Jasmyn Sanders1, Alexandra R. Hershberger2, Haley M. Kolp3, Miji Um2, Matthew Aalsma4, and Melissa A. Cyders2
Abstract Juvenile justice–involved youth face disproportionate rates of sexual abuse, which increases the risk of post-traumatic stress disorder (PTSD) and substance use disorders (SUDs), both of which are associated with poor long-term outcomes. The present study tested two mediation and moderation models, controlling for age, race, and history of physical abuse, with gender as a moderator, to determine whether PTSD symptoms serve as a risk factor and/or mechanism in the relationship between sexual abuse and substance use. Data were examined for 197 juvenile justice–involved youth (mean age ¼ 15.45, 68.9% non-White, 78.4% male) that completed court-ordered psychological assessments. Results indicated that PTSD symptoms significantly mediated the relationship between sexual abuse and drug (b ¼ 3.44, confidence interval [CI] [0.26, 7.41]; test for indirect effect z ¼ 2.41, p ¼ .02) and alcohol use (b ¼ 1.42, CI [0.20, 3.46]; test for indirect effect z ¼ 2.23, p ¼ .03). PTSD symptoms and gender were not significant moderators. Overall, PTSD symptoms mediate the relationship between sexual abuse and SUDs in juvenile justice–involved youth, which suggests viability of targeting PTSD symptoms as a modifiable risk factor to reduce the effects of sexual abuse on substance use in this high-risk population.
Keywords sexual abuse, substance use, PTSD, youth, juvenile justice
Substance use disorders (SUDs) occur in approximately 60% of juvenile justice–involved youth (Substance Abuse and Mental
Health Services Administration, 2016; Teplin et al., 2005).
This is particularly problematic, as juvenile justice–involved
youth with SUDs face a host of negative outcomes, some of
which include increased likelihood of having a co-occurring
severe mental illness (e.g., manic episode and psychosis;
Teplin, Abram, McClelland, Dulcan, & Mericle, 2002),
increased likelihood of recidivism (Conrad, Tolou-Shams,
Rizzo, Placella, & Brown, 2014), and increased likelihood of
engagement in sexual risk-taking behaviors, compared to youth
in the general population (Teplin et al., 2005). Although there
are multiple potential explanations for the high prevalence of
SUDs in this population, such as genetic risk or social norms in
line with substance use (Kendler, Prescott, Myers, & Neale,
2003), emerging research suggests sexual abuse victimization
may be one risk factor for the development of SUDs in juvenile
The prevalence of sexual abuse victimization in juvenile
justice–involved youth is high, with 31% of girls and 15% of boys (Baglivio et al., 2014; Dierkhising et al., 2013) in the
juvenile justice system reporting a history of sexual abuse.
Extensive research on adolescent and adult populations demon-
strate that a history of sexual abuse is associated with a host of
negative outcomes (Finkelhor, Cross, & Cantor, 2005; Mullers
& Dowling, 2008) including increased engagement in risky
sexual behaviors (Ruffolo, Sarri, & Goodkind, 2004; Saar,
Epstein, Rosenthal, & Vafa, 2015; Smith, Leve, & Chamber-
lain, 2006; Townsend, 2013), a greater vulnerability to revicti-
mization (Townsend, 2013), and increased rates of delinquency
and criminal behavior (Asscher, Van der Put, & Stams, 2015;
Baglivio et al., 2014; Townsend, 2013; Widom & Maxfield,
Importantly, sexual abuse is related to problematic sub-
stance use (Townsend, 2013). Adolescents with a history of
sexual abuse are 4 times more likely to have an SUD and nearly
1 Department of Psychology, University of Miami, Coral Gables, FL, USA 2 Department of Psychology, Indiana University—Purdue University,
Indianapolis, IN, USA 3 Department of Psychology, Ohio University, Athens, OH, USA 4 Section of Adolescent Medicine, Department of Pediatrics, Indiana University
School of Medicine, Indianapolis, IN, USA
Alexandra R. Hershberger, Department of Psychology, Indiana University—
Purdue University, 402 North Blackford Street, Indianapolis, IN 46202, USA.
Child Maltreatment 2018, Vol. 23(3) 226-233 ª The Author(s) 2017 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1077559517745154 journals.sagepub.com/home/cmx
3 times more likely to report problematic substance use in
adulthood in comparison to members of the general population
(Townsend, 2013). In addition, victims of sexual abuse begin
experimenting with drugs at a younger age (13.7 years old)
compared to those adolescents who are not victims of sexual
abuse (15.1 years old; Kingston & Raghavan, 2009; Townsend,
2013), and this earlier onset of substance use is associated with
a higher likelihood of developing an SUD (Moss, Chen, & Yi,
2014). Furthermore, substance use among sexual abuse victims
increases the likelihood of engaging in criminal activity
(Widom & White, 1997) and further exacerbates already
high recidivism rates among juvenile justice–involved youth
(Conrad et al., 2014).
One way in which sexual abuse may be related to substance
use in juvenile justice–involved youth is through the experience
of post-traumatic stress disorder (PTSD) symptoms. It is possible
that PTSD symptoms strengthen the relationship between sexual
abuse and substance use, as the experience of PTSD symptoms
could lead to substance use via self-medication (e.g., Wolitzky-
Taylor, Bobova, Zinbarg, Mineka, & Craske, 2012) in sexually
abused juvenile justice–involved youth. Thus, PTSD symptoms
in sexually abused juvenile justice–involved youth could serve
as a risk indicator for subsequent substance use. Additionally,
PTSD symptoms could have a mechanistic role between sexual
abuse and substance use in juvenile justice–involved youth, by
which decreasing PTSD symptoms could serve to mitigate sub-
stance use risk associated with sexual abuse. Regardless if PTSD
symptoms serve as a risk factor or mechanism in the relationship
between sexual abuse and substance use in juvenile justice–
involved youth, PTSD symptoms are a modifiable factor that
could be targeted through treatment, potentially decreasing the
relationship between sexual abuse and substance use and asso-
ciated negative outcomes.
