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. Author manuscript; available in PMC: 2008 Oct 1.
Published in final edited form as: J Subst Abuse Treat. 2007 Feb 22;33(3):295–302. doi: 10.1016/j.jsat.2006.12.010

Drug-Abusing Fathers: Patterns of Pair-Bonding, Reproduction, and Paternal Involvement

Thomas J McMahon a,*, Justin D Winkel b, Nancy E Suchman a, Bruce J Rounsaville a
PMCID: PMC2093946  NIHMSID: NIHMS32053  PMID: 17399935

Abstract

Despite concern about compromise of fathering as a public policy issue, very little is known about the status of drug-abusing men as parents. In this pilot study, 50 men enrolled in methadone maintenance treatment completed a structured research interview designed to generate basic information about patterns of pair-bonding, reproduction, and paternal involvement. Descriptive analysis of these data highlighted a number of trends in the nature of fathering that, although at odds with popular stereotypes, were similar to trends noted in research being done with other populations of disenfranchised men. Consistent with a developmental-ecological perspective on parenting, the findings raise questions about ways historical and situational influences interact within this population to compromise socially responsible efforts to function as a father. The results also raise questions about the extent to which public policy initiatives designed to promote more responsible fathering are reaching this population, and they raise questions about ways the drug abuse treatment system might better support men interested in being a more effective parent.

Keywords: Parents, Parental Role, Fathers, Father-Child Relations, Drug Abuse

1. Introduction

Over the course of the past 20 years, social and economic changes occurring throughout this culture have converged to make fathering one of the more prominent social issues of the new millennium (for reviews, see Cabrera & Peters, 2000; McLanahan & Carlson, 2002; Mincy & Pouncy, 2002). When defining the construct, policy analysts typically agree that fathering is a complex biopsychosocial process that determines how men go about begetting and parenting children (for discussion, see Federal Interagency Forum on Child and Family Statistics, 1998). After acknowledging that fathering has a profound effect on the well-being of mothers and children, researchers have begun to acknowledge that fatherhood is a developmental issue of concern to most men (for discussion, see Palkovitz, 2002), and they have begun to more closely examine patterns of pair-bonding, procreation, and paternal involvement from the perspective of men, particularly men considered at risk for socially irresponsible production and parenting of children (e.g., see Fox & Benson, 2004; Furstenberg, 1995; Kost, 2001; Nelson, Clampet-Lundquist, & Edin, 2002; Pasley & Braver, 2004).

Ironically, despite ongoing interest in the reproductive and parenting behavior of men, the status of drug-abusing men as fathers is rarely acknowledged in the conceptualization of public policy, service delivery, or clinical research focusing on the adverse consequences of drug abuse (McMahon & Rounsaville, 2002). Although research suggests that there are more fathers than mothers entering drug abuse treatment (e.g., see McMahon, Winkel, Luthar, & Rounsaville, 2005), very little is known about fathering occurring in the context of chronic drug abuse. Given the absence of an adequate database, public policy, service delivery, and clinical research continue to be defined by a deficit perspective on the fathering of drug-abusing men that assumes they are reproducing indiscriminately, woefully neglectful, and potentially dangerous (for discussion, see McMahon & Giannini, 2003). Amid calls for creative programs to increase the presence of men in the lives of children (for reviews, see Cabrera & Peters, 2000; McLanahan & Carlson, 2002; Mincy & Pouncy, 2002), there are only limited data to guide the development of psychosocial intervention designed to promote more responsible fathering by drug-abusing men (McMahon & Rounsaville, 2002). Consequently, this pilot study was designed to provide some basic data on patterns of pair-bonding, reproduction, and paternal involvement within a small, ethnically diverse sample of fathers enrolled in methadone maintenance treatment.

2. Materials and methods

2.1 Sample

The sample for this study was an ethnically diverse group of 50 fathers who had been enrolled in methadone maintenance treatment for an average of 15.75 (SD = 13.01) months. Potentially eligible men were recruited into the study via announcements posted in methadone maintenance clinics and a simple system of peer referral where men who completed the study were given wallet-size announcements for distribution to potentially eligible peers. To be eligible for admission men had to be the biological father of at least one minor child, they had to be opioid-dependent, they had to be enrolled in methadone maintenance treatment, and they had to speak English well enough to complete the research procedures.

