
      • Kelly L.C.
      • Spencer C.M.
      • Keilholtz B.
      • McAllister P.
      • Stith S.M.
      Is separate the new equal? A meta-analytic review of correlates of intimate partner violence victimization for Black and White women in the United States.
      ).
      Our findings on the association between intergenerational substance use and trauma and trajectories of substance use are consistent with current literature (
      • Haggerty K.P.
      • Carlini B.H.
      Understanding the intergenerational transmission of substance use and problem behavior: Implications for future research and preventive interventions.
      ;
      • Kerr D.C.R.
      • Tiberio S.S.
      • Capaldi D.M.
      • Owen L.D.
      Intergenerational congruence in adolescent onset of alcohol, tobacco, and marijuana use.
      ;
      • Bears Augustyn M.
      • Loughran T.
      • Larroulet P.
      • Fulco C.J.
      • Henry K.L.
      Intergenerational marijuana use: A life course examination of the relationship between parental trajectories of marijuana use and the onset of marijuana use by offspring.
      ;
      • Epstein M.
      • Bailey J.A.
      • Furlong M.
      • Steeger C.M.
      • Hill K.G.
      An intergenerational investigation of the associations between parental marijuana use trajectories and child functioning.
      ;
      • Neppl T.K.
      • Diggs O.N.
      • Cleveland M.J.
      The intergenerational transmission of harsh parenting, substance use, and emotional distress: Impact on the third-generation child.
      ). Yet, in this study, we quantified this association and measured the additional effect of each biological parent and grandparents, with that quantification being 30 % increased odds per each parent/grandparent combination. In addition, intergenerational substance use was associated with a significant likelihood of a lifetime CPS case among women with at least one child.
      • Neppl T.K.
      • Diggs O.N.
      • Cleveland M.J.
      The intergenerational transmission of harsh parenting, substance use, and emotional distress: Impact on the third-generation child.
      found that grandparents' problematic behaviors impacted their children's early initiation of substance use, and their children's resulting problematic behaviors and parenting adversely impacted their future grandchildren; these findings may offer insight into our results.
      Specific to women, the interplay of SUDs and sex/gender leave women and their subsequent children at higher odds of deleterious effects. The outcomes related to substance use are more pronounced among women due to biological factors (e.g., progressing to addiction quicker than men, hormones, increased drug cravings) and social factors (criminalization of substance use while pregnant) (
      • Faherty L.J.
      • Kranz A.M.
      • Russell-Fritch J.
      • Patrick S.W.
      • Cantor J.
      • Stein B.D.
      Association of punitive and reporting state policies related to substance use in pregnancy with rates of neonatal abstinence syndrome.
      ; ). In addition, gendered punitive measures, such as laws regarding substance use and pregnancies, are associated with worse substance use outcomes among pregnant women (
      • Faherty L.J.
      • Kranz A.M.
      • Russell-Fritch J.
      • Patrick S.W.
      • Cantor J.
      • Stein B.D.
      Association of punitive and reporting state policies related to substance use in pregnancy with rates of neonatal abstinence syndrome.
      ;
      • Louw K.A.
      Substance use in pregnancy: The medical challenge.
      ). Our study found that women released from prison were nearly four times more likely to continue substance use over time than community-recruited women. This finding suggests that women in prison may have more severe SUDs and/or may experience destabilization of incarceration once released. This increased stressor may trigger drug cravings and subsequent drug use.
      Furthermore, we found that intergenerational trauma was statistically significant with having a CPS case in our minimally adjusted regression model; however, after accounting for other sociodemographic and contextual factors (e.g., number of kids, homelessness, intergenerational substance use), this association was no longer significant. Intergenerational trauma is likely significantly underreported in this study, which may influence its non-significant association with substance use outcomes over time among this sample of women. Moreover, given that trauma was prevalent in this sample and that having caretakers with drug and alcohol problems may also be a uniquely traumatic experience, there may have been a lack of variability to detect a significant difference. Women on probation were more likely to have had an open CPS case; however, it may be the CPS case that has led to the sentence of probation. On the other hand, intergenerational substance use was associated with the likelihood of having an open CPS case. Research by
      • Rothenberg W.A.
      • Sternberg A.
      • Blake A.
      • Waddell J.
      • Chassin L.
      • Hussong A.
      Identifying adolescent protective factors that disrupt the intergenerational transmission of cannabis use and disorder.
      found that intergenerational transmission of substance use was disrupted in adolescents with high involvement in positive activities, higher grades, and active coping skills. It may be that culturally appropriate interventions to boost involvement in positive activities and promote coping skills and academic achievement could benefit minoritized children affected by intergenerational substance use and trauma. These interventions may increase positive outcomes and reduce the removal of children from their mothers, which has been shown to increase substance use and other adverse effects on Black mothers (
      • Harp K.L.
      • Oser C.B.
      A longitudinal analysis of the impact of child custody loss on drug use and crime among a sample of african american mothers.
      ).

      4.2 Limitations and strengths

      Our study findings should be contextualized within a few limitations, including the secondary analyses of the B-WISE data. First, we relied on self-reports on substance use, criminal justice status, and participants' knowledge of issues related to substance use and PTSD among their parents and grandparents. These data may be subject to recall bias, social desirability, or participants' ignorance of these matters within the families. In addition, the influence of exposure to substance use and trauma from non-biologically related parental figures are not captured in the data, presenting another limitation. We ask participants to recall any known PTSD among parents and grandparents; we acknowledge that the meaning of PTSD may vary significantly among participants and that trauma and PTSD are not synonymous, as not all those who experience trauma develop PTSD. In addition, this study used a non-random sampling technique and focused specifically on Black women in Kentucky; thus, our findings may not be generalizable to other populations of women. Yet, our study features a large, longitudinal design on an under-resourced and under-researched population of women.

      5. Conclusion

      Among Black women with varying levels of involvement in the criminal justice system, we observed an association between intergenerational substance use, continual substance use, and further traumatizing participants' children via CPS cases. Our findings highlight the pervasive generational effects of substance use and trauma and the dire need for early intervention and substance use treatment to mitigate these effects on minoritized women in the criminal justice system. Due to the limited research on intergenerational trauma and substance use, and the limitations within the existing literature, further research is needed in this area.

      Role of funding sources

      This study was funded by the National Institute on Drug Abuse (NIDA) K01DA051715 (PI: Jones) and R01DA022967 (PI: Oser). NIDA was not involved any part of this study (study design, collection, data analysis or interpretation, manuscript writing), nor were they involved in the decision to submit this paper for publication.

      CRediT authorship contribution statement

      Jones AA, Duncan M, and Oser C conceptualized the study. Jones AA drafted the manuscript; Duncan M conducted the analyses. All authors were involved in the interpretation of the data, revision, and finalization of the manuscript. All authors approve of this manuscript.

      Declaration of competing interest

      None.

      Acknowledgements

      We would like to acknowledge the Kentucky Department of Corrections permission to conduct the research study; however, this study is not endorsed by the Kentucky Department of Corrections.

      Appendix A. Supplementary data

      The following is the supplementary data related to this article.

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