Importantly, there is a burgeoning area of research that spe-
cifically aims to reduce PTSD symptoms in juvenile justice–
involved youth. Treatments, such as trauma affect regulation:
guide for education and therapy (TARGET; Ford, Chang,
Levine, & Zhang, 2013) and cognitive processing therapy
(CPT; Matulis, Resick, Rosner, & Steil, 2014), show initial
promise in reducing PTSD symptoms in juvenile justice–
involved youth, including those who have experienced sexual
abuse. An unexplored benefit of such treatments, however, is if
reductions in PTSD symptoms serve to mitigate substance use
risk associated with sexual abuse in juvenile justice–involved
youth. Determining whether PTSD symptoms serve to
strengthen or mediate the relationship between sexual abuse
and substance use in juvenile justice–involved youth is an
important step in clarifying treatment models for sexual abuse
victims in this high-risk population.
The goal of the current study was to test two alternative
models to better understand the way in which PTSD symptoms
might influence the relationship between sexual abuse and sub-
stance use in juvenile justice–involved youth. Specifically, we
examined the following research questions: (1) Is the relation-
ship between sexual abuse and substance use stronger in the
presence of PTSD symptoms (i.e., moderation) and (2) Is
sexual abuse related to substance use through PTSD symptoms
(i.e., mediation). Additionally, we examined each research
question with gender as a moderator. Differing base rates of
study variables by gender, such as sexual abuse (Baglivio et al.,
2014; Dierkhising et al., 2013), and varying mechanisms
thought to underlie posttraumatic stress responses by gender
(Norr, Albanese, Boffa, Short, & Schmidt, 2016), for example,
could result in varying relationships between sexual abuse,
PTSD symptoms, and substance use by gender. We also con-
trolled for history of physical abuse, as polyvictimization, par-
ticularly through multiple forms of abuse, is related to
psychological disorders and problems (e.g., substance use,
PTSD symptoms; Ford, Elhai, Connor, & Frueh, 2010).
This study is the first step in a program of research that seeks
to examine PTSD as a modifiable risk factor to reduce the
effects of sexual abuse on substance use in this high-risk pop-
ulation. We chose to examine PTSD as a moderator and med-
iator in the current sample, as opposed to alternative causal
models, given data that (1) sexual abuse typically temporally
precedes PTSD development (although PTSD does increase the
risk of revictimization) and (2) substance use is often a symp-
tom or result of PTSD.
Data were taken from existing charts of 247 juvenile justice–
involved youth in a Midwestern city, who were court ordered to
complete a psychological assessment between 2009 and 2016.
Youth completed integrated assessments, and a subset of that
data are included in the current report. Data from the assess-
ments were deidentified, and analysis of this archival data was
approved by the institutional review board.
Demographics. Youth reported their age, gender (girl or boy), and race.
PTSD. First, PTSD symptoms were assessed through the Youth Self-Report (YSR; Achenbach & Rescorla, 2001). The YSR is
self-report assessment in which youth rate themselves on var-
ious behavioral and emotional problems. Response options
range from 0 (not true) to 2 (very often or often true), and
scores are converted to t scores. For the PTSD Scale, t scores
<65 are considered to fall in the “normal” range, and t scores
over 65 correspond with increases in symptom severity. The
YSR has shown good reliability (e.g., Ebesutani, Berstein,
Martinez, Chorpita, & Weisz, 2011). Further, the YSR has been
validated for use in samples of juvenile justice–involved youth
(Vreugdenhil, van den Brink, Ferdinand, Wouters, & Dorelei-
jers, 2006). PTSD symptoms were used as a variable in anal-
yses for the present study.
Second, PTSD diagnosis (distinct from the YSR PTSD
Scale score) was made by a licensed clinical psychologist con-
ducting or supervising each youth’s assessment. Diagnoses
Sanders et al. 227
were based on a structured clinical interview and YSR corre-
spondence with Diagnostic and Statistical Manual of Mental
Disorders, Version IV, Revised (DSM-IV-TR), (American Psy-
chiatric Association, 2000) or Diagnostic and Statistical Man-
ual of Mental Disorders, Version 5 (DSM-5), (American
Psychiatric Association, 2013). Due to differences in diagnos-
tic criteria between DSM versions and limited variability in
dichotomous diagnoses, our analyses focused on the YSR
PTSD score. PTSD diagnosis was used as a descriptive mea-
sure for the present study and not examined in study analyses.
Substance use. First, substance use (illicit drug use and alcohol use) was assessed through the Adolescent Substance Use
Subtle Screening Inventory (SASSI-A2; Miller & Lazowski,
2001). The SASSI-A2 is a self-report questionnaire for which
youth self-report various substance use–related behaviors. The
present study examined substance use using the Face Valid
Other Drugs (FVOD; e.g., “Taken drugs to improve your think-
ing and feeling,” “Taken drugs so you could enjoy sex more”;
Miller, Renn, & Lazowski, 2001) Scale and the Face Valid
Alcohol (FVA; e.g., “Tried to kill yourself while drunk,”
“Drank alcohol during the day”; Miller et al., 2001) Scale of
the SASSI-A2, with each scale assessing substance use–related
problems on a scale from 0 (never) to 3 (repeatedly). Results
are provided as t scores based on norms derived from an ado-
lescent sample (mean age ¼ 15, standard deviation [SD]¼ 1.9) across addiction treatment centers, inpatient psychiatric hospi-
tals, outpatient behavioral health facilities, and juvenile correc-
tions programs. The SASSI-A2 FVA and FVOD Scales have
demonstrated acceptable to excellent reliability (a ¼ .61 and .95, respectively; Perera-Diltz & Perry, 2011) and test–retest
reliability (rs ¼ .71 and .92, respectively; Miller & Lazowski, 2001; Stein et al., 2005).
Second, an SUD diagnosis (distinct from the SASSI-A2
Scales) was made by a licensed clinical psychologist conduct-
ing or supervising each youth’s assessment. Diagnoses were
based on a structured clinical interview and SASSI-A2 corre-
spondence with DSM-IV-TR (American Psychiatric Associa-
tion, 2000) or DSM-5 (American Psychiatric Association,
2013). Due to differences in diagnostic criteria between DSM
versions and limited variability in dichotomous diagnoses, our
analyses focused on the SASSI-A2 scores. An SUD diagnosis
was used as a descriptive measure for the present study and not
examined in study analyses.
Sexual abuse. Youth self-reported their history of sexual abuse through a structured clinical interview. Sexual abuse was coded
as either reporting or not reporting sexual abuse. Additionally,
the relationship of alleged perpetrator to the victim of sexual
abuse was recorded (e.g., parent, paramour, relative).
Physical abuse. Youth self-reported their history of physical abuse through a structured clinical interview. Physical abuse
was coded as either reporting or not reporting physical abuse
and used as a covariate in analyses.