As a group, these opioid-dependent men were an average of 40.88 (SD = 7.33) years of age. Twenty-two (44%) of them were of Euro American heritage, 22 (44%) of them were of African American heritage, and six (12%) of them were of Hispanic heritage. They averaged 14.40 (SD = 10.33) years of heroin use that typically began before the birth of their first child when they were, on average, 21.44 (SD = 7.05) years of age. Twelve (24%) of the men were known to be HIV seropositive, and ongoing use of nicotine (92%), heroin (36%), alcohol (34%), powder cocaine (30%), crack cocaine (28%), and cannabis (28%) was common.

2.2 Measurement

All subjects admitted to the study completed a structured research interview designed to document critical dimensions of fathering from the perspective of men. A developmental-ecological perspective that acknowledges the contribution historical and situational influences can make to compromise of fathering guided development of this structured interview (for a review, see Belsky, 1993). Although some information about patterns of residence and paternal involvement was gathered for each biological child, the presence of fathers in the lives of their youngest biological child was explored in some detail. As much as possible, time-line follow-back procedures, logical sequencing of questions, visual representations of critical information, and cross-referencing of responses for logical consistency were used to increase the reliability of the data provided by each subject.

2.3 Procedure

After providing informed consent, the 50 men who enrolled in the study completed this research interview during a single evaluative session conducted by a research assistant with a bachelor degree in psychology. Participants received $30.00 compensation for time spent completing the study. The research protocol was approved by the Human Investigations Committee for the Yale University School of Medicine.

2.4 Data analysis

Quantitative data drawn from this structured research interview were systematically coded, sorted into clusters of variables representing historical versus current dimensions of fathering, and then compiled using descriptive statistics so that the psychosocial adjustment of the participants as fathers could be accurately summarized in a narrative description.

3. Results

3.1 Historical dimensions of pair-bonding, reproduction, and paternal involvement

3.1.1 Developmental precursors

When asked about developmental experiences commonly associated with risk for compromise of parenting as an adult, 46 (92%) of the 50 men who completed the study reported that their biological parents had lived together in the same household, most often while legally married. However, 21 (42%) of the men also reported that, if their biological parents had lived together, they had separated permanently when the men were, on average, 8.05 (SD = 5.43) years of age. Moreover, although most (90%) of them reported having had a positive relationship with their biological mother while growing up, fewer (62%) reported also having a positive relationship with their biological father who was often described as alcoholic. Surprisingly, despite the frequency of parental separation, only 14 (28%) of the men had lived with a step-father, foster-father, or similar father figure prior to their 18th birthday, and most (72%) of the men confirmed that there had been a positive male role model in their lives while they were growing up. Biological fathers (42%), uncles (26%), and older brothers (16%) were most frequently identified as positive male role models during their formative years.

When asked directly, 18 (36%) of the men confirmed developmental experiences they thought reflected a history of childhood abuse or neglect. Fourteen (28%) of the men thought that their basic physical or emotional needs had been neglected, most frequently by their biological fathers. Nine (18%) of the men thought that they had been emotionally abused, primarily by a foster parent, and nine (18%) of the men thought that they had been physically abused, most frequently by a biological father or foster parent. Similarly, eight (16%) of the men confirmed that they had been sexually abused, most frequently by an adult outside a caretaking role, and eight (16%) of the fathers reported that they had been involved with the child welfare system prior to their 18th birthday.

3.1.2 Economic resources to support family formation

As a group, the 50 men who completed the study confirmed that they had completed an average of 11.80 (SD = 1.75) years of formal education. Thirty-three (66%) men had completed high school, and 22 (44%) had completed some vocational training or college course work following completion of a high school diploma. Although most (92%) of the men had been employed on a full-time basis at some point in the past, it is noteworthy that four (8%) men reported that they had never worked on a full-time basis. The men who had been employed had worked for a maximum of 9.50 (SD = 6.90) years at the same full-time position, most frequently in a job requiring skilled (38%), semi-skilled (20%), or unskilled (30%) labor.

