Cocaine Babies: Florida's Substance-Exposed Youth. INSTITUTION 414 Florida Education Center, Tallahassee

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AUTHOR Harpring, Jayme TITLE Cocaine Babies: Florida's Substance-Exposed Youth. INSTITUTION 414 Florida Education Center, Tallahassee. PUB DATE [90] NOTE 113p.; Parts of the document have marginal and reduced print. PUB TYPE Information Analyses (070) Guides Non-Classroom Use (055)

EDRS PRICE MF01/PC05 Plus Postage. DESCRIPTORS Alcohol Abuse; Behavior Problems; *Child Development; *Cocaine; *Congenital Impairments; Drug Abuse; Early Childhood Education; Early Intervention; Family Environment; Incidence; *Intervention; Learning Problems; Resources; School Role; *Substance Abuse IDENTIFIERS *Fetal Drug Exposure; *Florida

ABSTRACT This report is designed to provide Florida's school personnel with assistance in working with students prenatally exposed to cocaine or other toxic substances. The report offers background data, practical strategies for teaching and learning, and resources for networking. The first chapter outlines statistics on the incidence of the problem of substance abuse in pregnant women, describes substances commonly used, and discusses symptoms of substance abuse. Chapter 2 examines the effects of prenatal exposure to alcohol and other drugs on the fetus, infants, toddlers, and older children. The next three chapters address the role.of the child's environment, the role of the school, and the role of other helping professionals. The final chapter discusses resources available to aid the helping professional, including two hotlines; 17 sources for information, consultation, and training; and a selected bibliography of approximately 25 items. Several journal articles and papers are appended, including "Infants Exposed to Cocaine in Utero: Implications for Developmental Assessment and Intervention" (Jane W. Schneider and others); "Drug Exposed Babies: Research and Clinical Issues" (Donna R. Weston and others); "The Development of Young Children of Substance-Abusing Parents: Insights from Seven Years of Intervention and Research" (Judy Howard and others); "Psychological and Behavioral Effects in Children Prenatally Exposed to Alcohol" (Ann Pytkowicz Streissguth and Robin A. LaDue); "Behavior and Learning Difficulties in Children of Normal Intelligence Born to Alcoholic Mothers" (Sally E. Shaywitz and others); and "Letter from Prison: A Cocaine-Addicted Mother." (JDD)

*********************************************************************** Reproductions supplied by EDRS are the best that can be made from the original document. *********************************************************************** U S Dtr.APITMEFIT OF EDUCATION Otfice or Educatonat Research and improvement EDUCATIONAL RESOURCES INFORMATION CENTER IERICI "Tars document has been reproduced as fece.ved Irons the person Or Organr2a1rOn oncnnalrnd .1 r Mmot changes hale been macte anotove ,e1),OduCloOn oaal.ty

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COCAINEBABIES: Florida's Substance-ExposedYouth

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D isttlbulad 11111 NORTH carnal. NEOKINAL E DUCATIONAL LADORATONY cc 1900 aping ANN O.k soak, Dm* 00521 (708) 5714700 2 COCAINE BABIES: Florida's Substance-ExposedYouth

Hot Topics

Produced by Jayme Harpring

For More InformationContact:

Dan Thomas 414 Florida EducationCenter Tallahassee, Florida32399-0400 (904) 488-7835

0 1

I ACKNOWLEDGEMENTS

Special thanks to the editorialreview committee:

Jean Battaglin, R.N., B.S., M.A. Community Health Nursing Consultant Family Health Services, State HealthOffice Florida Department of Health andRehabilitative Services

Schools Program Nancy Fontaine, M.A. Program Director, Drug-Free Prevention Center, Office of PolicyResearch and Improvement Florida Department of Education

Specialist Thrri Goens Senior Human Services Program Alcohol and Drug Abuse Program Florida Department of Health andRehabilitative Services

Pat Hollis Progrcun Specialist Bureau of Education for Exceptional.Students Florida Department of Education

Nancy Livesay, M.S. Resident Principal Office of Policy Research andImprovement Florida Department of Education

Specialist, Infants and 1?teltilers B.C. Parker Parent Involvement Program Pre-Kindergarten Handicapped Program Bureau of Education for ExceptionalStudents Florida Department of Education