Youth in the present sample were involved with the juvenile
court (e.g., through arrest, probation violation) and referred to
complete a court-ordered psychological assessment. Following
the referral, a licensed clinical psychologist or supervised doc-
toral student reported to the Juvenile Detention Center or the
youth’s current placement (e.g., group home, family home) to
complete the assessment. Clinicians conducted a structured
clinical interview and administered assessment measures,
including the YSR, SASSI-A2, and other measures unrelated
to the present study and not reported elsewhere. Clinicians used
assessment information to compile an integrated report for each
youth, which was submitted to the Marion County Juvenile
Court upon completion. Trained research assistants entered
YSR and SASSI-A2 data taken directly from the assessment
reports for each youth. Additionally, research assistants coded
whether or not the youth reported ever experiencing sexual
abuse (any form of illegal sex act conducted against the youth)
or physical abuse (any form of illegal physical act conducted
against the youth, not including physical altercations between
peers) based on the background information provided in the
assessment report. Twenty percent of the data were recoded
for interrater reliability. There were no discrepancies between
coders on study variables.
First, we examined sample characteristics stratified across sex-
ual abuse and gender. Second, we conducted moderated regres-
sion analyses using Hayes’s (2013) process macro, controlling
for age, race, and history of physical abuse (0 ¼ no abuse, 1 ¼ abuse), with sexual abuse (0¼ no abuse, 1¼ abuse) entered as the independent variable, PTSD symptoms (YSR PTSD Scale)
entered as the moderator, and gender (0 ¼ boys, 1 ¼ girls) entered as a second moderator (three-way interaction). Two
analyses were conducted with drug use and alcohol use as
dependent variables in separate models. Third, we conducted
moderated mediation analyses using Hayes’s (2013) process
macro, controlling for age, race, and history of physical abuse,
with sexual abuse entered as the independent variable, PTSD
symptoms entered as the mediator, and gender entered as a
moderator of the relationship between the independent and
dependent variable. Two analyses were conducted with drug
use and alcohol use as dependent variables in separate models.
Of the 247 youth completing court-ordered psychological
assessments, 197 provided data for PTSD Scales, drug use, and
alcohol use, making the final sample N ¼ 197 (mean age ¼ 15.45, SD ¼ 1.31, range ¼ 13–18; 61.6% Black, 21.6% White, 3.2% Hispanic, 4.1% multiracial; 9.5% not specified; 78.4% male). Those youth who were not administered measures of
PTSD, drug use, or alcohol use did not differ significantly in
228 Child Maltreatment 23(3)
age or gender from youth who completed these measures.
Those completing the drug and alcohol use scales were more
likely to have a cannabis use disorder diagnosis compared to
those not completing (w2¼ 7.29, p¼ .007). The majority of the sample was non-White (68.9%) and male (79.5%). The major- ity of assessments were conducted at the juvenile detention
center (82.1%) with youths having an average of six (SD ¼ 3.80) criminal referrals to the court. Of the 197 youth, 17.3% were diagnosed with PTSD, and 44.7% were diagnosed with a cannabis use disorder, with a small proportion meeting criteria
for alcohol use disorder (3%) and stimulant use disorder (1.5%).
Average drug use score was 56.32 (SD ¼ 12.67, range ¼ 6– 96), average alcohol use score was 45.75 (SD ¼ 7.10, range ¼ 39–95), and average PTSD score was 60.49 (SD ¼ 9.99, range ¼ 50–95). Alcohol use, drug use, and PTSD Scales were all significantly correlated (rs ¼ .31–.52, ps < .05; see Table 1).
A total of 13.2% of the sample reported any history of sexual abuse (7.8% of boys and 33.3% of girls in the sample) and 16% of the sample reported any history of physical abuse. A total of
2.9% of youth reported a history of both physical and sexual abuse. Girls were more likely than boys to report a history of
sexual abuse (w2 ¼ 17.73, p < .001) and physical abuse (w2 ¼ 5.97, p¼ .02), and boys and girls were similarly likely to report a history of both physical and sexual abuse (w2¼ 2.57, p¼ .11; see Table 2). Youth who reported a history of sexual abuse
were more likely to be diagnosed with PTSD compared to those
not reporting a history of sexual abuse (w2 ¼ 9.43, p < .002). Youth reporting only physical abuse (and not sexual abuse)
compared to youth reporting sexual abuse (and not physical
abuse) did not differ significantly in rate of PTSD diagnosis
(w2 ¼ 1.99, p ¼ .16), but youth reporting sexual abuse (and not physical abuse) scored higher on the PTSD Scale, t(41) ¼ �1.89, falling short of significance (p ¼ .07).
Table 1. Correlation Between Study Variables.
1 2 3 4 5 6 7 8 9
1. Age �.06 �.06 .09 .06 .0 .009 �.02 �.06 2. PTSD score — .18* .31** .10 .41** .06 �.06 .006 3. PTSD diagnosis — — �.03 �.08 .02 �.02 �.02 .09 4. FVA score — — .53** .52** �.007 �.04 .03 5. Alcohol use disorder diagnosis — — — — .27** �.002 �.02 �.001 6. FVOD score — — — — — .29** �.04 .06 7. Cannabis or other illicit drug use disorder diagnosis — — — — — — �.07 �.18* 8. Sexual abuse — — — — — — — �.03 9. Physical abuse
Note. PTSD ¼ post-traumatic stress disorder; FVA ¼ Face Valid Alcohol; FVOD ¼ Face Valid Other Drugs. *p < .05. **p < .001.
Table 2. Sample Characteristics by Sexual Abuse and Gender.