3.1.3 Patterns of pair-bonding

By their report, these 50 fathers had been involved in an average of 4.78 (SD = 3.90) serious heterosexual partnerships. Most (60%) of those relationships involved periods of cohabitation. The others were characterized as legal marriages (16%) or serious, committed relationships that did not involve cohabitation (24%). Most (90%) of the men had lived with at least one woman, and most (62%) had been legally married at least once. When compared with other serious, committed relationships (M = 22.84; SD = 7.21), legal marriages and periods of cohabitation began when the men were older (M = 26.36; SD = 7.35 and M = 28.18; SD = 8.32). There were also indications that, when compared with both periods of cohabitation and other serious, committed relationships (M = 3.58; SD = 3.87 and M = 2.57; SD = 3.27), the legal marriages had lasted much longer (M = 8.69; SD =7.51).

3.1.4 Patterns of reproduction

As a group, these 50 fathers had a total of 119 children (M = 2.38, SD = 1.76) with 78 different women (M = 1.56, SD = 0.88). As the descriptive statistics suggest, most of the men had one, two, or three children with either one or two women. As a group, the men first became a father when they were, on average, 23.68 (SD = 5.82) years of age. Most of the children were conceived with women whom the men were either married to (48%) or living with (40%). At some point 107 (90%) of these 119 children had lived in the same household as their drug-abusing father. Although nine (18%) of the men reported that there were questions about the paternity of 14 additional children that people believed they may have fathered, none of those men had been involved in a legal process to clarify paternity.

3.1.5 Paternal involvement with youngest biological child

According to the fathers, they were an average of 29.90 (SD = 6.26) years old at the time their youngest biological child was born. For many (46%) of them, this was their first and only child. When the child was born, a majority (72%) of the men were actively using illicit drugs, and very few (26%) were receiving any drug abuse treatment. Although sexual partnerships organized around the abuse of drugs are common, a relatively limited proportion (22%) of the mothers were also actively using alcohol and illicit drugs when the child was delivered. Despite their ongoing drug abuse, 35 (70%) of the fathers reported being present at the hospital when the child was born, most (92%) of the men were listed as the father on the birth certificate, and most (74%) of the children had been given their surname.

Following the birth, most (86%) of the men had lived with their youngest child, most (96%) of the them had seen the child more than once a week at some point in the past, and most (94%) of them confirmed that they had somehow provided financial support for the child. Although pleased to be a father, most (72%) of the men reported that the birth of the child did not have any effect on their drug abuse, and a majority (60%) of the men acknowledged being intoxicated at some point while caring for the child. Despite their ongoing drug use, only 11 (22%) of the men reported that there had been a child welfare complaint concerning the care of this child, and only two (4%) of the children had ever been in the custody of a child welfare agency.

3.1.6 Previous involvement as a father figure to other children

Thirty-two (64%) of the men reported that, at some point, they had also lived as a father figure with children they did not conceive. Over time, these 32 men had lived with a total of 109 children they did not conceive (M = 3.41; SD = 2.27). For most (84%) of them, this had occurred because they had lived with a woman who had children from a previous relationship.

3.1.7 Criminal activity and family process

As expected, virtually all (98%) of the 50 fathers had been arrested, most (90%) had been convicted of a crime, and most (72%) of them had been incarcerated for an average of 43.92 (SD = 51.87) months. When asked about patterns of arrest, 25 (50%) of the men reported that the police had been called to their home in response to a domestic disturbance, and 16 (32%) of the men confirmed that they had been arrested for assaulting a sexual partner. Despite the relatively frequent incidence of domestic violence, only 10 (20%) of the fathers confirmed that a friend or family member had accused them of somehow neglecting or abusing a child, and most (80%) of the complaints from friends and family members involved concern about neglect.

In addition, two (4%) of the fathers confirmed accusations of physical abuse, and only one (2%) of them confirmed that a formal complaint had been made to the police or child welfare system. One (2%) of the fathers confirmed an accusation of sexual abuse that was not reported to the police or the child welfare system, and four (8%) of the fathers confirmed a history of arrest for risk of injury to a minor or similar criminal charge, typically in the context of an arrest for another crime. Given their employment history, it was surprising that only 10 (20%) of the fathers confirmed that a sexual partner or other family member had complained about their failure to provide financial support for a child. Sixteen (32%) of the fathers reported that they had been contacted by a state agency concerning financial support of a child, and only 12 (24%) of them indicated that they had ever been summoned to court for a hearing concerning financial support of a child.