Thanks to those who providedinformation and other assistance: Dan Griffith. Ph.D. Cathy Bishop, M.S.W. Developmental Psychologist Program Specialist Supervisor National Association of Perinatal Researchand l do anon Bureau of Educational for ExceptionalStudents Florida Department of Education Vicki Kropenske. P.I .N Carol Cole, M.A. Director Child Development Specialist/Teacher Statewide Outreach Training Project Salvin Education Center UCLA Department of Pediatrics Los Angeles Unified School District

Kate Howze, M.A. Don Darling Community Relations Specialist Administrator for Student Services Juvenile Welfare Board of Pinellas County Division of Public Schools Florida Department of Education

Wendell Howze, Ph.D. Linda Dclapenha Assistant Principal. Northeast highSchool Supervisor Pinellas County School District Primary Diagnostic Services Hillsborough County Public Schools A MESSAGE FROM THECOMMISSIONER OFEDUCATIONN

Please accept this copy of the most recentHOT TOPICS publication, COCAINE BABIES: FLORIDA'SSUBSTANCE-EXPOSED CHILDREN. This publication was developed by the PreventionCenter in the Department of Education's Office of Policy Research and Improvement(OPRI). The HVT TOPICS seriesis designed to keep educators and policymakersup-to-date on important issues andtrends in education. Each publication is developedwith the input of education and content experts, and contains the most recentavailable information and research.

Parents, social service providers and educators mustwork together to successfully teach and nurture substance-exposed children.The intent of COCAINEBABIES: FLORIDA'S SUBSTANCE-EXPOSED CHILDRENis to provide assistance in working with these special students. The challengeof meeting the needs of substance- exposed children is here in hundreds of pre-kindergarten,kindergarten, and elementary school classnxmls.

I am aware that teachers, principals, districtadministrators, school nurses, counselors, and psychologists need assistance inidentifying and educating substance- exposed children. COCAINE BABIES:FLORIDA'S SUBSTANCE-EXPOSED CHILDREN provides some of that help. Included is a summaryof current publications on this critical issue. Alsoincluded is a resource list with contactsof organizations around Florida which parents and educators cancall on for additional information.

Our intent is to serve you and your staff withusable information on issues of high priority in public education.If we can be of further assistance,please call Nancy Fontaine, Program Director, Drug-Free Schools, orDan Thomas, Public Information Specialist, Prevention Center, (904) 488-6304.

Betty Ca Comm'oner of Education I EXECUTIVE SUMMARY I

In recent years the problem of substance abuse during pregnancyhas intensified dramatically due to the widespread use of cocaine and its highly addictive derivative,crack. Pervading all social strata, and including teenagers who are often completely unawareof the possible consequences to an unborn child, drug use among pregnant women is shockingly prevalent.Researchers now estimate that one in ten newborns across the U.S. is a substance-exposedchild. (Throughout this document, the terms "substance-exposed child" and "prenatally-exposed child" will be used interchangeably.)

The statistics on the prevalence of drug use during pregnancy have seriousimplications for our educational systems, because substance-exposed children often are unable tofunction in a traditional school classroom. The absence of consistent physical and emotional nurturancein their early lives causes these children to have difficulty with even the mostbasic skills, like processing and following directions, playing with toys, or interacting with others. Further, they are at riskfor chronic health problems, social and psychological maladjustment, and school failure. Withoutintervention, their prospects for a successful future are dim.

Yet there is hope. Substance-exposed children do respond to a classroom environmentdesigned to meet their particular needs. Smaller classes that provide astructured learning environment are essential. With individualized attention from teachers trained to work withspecial neurological and behavioral problems, prenatally-exposed children are able to grow emotionally,socially, and intellectually.In coordination with other helping professionals working to servedrug-involved families, educators have the opportunity to significantly enhance the lives ofsubstance-exposed children.

Cocaine Babies:Florida's Substance-Exposed Children was created to provideteachers, principals, district administrators, school nurses, counselors, psychologists,and others working with prenatally-exposed children with background data, practical strategies forteaching and learning, and resources for networking. Several themes expressed inthis document represent the current thrust of research and practice in the area of substance abuse during pregnancy:

- prenatal substance abuse can cause awide range of impairments which can either bemitigated or exacerbated by the child's early environment;

early intervention is very effective in helping substance-exposedchildren, particularly when the entire family is involved and services provided by professionalsof all disciplines are coordinated;

- the fundamental processesof bonding and attachment are particularlyvulnerable to the stresses caused by prenatal exposure to alcohol and otherdrugs, andcan inhibitemotional, social, and intellectual development in later years;

the emotional and intellectual problems resulting from prenatal exposure toalcohol and other drugs are often very subtle, and frequently occur in children ofnormal intelligence; school setting with a great deal ofindividualized -substance-exposed children require a attention, characterized byunderstanding, patience, structure, andconsistency;