Boys (n ¼ 153) Girls (n ¼ 42) Test Statistic p Sexual Abuse No Sexual Abuse Test Statistic p
PTSD Scale 60.50 (10.30) 60.45 (8.88) 0.03 .98 65.27 (12.69) 59.77 (9.35) �2.66 .009 FVA (alcohol use) 45.06 (5.90) 48.29 (10.10) �2.65 .009 47.77 (7.83) 45.44 (6.96) �1.57 .12 FVOD (drug use) 56.60 (12.89) 55.31 (11.91) 0.59 .56 56.00 (11.56) 56.37 (12.86) 0.14 .89 PTSD diagnosis 13.5% 31% 7.01 .008 38.46% 14.03% 9.43 .002 Sexual abuse only 5.84% 26.32% 17.73 <.001 Physical abuse only 10.95% 21.05% 5.97 .02 Sexual and physical abuse 2.19% 5.26% 2.57 .11 Cannabis use disorder 46.45% 38.09% 0.93 .33 38% 45.6% 0.47 .49 Stimulant use disorder 1.3% 2.4% 0.26 .61 0 3.5% 0.46 .50 Alcohol use disorder 3.2% 2.4% 0.08 .78 0 3.5% 0.94 .33
Sexual Abuse Perpetrator Boys (n ¼ 14) Girls (n ¼ 17) Parent or paramour 21.4% 27.8% 0.17 .68 Adult relative 14.3% 5.6% 0.71 .40 Known adult nonrelative 28.6% 22.2% 0.17 .68 Adult stranger 7.1% 5.6% 0.03 .85 Child relative 28.6% 5.6% 3.16 .08 Known child nonrelative 14.3% 22.2% 0.33 .57
Note. Ranges for scale scores were as follows: PTSD YSR scale score ¼ 0–95; FVA ¼ 0–95; FVOD ¼ 6–96. Boys reports of sexual abuse n ¼ 14, girls reports of sexual abuse n ¼ 17. PTSD ¼ post-traumatic stress disorder; FVA ¼ Face Valid Alcohol; FVOD ¼ Face Valid Other Drugs; YSR ¼ Youth Self-Report. Significant p-values at the p<.05 level are bolded.
Sanders et al. 229
Moderation analyses: Is the relationship between sexual abuse and substance use stronger in the presence of PTSD symptoms and variable by gender?
Drug use. First, sexual abuse was not significantly related to drug use (b ¼ 10.69, p ¼ .60). Second, PTSD symptoms were significantly related to drug use (b ¼ 0.66, p < .001). Third, PTSD symptoms did not significantly moderate the relation-
ship between sexual abuse and drug use (b ¼ �0.27, p ¼ .35). Fourth, gender did not significantly moderate the overall model
for drug use (b ¼ 0.64, p ¼ .24). Alcohol use. First, sexual abuse was not significantly related
to alcohol use (b ¼ 16.08, p ¼ .18). Second, PTSD symptoms were significantly related to alcohol use (b ¼ 0.23, p < .001). Third, PTSD symptoms did not significantly moderate the rela-
tionship between sexual abuse and alcohol use (b¼�0.22, p¼ .17). Fourth, gender did not significantly moderate the overall
model for alcohol use (b ¼ 0.40, p ¼ .20).
Moderation mediation analyses: Is sexual abuse related to substance use through PTSD symptoms and does this vary by gender?
Drug use. First, sexual abuse was significantly related to PTSD symptoms (b ¼ 5.86, p ¼ .009). Second, PTSD symp- toms were significantly related to drug use (b¼ 0.59, p < .001). Third, sexual abuse was negatively related to drug use (b ¼ �7.52, p ¼ .05). Fourth, the relationship between sexual abuse and drug use was not moderated by gender (b ¼ 9.02, p ¼ .11).
Fifth, PTSD significantly mediated the relationship between
sexual abuse and drug use (b ¼ 3.44, 95% confidence interval [CI]¼ [0.26, 7.41]; test of indirect effect z¼ 2.41, p ¼ .02; see Figure 1).
Alcohol use. First, sexual abuse was significantly related to PTSD symptoms (b ¼ 5.86, p ¼ .009). Second, PTSD symp- toms were significantly related to alcohol use (b ¼ 0.24, p < .001). Third, sexual abuse was not significantly related to alco-
hol use (b ¼ �0.57, p ¼ .80). Fourth, the relationship between sexual abuse and alcohol use was not moderated by gender
(b ¼ 0.68, p ¼ .80). Fifth, PTSD significantly mediated the relationship between sexual abuse and alcohol use (b ¼ 1.42, 95% CI [0.20, 3.46]; test of indirect effect z¼ 2.23, p¼ .03; see Figure 1).
Juvenile justice–involved youth face a disproportionate amount
of negative outcomes compared to their same-age peers (e.g.,
Hershberger , Zapolski, & Aalsma, 2016; Fazel, Doll, & Lang-
strom, 2008) and exhibit high rates of sexual abuse, PTSD, and
substance use. Despite their high-risk nature, it is unclear how
best to reduce negative outcomes associated with sexual abuse
in juvenile justice–involved youth. There are viable treatments
targeting trauma, including sexual abuse, in this population
(e.g., Ford et al., 2013; Matulis et al., 2014), which reduce
PTSD symptoms; however, this study is unique in that it sug-
gests targeting PTSD symptoms as a means of reducing sexual
abuse–related substance use risk in juvenile justice–involved
youth. These findings provide support that not only may sexual
abuse serve as a risk indicator for PTSD and substance use in
juvenile justice–involved youth, but that PTSD may be a prime
modifiable risk factor to reduce the effects of sexual abuse on
subsequent substance use in this high-risk population. Once a
child experiences sexual abuse, it is no longer a preventable or
modifiable risk factor and intervening on substance use alone
underestimates the role PTSD symptomatology plays in the
onset and maintenance of substance use behaviors. PTSD
symptoms appear to mediate, rather than moderate, the rela-
tionship between sexual abuse and substance use in juvenile
justice–involved youth, which suggests that reducing PTSD
symptoms could protect against and reduce substance use in
this population. This is important, given the negative outcomes
associated with substance use in this high-risk group.
One likely explanation for the relationship between sexual
abuse and substance use through PTSD observed in the present
study is the self-medication hypothesis (Khantzian, 1987). The
self-medication hypothesis (Khantzian, 1987) indicates that
certain drugs are chosen deliberately by individuals who wish
to suppress or avoid their negative experiences and emotions.
Juvenile justice–involved youth often display high rates of
avoidant PTSD symptoms (Kerig & Becker, 2010), and sub-
stance use is often cited as one coping strategy used by sexually
victimized youth (Kilpatrick et al., 2003). Thus, juvenile jus-
tice–involved youth who are victims of sexual abuse may use
Figure 1. Results of mediation models run using Andrew Hayes process macro (Hayes, 2013), controlling for age, gender, and race. Top: Results indicated that the indirect effect of sexual abuse on drug use through post-traumatic stress disorder (PTSD) scores was sig- nificant (b ¼ 3.44, 95% confidence interval [CI] ¼ [0.26, 7.41]; test of indirect effect z ¼ 2.41, p ¼ .02). Bottom: Results indicated that the indirect effect of sexual abuse on alcohol use through PTSD scores was significant (b¼ 1.42, 95% CI [0.20, 3.46]; test of indirect effect z¼ 2.23, p ¼ .03).