When recounting their legal history, 13 (26%) of the fathers confirmed that a child, most frequently a biological child, had been present when they had been arrested. Twenty-seven (54%) of men reported that they had written to a child or called a child on the telephone while incarcerated, and seventeen (34%) of them reported that they had been visited by a child while incarcerated. As might be expected, fathers had made an effort to maintain contact with their biological children more so than children they did not conceive.

3.2 Current dimensions of pair-bonding, reproduction, and paternal involvement

3.2.1 Current economic resources to support children

Despite their generally positive vocational-educational history, only 15 (30%) of the 50 fathers were employed at the time of the interview. Moreover, among those working, most (80%) were working in the underground economy on a part-time basis. Only four (8%) of the men were legally employed on a full-time basis. The most common sources of financial support were informal assistance from family and friends (50%), public welfare for single persons (48%), Social Security disability benefits (38%), and TANF benefits (32%). Only two (4%) men were engaged in any type of vocational-educational training, and despite the recent changes in welfare policy, only one (2%) of them was involved in vocational training through a welfare-to-work initiative.

3.2.2 Current family situation

At the time of the interview, seven (14%) of the men were legally married and living with a spouse, five (10%) of them were legally married but separated from a spouse, and 14 (28%) of them were living with a sexual partner. The average age of their 117 surviving biological children was 15.35 (SD = 8.45) years. Two (4%) fathers had a child who had died. A majority (63%) of the surviving children were still minors. Fathers and mothers were jointly the legal guardian of 55 (47%) of the children, 40 (34%) of the children were beyond the age of majority, mothers alone were the legal guardian of 13 (11%) of the children, and fathers alone were the legal guardian of three (3%) children. Five fathers had a total of six (5%) children whose legal guardianship had been transferred to a grandparent, another member of their extended family, or the child welfare system.

Although fathers frequently remained the legal guardian of their minor biological children, relatively few (28%) men were living with any of those children. The largest proportion (42%) of the 117 children were living with their single biological mother, and a sizable proportion (28%) were living independently as an adult. Only 21 (18%) of the 117 children were living with both their biological father and biological mother. Four (3%) of the 117 children were living with their single biological father, and only 5 (4%) of the 117 children were living with their biological mother and an alternate father figure.

At the time of the interview, the 50 fathers reported that, over the course of the previous year, they had seen 34 (29%) of their 117 children daily, 30 (26%) of their 117 children weekly to several times weekly, and 23 (18%) of their 117 children monthly to several times monthly. Surprisingly, only 17 (14%) of the 117 children had not seen their father at least once in the previous year. Consistent with this, only seven (14%) of the 50 fathers had not seen any of their children at least once in the past year.

3.2.3 Family secrets

According to the men, 68 (58%) of these 117 surviving children knew that their father had a drug abuse problem. Twenty (40%) of the fathers reported that they had talked directly with at least one of their children about their drug abuse. Children who reportedly knew of their father’s drug abuse history tended to be older (M = 12.96; SD = 6.06) than children who did not know (M = 6.90; SD = 4.70). Similarly, children the men had talked to directly about their drug abuse tended to be older (M = 14.30; SD = 5.90) than children they had not spoken to (M = 7.83; SD = 5.10).

3.2.4 Current patterns of paternal involvement with youngest biological child

At the time of the interview, the 50 youngest children of these fathers were an average of 10.42 (SD = 6.26) years of age. Thirty-five (70%) of the men were still the child’s legal guardian, primarily because, after they were listed as the biological father on the birth certificate, there had not been any legal intervention to change guardianship. However, only 14 (28%) of the fathers were still living with this child. Men who were no longer living with the child reported that they had left when the child was, on average, 6.32 (SD =3.96) years of age. Twenty-five (69%) of the men no longer living with their youngest child acknowledged that their drug abuse had played a role in their separation from the child. Surprisingly, at the time of the interview, 41 (82%) of the fathers were still somehow providing financial support for the child, despite the fact that only 13 (26%) of them were under court order to do so. Welfare benefits (36%), income from work done in the underground economy (36%), and disability benefits (24%) were the most common sources of financial support.

During the previous year, 17 (34%) of the fathers had seen their youngest child daily. Twelve (24%) of them had seen the child weekly to several times weekly; six (12%) of them had seen the child monthly to several times monthly; and seven (14%) had seen the child less than monthly. Eight (16%) of the men had not seen the child at all in the previous year, primarily because the child lived too far away to visit or the biological mother refused contact without the legal authority to do so.