- a wide rangeof resources in a variety of areas,including specific teaching strategies for prenatally-exposed children, are availablefor educators and other helpingprofessionals. these children The full tragedy of Florida'ssubstance-exposed children has yet to unfold. As serious problems unless they reach adolescence and adulthood,they will be likely candidates for more the challenge of providing this and their families receive the helpthey now need. Schools are faced with special assistance. Though additional resourcesmay be required, the benefits tosubstance-exposed children, their families, and society areinvaluable_ TABLE OF CONTENTS 01.:*>ti.~.374,1~WAVONONIN>JNiNMIAVN.MCJN.X.CMIONMK.,

o . ACKNOWLEDGEMENTS o LETTER FROM COMMISSIONER CASTOR o EXECUTIVE SUMMARY Chapter 1

WHAT IS THE PROBLEM ? STATISTICS 3 SUBSTANCES 6 SYMPTOMS 8 FEATURES: Prenatal Drug Use in Pinellas County 9 Addicted Infants and Their Mothers.. 10

Chapter 2

WHAT ARE THE EFFECTS OF PRENATALEXPOSURE TO ALCOHOL AND OTHER DRUGS ? CATEGORIES OF EFFECTS 13 EFFECTS ON THE FETUS AND INFANT 14 15 FEATURE: Cocaine and Infant Communication EFFECTS ON TODDLERS AND OLDERCHILDREN 18 FEATURES: Low Birthweight: What Does It Mean? 23 Drugs and Breastfeeding 24 Withdrawal: The Neonatal AbstinenceSyndrome 24

Chapter 3

WHAT IS THE ROLE OF THECHILD'S ENVIRONMENT ? PROFILE OF THE PREGNANTSUBSTANCE ABUSER 27 THE CHILD'S PLACE IN THESUBSTANCE-ABUSING FAMILY 28 FEATURES: Substance Abuse and TeenagePregnancy 29 The Risk of AIDS 30 SUBSTANCE ABUSE, BONDING, ANDATTACHMENT 30 Chapter 4 ? THAT IS THE ROLE OF THE SCHOOL 35 ROLES OF THE SCHOOLSTAFF 37 IDENTIFYING AT-RISKCHILDREN A MODEL SCHOOLPROGRAM Exposed Children's Committee ....55 FEATURES:Hillsborough County's Drug Operation PAR's ChildDevelopment and 56 Family Guidance Center

Chapter 5

WHAT IS THE ROLE OFOTHER HELPINGPROFESSIONALS ? FLORIDA'S REPORTINGREQUIREMENTS 59 Substance-Abused Newborns 61 FEATURES:Chart: Reporting and Referring 62 A CONTINUUM OFSERVICES IN FLORIDA 63 LEGAL ISSUES

Chapter 6 AVAILABLE TO AID THEHELPING PROFESSIONAL ? WHAT RESOURCES ARE 67 HOTLINES CONSULTATION, AND TRAINING 67 SOURCES FOR INFORMATION, 6g SELECTED BIBLIOGRAPHY

71 Appendix A: SELECTEDRESEARCH ARTICLES

PRISON: THE STORY OF ACOCAINE-ADDICTED Appendix B: LETTER FROM 113 MOTHER it IL Chapter 1j

WHAT IS THE PROBLEM?

Statistics

Substances

Symptoms Chapter 1 WHAT IS THE PROBLEM?

STATISTICS and other No one can say precisely how many babies areaffected by prenatal exposure to alcohol drugs, but estimates do exist. Other statistics onrelated problems like child abuse andneglect and juvenile crime are also instructive in two important ways.First, they point to the fact that theproblem substance-exposed infants in isolation. ismultifaceted, much more complex than the tragedy of Second, such related statistics show a sharp increasesince crack cocaine achieved widespreadpopularity throughout the United States.

how many pregnant women are using alcohol andother drugs?

used drugs while Approximately 1 in 10 pregnant women were found to have pregnant, according to a 1988 survey of36 mostly urban, public, andprivate hospitals across the United States. Reports of usageranged from 0.4% to 27%, depending on the thoroughness of the assessments.The number of public aid patients was not a factor.

Fifteen percent of women of childbearing age (15 to 44years) currently use alcohol and other drugs.Of these, 34 million consume alcohol,18 million smoke cigarettes, and more than 6 million use illicitdrugs.2

How large is the problem of cocaine use by pregnantwomen?