230 Child Maltreatment 23(3)
substances as a means to cope with or alleviate emotional dis-
tress. Interventions designed to provide more adaptive ways to
cope with or alleviate emotional distress have the potential to
reduce the reliance on substance use in this population.
Although previous research indicates mixed findings for the
relationship between PTSD and substance use in juvenile jus-
tice–involved youth (Abram et al., 2004; Danielson et al.,
2010; Dierkhising et al., 2013; Kingston & Raghavan, 2009;
Rosenberg et al., 2014), present findings support PTSD as a
proximal factor to substance use among youth who are victims
of sexual abuse.
Given that one way by which sexual abuse is related to
greater substance use is through the presence of greater PTSD
symptomology, it appears trauma-informed treatment could be
critical to reducing substance use in juvenile justice–involved
youth with sexual abuse. One well-studied model of trauma-
focused treatment for substance use is seeking safety (Najavits,
2002), and although this evidence-based treatment has not been
well-studied in juvenile justice–involved youth, it certainly
provides one framework for addressing issues highlighted in
the present study. Such therapies are easily implemented (Naja-
vits, Gallop, & Weiss, 2006) and provide psychoeducation on
the complex interplay between trauma and substance use. Risk
reduction through family therapy (Danielson et al., 2010;
Danielson et al., 2012) also demonstrates efficacy in reducing
substance use and PTSD symptoms in adolescent victims of
sexual assault, and such treatments could be expanded to exam-
ine efficacy in juvenile justice populations. Additionally, there
are trauma-related treatments for juvenile justice–involved
youth, such as TARGET (Ford et al., 2013) and CPT (Matulis
et al., 2014), which show initial evidence of reducing PTSD
symptomology in this population and thus could serve to miti-
gate sexual abuse–related substance use risk in this population.
It is imperative that trauma treatment research in juvenile jus-
tice–involved youth tracks not only changes in PTSD symp-
toms but also changes in substance use and related problems, to
best examine the mechanistic role of trauma-informed treat-
ment in reducing sexual abuse–related substance use risk.
It is important to note that the present findings are cross-
sectional; thus, there are other plausible reasons for the
observed relationships. For example, genetic factors may put
individuals at high risk for both PTSD and substance use
(Kendler et al., 2003). Although cross-sectional data are lim-
ited in making causal inferences, we view the current study as
the first step in a program of research examining these temporal
relationships in prospective designs and designing and testing
interventions to reduce substance use and risk in this high risk,
though relatively understudied, population. It is our aim that
this initial study will stimulate additional and much-needed
research and intervention design and testing in this group.
Additionally interesting, gender did not significantly
moderate the models examined in the present study. This
may indicate that there is no differential risk by gender in
juvenile justice–involved youth for the impact PTSD symp-
toms have on sexual abuse–related substance use or that the
relationship between sexual abuse and substance use does
not vary by gender in this population. First, although
research suggests varying mechanisms, such as anxiety sen-
sitivity, underlie posttraumatic responses by gender (Norr
et al., 2016), these gender differences may not extend to
reflect variable outcomes by gender, specifically sexual
abuse–related substance use.
Additionally, research indicates that juvenile justice–
involved girls experience sexual abuse at rates more than dou-
ble of boys (Baglivio et al., 2014; Dierkhising et al., 2013), but
it is possible that negative outcomes, particularly substance
use, associated with sexual abuse, cut across gender. It is also
possible that we were underpowered to detect an effect (N¼ 42 girls) and there are gender differences in the impact that PTSD
symptoms have on sexual abuse–related substance use and the
direct relationship between sexual abuse and substance use.
Future research should aim to clarify the role of gender in
negative outcomes associated with sexual abuse in order to best
Although the present study is important in that it suggests
viability of a novel intervention approach to reduce substance
use in high-risk, juvenile justice–involved youth, there are
some limitations to discuss. First, as common in many studies,
data were self-report in nature and thus subject to self-report
bias. Additionally, the sample was limited in the number of
youth reporting sexual abuse; thus, null findings might reflect
failure to find a true effect. Present data are cross-sectional, and
no causal pathways can be determined from our findings,
although they can suggest viability of examining these relation-
ships in temporal models in the future. For the present study,
we were given access to juvenile justice–involved youth’s
assessment reports, which did not include individual item
scores on study measures, thus we could not compute reliability
for the measures; however, the YSR and SASSI-A2 demon-
strate good psychometric properties across studies (e, g. Miller
& Lazowski, 2001; Stein et al., 2005; Vreugdenhil et al., 2006),
increasing our confidence in these measures in the present
study. The present sample had a limited number of females
and non-Whites, thus results may not generalize beyond the
demographic makeup of the present sample, although this
makeup does reflect typical juvenile justice populations (Child
Trends Data Bank, 2015; Teplin et al., 2002). Last, although we
controlled for history of physical abuse, there are other traumas
juvenile justice–involved youth often experience, such as emo-
tional abuse, which may serve to amplify their trauma-related
risk of substance use. The present findings cannot determine
whether sexual abuse–related risk of substance use through
PTSD symptomology can be better accounted for by polyvic-
timization beyond sexual abuse and physical abuse; however,
as we detected the present findings after controlling for the
additional presence of physical abuse, this increases our confi-
dence that particular attention should be paid to sexual abuse–
related substance use. In light of these limitations, we hope our
findings will move the research field of juvenile justice–
involved youth forward, particularly in measuring and examin-
ing PTSD symptom change as a means of mitigating sexual
abuse–related substance use risk.
Sanders et al. 231
Juvenile justice–involved youth face disproportionate rates of
sexual abuse, which increases the risk of PTSD and SUDs, both
of which are associated with negative long-term outcomes.
However, how best to reduce the effects of sexual abuse in this
group is not yet clear. Overall, findings suggest viability that
targeting PTSD symptoms in juvenile justice–involved youth
has potential as a prime modifiable treatment target to reduce
the effects of sexual abuse on substance use in this high-risk
population. We view the current study as providing key initial
evidence, which should be replicated in temporal work, includ-
ing the design and testing of PTSD interventions to reduce risk
in this high-risk population.