3.2.5 Current involvement as a father figure to other children

Although prevalent in the past, only six (12%) of the 50 fathers were currently living with 12 children they did not conceive. By their report, the fathers had been living with these children for 1 to 4 years, and the children were, on average, 9.58 (SD = 4.89) years of age. Seven (58%) of these children were described as the biological child of a sexual partner. The other five (42%) were described as nieces or nephews.

3.3 Clinical intervention

When asked about their interest in clinical intervention, 48 (96%) of the 50 men indicated that, if available within their drug abuse treatment program, they would be interested in attending group counseling for men interested in being a more effective parent. Forty-two (84%) of the men indicated that, if available, they would be interested in participating in individual counseling designed to help them be a more effective father. Twelve (24%) of the men indicated that, if available, they would be interested in legal consultation concerning family matters.

4. Discussion

When considered with the existing literature on fathering, the results of this study highlight a number of trends within this limited sample of drug-abusing men that are at odds with popular stereotypes but consistent with the findings of work done with other populations of disenfranchised men. Rather than confirming patterns of indiscriminate reproduction and woeful neglect of children, the data provided by these drug-abusing fathers suggested that, while struggling with their addiction, they had made some attempt to conceive and parent children in a socially responsible manner. Ironically, the same data that reflected socially responsible efforts to father children also reflected significant compromise of fathering. Taken together, data highlighting historical versus current dimensions of fathering suggested that these men had been most involved early in their lives of their children but their involvement had deteriorated over time as their drug abuse continued, the relationships with the mothers of their children deteriorated, and their capacity to provide financial support eroded.

When patterns of pair-bonding, reproduction, and paternal involvement have been closely examined within overlapping, disenfranchised populations of men, researchers have frequently noted a pattern of similar findings. For example, in a large study of less educated, low income men who conceived a child outside a legal marriage, researchers documented socially responsible efforts to parent children early in their life that were quickly undermined as relationships with mothers deteriorated in the context of social, interpersonal, and psychological problems (Carlson & McLanahan, 2002, 2004; Carlson, McLanahan, & Brooks-Gunn, 2005; Gibson-Davis, Edin, & McLanahan, 2005; McLanahan & Carlson, 2004; Waller & McLanahan, 2005). This general trend for paternal involvement to deteriorate over time as sexual partnerships dissolve in the context of psychosocial stress has also been noted in research done with teenage fathers, African-American fathers, and divorced, middle-income fathers of largely European heritage (e.g., see Coley & Chase-Lansdale, 1999; Furstenberg, 1995; Furstenberg & Harris, 1993; Pasley & Braver, 2004).

When considered with the results of other research, the results of this study also highlight several trends noted in the evolving literature on the nature of fathering. Given the results of research examining the correlates of paternal involvement (e.g., see Mincy, Garfinkel, & Nepomnyaschy, 2005), the relatively high rate of paternity acknowledged on birth certificates and the relatively high number of children given their father’s surname may, even in the context of ongoing drug abuse, serve to reinforce psychological connections to children and promote support of mothers. The relatively high rates of financial support evolving from sources other than competitive employment are also consistent with patterns noted in other populations of socially and economically disenfranchised fathers (e.g., see Perloff & Buckner, 1996). The brief, less consistent periods of involvement in the lives of children they did not conceive, primarily through cohabitation with sexual partners, is also very consistent with other research that suggests men generally make more of an effort to provide emotional and financial support to their biological children (e.g., see Kaplan, Lancaster, & Anderson, 1998).

Given the empirical links between chronic drug abuse and risk for arrest, conviction, and incarceration, confirmation of efforts to maintain contact with biological children while incarcerated was not surprising, and the finding highlights the need for public policy analysts to carefully consider the impact of incarceration on fathering (for discussion, see Arditti & McClintock, 2001; Hairston, 2001; Rosen, 2001). The presence of a few single custodial fathers within this sample is also consistent with trends toward a small, but growing, number of single-parent households headed by men. Previous work done with other populations suggests that these men are likely to have become custodial fathers by default, they may be ambivalent about their status as a single parent, and they may be looking for formal and informal support from extended family, sexual partners, and the social service system (Hamer & Marchioro, 2002).