Recent studies in the United States reported: Cocaine-addicted babies account for 80% of thesubstance-affected babies born to women participating in the treatment programat NorthwesternMemorial lospital's Perinatal Center for Chemical Dependencein Chicago.'

Fifty-eight percent of the women seeking obstetrics care atthe Family Center of Jefferson Medical College in Philadelphia currentlyshow cocaine in their urine screens; in 1985, theproportion was 7%. 2

Of the 1226 women who gave birth at BostonCity Hospital between 1986 and 1988, 27% had smoked marijuana and 18% hadused cocaine during their pregnancies.2 1988, marijuana users In a study conducted atBoston City Hospital in gave birth to babieswho wen three ounceslighter and one-fifth of an inch shorter than babies born tonon-marijuana smokers. Cocaine use was associatedwith even shorter and lighterweight infants.2

How many babies are affected?

Arecent national study suggeststhat as many as 375,0(X) infants maybe affected by substance abuse eachyear.1

An estimated 50,000 babies a yearsuffer the effects of maternalalcohol use during pregnancy;10% suffer irreversible birthdefects? Alcohol It is estimated that there arebetween one and three cases of Fetal Syndrome among every 1,0(X) livebirths.;

What are the statisticsfor Florida?

An estimated 5.5% of the185,000 babies born in 1988 inFlorida were substance-exposed newborns

drugs In 1988-89, 10,425 newbornsborn in Florida were exposed to prenatally.

be 70% of the substance-exposednewborns in Florida are estimated to "cocaine babies" who test positivefor cocaine as well as otherdrugs.4

be 13% of the substance-exposednewborns in Florida are estimated to "cocaine-involved babies" whose mothershave a history of cocaine use,but do not test positive for cocaine atbirth.4 be 17% of the substance-exposednewborns in Florida arc estimated to "other-substance-exposed newborns,"affected by marijuana, alcohol, amphetamines, heroin and/or otherdrugs, but not cooztine.1

4 4 Only 36% of the mothers of Honda'ssubstance-exposed babies reported receiving any prenatal care.4

Low birthweight was a problem for 38% ofthe exposed babies who did not have prenatal care, and for 26% of those whodid have prenatal care. Thus, prenatal care made a difference despite exposure todrugs. 4

3442 cases involving substance-exposed newborns werehandled by HRS in fiscal year (FY) 1988-89, as compared with 1930 inFY 1987-88. 4835 cases are estimated for FY 1989-90and 6219 in FY 1990-91.4

Are there any options for substatr...-abusingpregnant women?

In a telephone survey of 18 public and privatehospitals, two-thirds said that they had no place to refer substance-abusing pregnant womenfor treatment.5

Sources:

National Association for Perinatal Addiction Researchand Education (NAPARE)

2 National Institute On Drug Abuse (NIDA)

Florida Alcohol and Drug Abuse Association (FADAA)

Florida Department of I lealth and RehabilitativeServices (HRS)

5 U.S. House of Representatives National SelectCommittee on Children, Youth andFamilies

5 SUBSTANCES WAWAVAY.WIYVVI,NWV*ryetm.Ve*WWAVAWNIVWW.W.W.enWAW.WMAWO.,,N, Substances like Among substance-abusing pregnant women,polydrug use tends to be the rule. conjunction with a primary "drugof choice," such alcohol and nicotine, forexample, are often used in identify the particular effects onthe fetus of specific drugs as crack cocaine.This makes it difficult to be used by a pregnant womanwithout risk in isolation from one another.No substance, however, may to the developingbaby.

What are the most commonlyused substances?

is the active ALCOHOL is the most widely usedand abused drug in the U.S.. Ethanol ingredient, which acts as a central nervoussystem depressant to slowdown bodily different people in functions like heart rate, pulse,and respiration. Alcohol affects different ways, depending on the amountconsumed, body weight, gender, the presence of food in the body, and theexpectations one holds.In small quantities, alcohol may it can cause bring on feelings of well-beingand relaxation; in larger amounts intoxication, sedation, unconciousncss,and even death.

that is COCAINE is a short-acting,powerful central nervous systemstimulant extracted from the South American cocabush. The cocaine (cocainehydrochloride) available in this country is a purewhite crystalline powder combinedwith adulterants added to stretch the supply andincrease the seller's profit.Talc, flour, laxatives. additives used to cut cocaine.Cocaine sugar, and localanesthetics are just a few of the converted into a smokable is snorted through the nose,injected into a muscle or vein, or form called freebase.