The authors would like to acknowledge Katie Schwartz for her coor-
dination of the forensic psychology clinic at the Indiana University
School of Medicine.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for
the research, authorship, and/or publication of this article: The pre-
paration of this article was supported in part by an F31 grant to Alex-
andra Hershberger (F31 AA024682) and fellowship to Jasmyn N.
Sanders (R25 GM109432) both under the mentorship of Melissa A
Abram, K. M., Teplin, L. A., Charles, D. R., Longworth, S. L.,
McClelland, G. M., & Dulcan, M. K. (2004). Posttraumatic stress
disorder and trauma in youth in juvenile detention. Archives of
General Psychiatry, 61, 403–410. doi:10.1001/archpsyc.61.4.403
Achenbach, T. M., & Rescorla, L. (2001). ASEBA school-age forms
& profiles. Burlington, VT: University of Vermont, Research Cen-
ter for Children, Youth, & Families.
American Psychiatric Association. (2000). Diagnostic and statistical
manual of mental disorders: DSM-IV-TR. Washington, DC: Amer-
ican Psychiatric Association.
American Psychiatric Association. (2013). Diagnostic and statistical
manual of mental disorders : DSM-5(5th ed.). Arlington, VA:
American Psychiatric Association.
Asscher, J. J., Van der Put, C. E., & Stams, G. J. J. M. (2015). Gender
differences in the impact of abuse and neglect victimization on
adolescent offending behavior. Journal of Family Violence, 30,
Baglivio, M. T., Epps, N., Swartz, K., Huq, M. S., Sheer, A., & Hardt,
N. S. (2014). The prevalence of adverse childhood experiences
(ACE) in the lives of juvenile offenders. Office of Juvenile Justice
and Delinquency Prevention Journal of Juvenile Justice, 3, 1–14.
Retrieved from http://www.journalofjuvjustice.org/JOJJ0302/ arti
Child Trends Data Bank. (2015). Indicators on children and youth.
Juvenile Detention, 1–17. Retrieved from http://www.childtrends.
Conrad, S. M., Tolou-Shams, M., Rizzo, C., Placella, N., & Brown, L.
K. (2014). Gender differences in recidivism rates for juvenile jus-
tice youth: The impact of sexual abuse. Law and Human Behavior,
38, 305–314. doi:10.1037/lhb0000062
Danielson, C., Macdonald, A., Amstadter, A. B., Hanson, R., de Are-
llano, M. A., Saunders, B. E., . . . Kilpatrick, D. G. (2010). Risky
behaviors and depression in conjunction with—or in the absence
of—lifetime history of PTSD among sexually abused adolescents.
Child Maltreatment, 15, 101–107.
Danielson, C., McCart, M. R., de Arellano, M. A., Macdonald, A.,
Doherty, L. S., & Resnick, H. S. (2012). Risk reduction for sub-
stance use and trauma-related psychopathology in adolescent sex-
ual assault victims: Findings from an open trial. Child
Maltreatment, 15, 261–268.
Dierkhising, C. B., Ko, S. J., Woods-Jaeger, B., Briggs, E. C., Lee, R.,
& Pynoos, R. S. (2013). Trauma histories among justice-involved
youth: Findings from the National Child Traumatic Stress Net-
work. European Journal of Psychotraumatology, 4, 1–12. doi:10.
Ebesutani, C., Bernstein, A., Martinez, J. I., Chorpita, B. F., & Weisz,
J. R. (2011). The youth self report: Applicability and validity
across younger and older youths. Journal of Clinical Child &
Adolescent Psychology, 40, 338–346.
Fazel, S., Doll, H., & Långström, N. (2008). Mental disorders among
adolescents in juvenile detention and correctional facilities: A sys-
tematic review and metaregression analysis of 25 surveys. Journal
of the American Academy of Child & Adolescent Psychiatry, 47,
Finkelhor, D., Cross, T. P., & Cantor, E. N. (2005). How the justice
system responds to juvenile victims: A comprehensive model of
case flow. Trauma, Violence, & Abuse, 6, 83–102. doi:10.1177/
Ford, J. D., Chang, R., Levine, J., & Zhang, W. (2013). Randomized
clinical trial comparing affect regulation and supportive group
therapies for victimization-related PTSD with incarcerated
women. Behavior Therapy, 44, 262–276. doi:10.1016/j.beth.
Ford, J. D., Elhai, J. D., Connor, D. F., & Frueh, B. C. (2010).
Poly-victimization and risk of posttraumatic, depressive, and
substance use disorders and involvement in delinquency in a
national sample of adolescents. Journal of Adolescent Health,
Hayes, A. F. (2013). Introduction to mediation, moderation, and con-
ditional process analysis: A regression-based approach. New
York, NY: Guilford Press. Hershberger, A., Zapolski, T., &
Aalsma, M. C. (2016). Social support as a buffer between discrim-
ination and cigarette use in juvenile offenders. Addictive beha-
viors, 59, 7-11.
Hershberger, A., Zapolski, T., & Aalsma, M. C. (2016). Social support
as a buffer between discrimination and cigarette use in juvenile
offenders. Addictive behaviors, 59, 7–11.
Kendler, K. S., Prescott, C. A., Myers, J., & Neale, M. C. (2003). The
structure of genetic and environmental risk factors for common
232 Child Maltreatment 23(3)
psychiatric and substance use disorders in men and women.
Archives of General Psychiatry, 60, 929–937.
Kerig, P. K., & Becker, S. P. (2010). From internalizing to externaliz-
ing: Theoretical models of the processes linking PTSD to juvenile
delinquency. In S. J. Egan (Ed.), Posttraumatic stress disorder
(PTSD): Causes, symptoms and treatment (pp. 33–78). Haup-
pauge, NY: Nova Science.
Khantzian, E. J. (1987). The self-medication hypothesis of addictive
disorders: Focus on heroin and cocaine dependence. In: D. F. Allen
(eds) The cocaine crisis (pp. 65–74). Boston, MA: Springer.
Kilpatrick, D. G., Ruggiero, K. J., Acierno, R., Saunders, B. E.,
Resnick, H. S., & Best, C. L. (2003). Violence and risk of PTSD,
major depression, substance abuse/dependence, and comorbidity:
Results from the National Survey of Adolescents. Journal of Con-
sulting & Clinical Psychology, 71, 602–700. doi:10.1037/0022-
Kingston, S., & Raghavan, C. (2009). The relationship of sexual
abuse, early initiation of substance use, and adolescent trauma to
PTSD. Journal of Traumatic Stress, 22, 65–68. doi:10.1002/jts.