In addition to suggesting that drug abuse contributes directly to compromise of fathering, the results of this study raise questions about ways historical influences might interact with ongoing drug abuse to compromise socially responsible efforts to function as a father. While some men confirmed positive relationships with fathers they frequently identified as positive male role models, others reported generally poor relationships with alcoholic biological fathers who they believed had neglected and physically abused them. Research exploring the potential influence of fathers on the parenting of men across generations is limited, but there are indications that developmental experiences with fathers do influence the manner in which men go about producing and parenting children (e.g., see Furstenberg & Weiss, 2000; Kost, 2001). As conceptual models of fathering evolve, the results of this study suggest that it will be important to understand how negative experiences with fathers and father figures contribute to compromise of fathering across generations. As suggested by Furstenberg and Weiss, it will also be important to understand how, even in the context of chronic drug abuse, both positive and negative experiences with fathers and father figures may motivate some men to maintain a presence in the lives of their children.

Although this descriptive study provides some information about the psychosocial adjustment of drug-abusing fathers, there are a number of limitations that deserve mention. First, the data summarized here were obtained from a small, self-selected sample of men who may not accurately represent any population of drug-abusing fathers. Second, although the perspective of fathers must be documented, it is important to acknowledge that data collected from mothers or children may have provided a somewhat different perspective on the parenting of these drug-abusing men.(e.g., see Caspi et al., 2001; Coley & Morris, 2002; Pasley & Braver, 2004). Next, because more comprehensive, more sophisticated measures were not included, it was not possible to better characterize either the quality of the parenting behavior or the quality of father-child relationships. Finally, because the research design did not include a demographically matched sample of men living in urban poverty with no history of alcohol or drug abuse, it was not possible to more clearly document the potential influence of the drug abuse on fathering.

Despite the limitations of the data, the results of this study raise questions about ways the drug abuse treatment system might better support drug-abusing men interested in being a more effective parent. Unfortunately, parenting has consistently been defined as a treatment issue relevant only for substance-abusing women (McMahon & Rounsaville, 2002), and even when substance-abusing fathers have been included in clinical trials, the efficacy of parent intervention has, thus far, been relatively modest (e.g., see Catalano, Haggerty, Fleming, Brewer, & Gainey, 2002). Building upon the work of Luthar and Suchman (2000), this research group (McMahon & Giannini, 2003; McMahon & Rounsaville, 2002) has argued that gender differences in the nature of both drug abuse and parenting need to be acknowledged in the development of gender-specific approaches to psychosocial intervention for drug-abusing fathers. When asked, most of the men who enrolled in this study expressed interest in clinical intervention designed to help them be a more effective parent. Given their interest, professionals throughout the drug abuse treatment system should begin exploring ways to (a) engage drug-abusing men in a dialogue about parenting issues, (b) enhance whatever intrinsic motivation they may have for change, (c) support socially responsible efforts at fathering, and (d) address the parenting deficits they bring to treatment (for discussion, see McMahon & Giannini, 2003; McMahon & Rounsaville, 2002).

Despite the limitations of these data, the results of this study also highlight the need for public policy grounded in a clearer understanding of this population of men at risk for socially irresponsible production and parenting of children. Given public policy initiatives designed to promote change within the public welfare and child protection systems (for reviews, see Cabrera & Peters, 2000; McLanahan & Carlson, 2002; Mincy & Pouncy, 2002)), the relatively low rates of paternity, the frequent documentation of paternity on birth certificates, the relatively low rates of legal mandates for child support, the number of men receiving public entitlements, the limited involvement in vocational-educational rehabilitation, and the relatively low rates of contact with the child protection system were all somewhat surprising. If replicated in more representative samples of drug-abusing men, these findings would suggest that policy changes designed to promote more responsible fatherhood may not be directly relevant to family systems affected by paternal drug abuse. To promote more responsible fathering by drug-abusing men, federal, state, and private organizations may need to pursue policy initiatives designed specifically to reach this hidden population of fathers, mothers, and children.

Acknowledgments

This research was supported by the National Institute on Drug Abuse (Grants No. P50 DA09241, R01 DA020619, K23 DA014606, and K05 DA000089).

A preliminary report of this study was presented in August of 1998 at the annual convention of the American Psychological Association, San Francisco, CA, USA.

The authors would like to thank the clients and staff at The APT Foundation in New Haven, Connecticut for their support of this project. They would also like to thank Lisa Maccarelli and Daniel Csuka for their comments on the content of this manuscript.

Footnotes

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