Matulis, S., Resick, P. A., Rosner, R., & Steil, R. (2014). Develop-
mentally adapted cognitive processing therapy for adolescents suf-
fering from posttraumatic stress disorder after childhood sexual or
physical abuse: A pilot study. Clinical Child and Family Psychol-
ogy Review, 17, 173–190. doi:10.1007/s10567-013-0156-9
Moss, H. B., Chen, C. M., & Yi, H. Y. (2014). Early adolescent
patterns of alcohol, cigarettes, and marijuana polysubstance use
and young adult substance use outcomes in a nationally represen-
tative sample. Drug and Alcohol Dependence, 136, 51–62.
Miller, F. G., & Lazowski, L. E. (2001). The Adolescent Substance
Abuse Subtle Screening Inventory-A2 (SASSI-A2) manual. Spring-
ville, IN: SASSI Institute.
Miller, F. G., Renn, W. R., & Lazowski, L. E. (2001). Adolescent
SASSI-A2 user’s guide. Bloomington, IN: Baugh Enterprises.
Mullers, E. S., & Dowling, M. (2008). Mental health consequences of
child sexual abuse. British Journal of Nursing, 17, 1428–1433. doi:
Najavits, L. M. (2002). Seeking safety: A treatment manual for PTSD
and substance abuse. New York, NY: Guilford Press.
Najavits, L. M., Gallop, R. J., & Weiss, R. D. (2006). Seeking safety
therapy for adolescent girls with PTSD and substance use disorder:
A randomized controlled trial. The Journal of Behavioral Health
Services & Research, 33, 453–463.
Norr, A. M., Albanese, B. J., Boffa, J. W., Short, N. A., & Schmidt, N.
B. (2016). The relationship between gender and PTSD symptoms:
Anxiety sensitivity as a mechanism. Personality and Individual
Differences, 90, 210–213. doi:10.1016/j.paid.2015.11.014
Perera-Diltz, D. M., & Perry, J. C. (2011). Screening for adolescent
substance-related disorders using the SASSI-A2: Implications for
nonreporting youth. Journal of Addictions & Offender Counseling,
Rosenberg, H. J., Vance, J. E., Rosenberg, S. D., Wolford, G. L.,
Ashley, S. W., & Howard, M. L. (2014). Trauma exposure, psy-
chiatric disorders, and resiliency in juvenile-justice-involved
youth. Psychological Trauma: Theory, Research, Practice, and
Policy, 6, 430.
Ruffolo, M. C., Sarri, R., & Goodkind, S. (2004). Study of delinquent,
diverted, and high-risk adolescent girls: Implications for mental
health intervention. Social Work Research, 28, 237–245. doi:10.
Saar, M. S., Epstein, R., Rosenthal, L., & Vafa, Y. (2015). The sexual
abuse to prison pipeline: The girls’ story. Georgetown Law Center
on Poverty & Inequality, 1–43. Retrieved from http://rights4girls.
Smith, D. K., Leve, L. D., & Chamberlain, P. (2006). Adolescent girls’
offending and health-risking sexual behavior: The predictive role
of trauma. Child Maltreatment, 11, 346–353. doi:10.1177/
Stein, L. A. R., Lebeau-Craven, R., Martin, R., Colby, S. M., Barnett,
N. P., Golembeske, C., . . . Penn, J. V. (2005). Use of the adoles-
cent SASSI in a juvenile correctional setting. Assessment, 12,
Substance Abuse and Mental Health Services Administration. (2016).
Criminal and juvenile justice: Overview. Retrieved from https://
Teplin, L. A., Abram, K. M., McClelland, G. M., Dulcan, M. K., &
Mericle, A. A. (2002). Psychiatric disorders in youth in juvenile
detention. Archives of General Psychiatry, 59, 1133–1143.
Teplin, L. A., Elkington, K. S., McClelland, G. M., Abram, K. M.,
Mericle, A. A., & Washburn, J. J. (2005). Major mental disorders,
substance use disorders, comorbidity, and HIV-AIDS risk beha-
viors in juvenile detainees. Psychiatric Services, 56, 823–828.
Townsend, C. (2013). Prevalence and consequences of child sexual
abuse compared with other childhood experiences. Darkness to
Light, 1–19. Retrieved from www.d2l.org
Vreugdenhil, C., van den Brink, W., Ferdinand, R., Wouters, L., &
Doreleijers, T. (2006). The ability of YSR scales to predict DSM/
DISC–C psychiatric disorders among incarcerated male adoles-
cents. European Child & Adolescent Psychiatry, 15, 88–96.
Widom, C. S., & Maxfield, M. G. (2001). An update on the “cycle of
violence.” National Institute of Justice Research in Brief, 1–8.
Retrieved from https://www.ncjrs.gov/pdffiles1/nij/184894.pdf
Widom, C. S., & White, H. R. (1997). Problem behaviors in abused
and neglected children grown up: Prevalence and co-occurrence of
substance abuse, crime, and violence. Criminal Behavior & Mental
Health, 7, 287–310. doi:10.1002/cbm.191
Wolitzky-Taylor, K., Bobova, L., Zinbarg, R. E., Mineka, S., &
Craske, M. G. (2012). Longitudinal investigation of the impact
of anxiety and mood disorders in adolescence on subsequent sub-
stance use disorder onset and vice versa. Addictive Behaviors,
37(8), 982–985. doi:10.1016/j.addbeh.2012.03.026
Sanders et al. 233
<< /ASCII85EncodePages false /AllowTransparency false /AutoPositionEPSFiles true /AutoRotatePages /None /Binding /Left /CalGrayProfile (Gray Gamma 2.2) /CalRGBProfile (sRGB IEC61966-2.1) /CalCMYKProfile (U.S. Web Coated \050SWOP\051 v2) /sRGBProfile (sRGB IEC61966-2.1) /CannotEmbedFontPolicy /Warning /CompatibilityLevel 1.3 /CompressObjects /Off /CompressPages true /ConvertImagesToIndexed true /PassThroughJPEGImages false /CreateJobTicket false /DefaultRenderingIntent /Default /DetectBlends true /DetectCurves 0.1000 /ColorConversionStrategy /LeaveColorUnchanged /DoThumbnails false /EmbedAllFonts true /EmbedOpenType false /ParseICCProfilesInComments true /EmbedJobOptions true /DSCReportingLevel 0 /EmitDSCWarnings false /EndPage -1 /ImageMemory 1048576 /LockDistillerParams true /MaxSubsetPct 100 /Optimize true /OPM 1 /ParseDSCComments true /ParseDSCCommentsForDocInfo true /PreserveCopyPage true /PreserveDICMYKValues true /PreserveEPSInfo true /PreserveFlatness false /PreserveHalftoneInfo false /PreserveOPIComments false /PreserveOverprintSettings true /StartPage 1 /SubsetFonts true /TransferFunctionInfo /Apply /UCRandBGInfo /Remove /UsePrologue false /ColorSettingsFile () /AlwaysEmbed [ true ] /NeverEmbed [ true ] /AntiAliasColorImages false /CropColorImages false /ColorImageMinResolution 266 /ColorImageMinResolutionPolicy /OK /DownsampleColorImages true /ColorImageDownsampleType /Average /ColorImageResolution 175 /ColorImageDepth -1 /ColorImageMinDownsampleDepth 1 /ColorImageDownsampleThreshold 1.50286 /EncodeColorImages true /ColorImageFilter /DCTEncode /AutoFilterColorImages true /ColorImageAutoFilterStrategy /JPEG /ColorACSImageDict << /QFactor 0.40 /HSamples [1 1 1 1] /VSamples [1 1 1 1] >> /ColorImageDict << /QFactor 0.76 /HSamples [2 1 1 2] /VSamples [2 1 1 2] >> /JPEG2000ColorACSImageDict << /TileWidth 256 /TileHeight 256 /Quality 30 >> /JPEG2000ColorImageDict << /TileWidth 256 /TileHeight 256 /Quality 30 >> /AntiAliasGrayImages false /CropGrayImages false /GrayImageMinResolution 266 /GrayImageMinResolutionPolicy /OK /DownsampleGrayImages true /GrayImageDownsampleType /Average /GrayImageResolution 175 /GrayImageDepth -1 /GrayImageMinDownsampleDepth 2 /GrayImageDownsampleThreshold 1.50286 /EncodeGrayImages true /GrayImageFilter /DCTEncode /AutoFilterGrayImages true /GrayImageAutoFilterStrategy /JPEG /GrayACSImageDict << /QFactor 0.40 /HSamples [1 1 1 1] /VSamples [1 1 1 1] >> /GrayImageDict << /QFactor 0.76 /HSamples [2 1 1 2] /VSamples [2 1 1 2] >> /JPEG2000GrayACSImageDict << /TileWidth 256 /TileHeight 256 /Quality 30 >> /JPEG2000GrayImageDict << /TileWidth 256 /TileHeight 256 /Quality 30 >> /AntiAliasMonoImages false /CropMonoImages false /MonoImageMinResolution 900 /MonoImageMinResolutionPolicy /OK /DownsampleMonoImages true /MonoImageDownsampleType /Average /MonoImageResolution 175 /MonoImageDepth -1 /MonoImageDownsampleThreshold 1.50286 /EncodeMonoImages true /MonoImageFilter /CCITTFaxEncode /MonoImageDict << /K -1 >> /AllowPSXObjects false /CheckCompliance [ /None ] /PDFX1aCheck false /PDFX3Check false /PDFXCompliantPDFOnly false /PDFXNoTrimBoxError true /PDFXTrimBoxToMediaBoxOffset [ 0.00000 0.00000 0.00000 0.00000 ] /PDFXSetBleedBoxToMediaBox false /PDFXBleedBoxToTrimBoxOffset [ 0.00000 0.00000 0.00000 0.00000 ] /PDFXOutputIntentProfile (U.S. Web Coated \050SWOP\051 v2) /PDFXOutputConditionIdentifier (CGATS TR 001) /PDFXOutputCondition () /PDFXRegistryName (http://www.color.org) /PDFXTrapped /Unknown /CreateJDFFile false /Description << /ENU <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> >> /Namespace [ (Adobe) (Common) (1.0) ] /OtherNamespaces [ << /AsReaderSpreads false /CropImagesToFrames true /ErrorControl /WarnAndContinue /FlattenerIgnoreSpreadOverrides false /IncludeGuidesGrids false /IncludeNonPrinting false /IncludeSlug false /Namespace [ (Adobe) (InDesign) (4.0) ] /OmitPlacedBitmaps false /OmitPlacedEPS false /OmitPlacedPDF false /SimulateOverprint /Legacy >> << /AllowImageBreaks true /AllowTableBreaks true /ExpandPage false /HonorBaseURL true /HonorRolloverEffect false /IgnoreHTMLPageBreaks false /IncludeHeaderFooter false /MarginOffset [ 0 0 0 0 ] /MetadataAuthor () /MetadataKeywords () /MetadataSubject () /MetadataTitle () /MetricPageSize [ 0 0 ] /MetricUnit /inch /MobileCompatible 0 /Namespace [ (Adobe) (GoLive) (8.0) ] /OpenZoomToHTMLFontSize false /PageOrientation /Portrait /RemoveBackground false /ShrinkContent true /TreatColorsAs /MainMonitorColors /UseEmbeddedProfiles false /UseHTMLTitleAsMetadata true >> << /AddBleedMarks false /AddColorBars false /AddCropMarks false /AddPageInfo false /AddRegMarks false /BleedOffset [ 9 9 9 9 ] /ConvertColors /ConvertToRGB /DestinationProfileName (sRGB IEC61966-2.1) /DestinationProfileSelector /UseName /Downsample16BitImages true /FlattenerPreset << /ClipComplexRegions true /ConvertStrokesToOutlines false /ConvertTextToOutlines false /GradientResolution 300 /LineArtTextResolution 1200 /PresetName ([High Resolution]) /PresetSelector /HighResolution /RasterVectorBalance 1 >> /FormElements true /GenerateStructure false /IncludeBookmarks false /IncludeHyperlinks false /IncludeInteractive false /IncludeLayers false /IncludeProfiles true /MarksOffset 9 /MarksWeight 0.125000 /MultimediaHandling /UseObjectSettings /Namespace [ (Adobe) (CreativeSuite) (2.0) ] /PDFXOutputIntentProfileSelector /DocumentCMYK /PageMarksFile /RomanDefault /PreserveEditing true /UntaggedCMYKHandling /UseDocumentProfile /UntaggedRGBHandling /UseDocumentProfile /UseDocumentBleed false >> ] /SyntheticBoldness 1.000000 >> setdistillerparams << /HWResolution [288 288] /PageSize [612.000 792.000] >> setpagedevice