CRACK is a nearly pure form ofcocaine that comes in the formof a light brown smoked, crack delivers a burst ofcocaine or milky whitepellet or "rock." Because it is high. Persons who smoke crack to the brain in lessthan 15 seconds, causing a dramatic Yet within minutes the user report feeling extremelypowerful and sexually aroused. euphoria is replaced by severedepression, paranoia, and is left craving more, as the cycle that can irritability. In this way, crack usersrapidly enter into a continuous weeks. leave them physically andpsychologically addicted in as little as two

THC (delta- MARIJUANA is a crude drug madefrom the plant Cannabis Saliva. 9-tetrahydrocannabinol) is the mainmind-altering ingredient, thoughburning or the body. smoking marijuana allows as many as2,(X/) secondary chemicals to enter particles of the plant. The A marijuana cigarette or"joint" is made from the dried strength of marijuana's effectdepends on the amount of THCit contains.

6 PCP is phencyclidine, a synthetic drug firstdeveloped as an anesthetic agent for surgery in the 1950's. Today thereis no legal use for PCP. PCP is notoriousfor its variety of effects and for its unpredictability,acting at different times as a stimulant, depressant, or hallucinogen. PCP comes in severaldifferent forms in its original form as a white or yellowish-white powder, as atablet, or as a capsule. Different methods of use induce different effects. The mostpopular is smoking marijuana, parsley, or tobacco sprinkled with PCP powder. PCP canalso be snorted, injected, or taken orally by capsule ortablet.

LSD, or lysergic acid diethylamide, is a derivative of ergot, afungus that grows on rye and other grains. Early onit was used to treat mental disorders,alcoholism, epilepsy, and terminal cancer.Despite its later illicit status,it became popular when interest in its alleged mystical effects grew. LSDis a potent hallucinogen or psychedelic drug, even when taken in extremely small amounts.One ounce is able to supply about 300,000 doses. LSD isodorless, colorless, and tasteless. In its liquid form it is placed in or on another substance - sugarcubes, postage stamps, "microdots" (tiny balls of compacted powder), "windowpane"(small squares of gelatin sheets or cellophane), and "blotter" (small squaresof paper) and licked off or swallowed.

OPI ATES are central nervous system depressants which areoften used medically to relieve pain. Opiates are classified as narcotics,and include such drugs as heroin, codeine, opium, and morphine. They are derived from aresin taken from poppy plants found in countries throughout the world. Some opiates,like Demerol, Darvon, Percodan, Dilaudid, and Methadone, are synthesizedby modifying the chemicals found in opium.All have a high potential for abuse. They arefound in a variety of forms, including powders, liquids, tablets, syrups,and capsules.

1 A ..... SYMPTOMS MAWA,...4.WAWVW*VANWI4YOMANNYNAVW,,,WANYANWAVA,..* typically fail to Professionals who work with pregnant womenusing alcohol and other drugs hospital incidence survey conducted recognize and confront substance usein their clients. A national in pregnancy is one of the mostcommonly missed by NAPARE, for example,found that substance abuse NAPARE president Dr. Ira Chasnoff,"Many of of all obstetric and neonataldiagnoses. According to is born addicted, often with severephysical these cases are unrecognizeduntil after birth when the baby Chasnoff asserts, accounts for thehigh rate of infant or neurologicaldamage." This lack of recognition, morbidity and mortality in theseinfants.

What might indicate the use ofthese substances? LOOK FOR PHYSICAL SYMPTOMS. DRUGA +... - V', insensitivity to pain, nausea, vomiting, watery brief intense euphoria,elevated blood COCAINE eyes, runny nose , needlemarks on arms, andheartrate, restlessness, (coke, rock, pressure needles, syringes, spoons, pinpoint pupils, excitement, feeling of well-beingfollowed crack, base) cold moist skin, weight loss by depression breath, intoxication, slurred speech, unsteady walk, smellofalcohol on clothes or ALCOHOL intoxicated behavior, hangover, glared eyes (beer. wine, relaxed inhibitions, impaired coordination, liquor) slowed reflexes altered perceptions, red eyes, drymouth, rolling papers, pipes, dried plainmaterial. MARIJUANA increased (pot, dope, grass, reduced concentration and coordination, odor of burnt hemp rope, roach clips, weed, herb, hash, euphoria, laughing, hunger eating behavior joint) focus on capsules, tablets, "microdots", blotter squares HALLUCINOGENS altered mood and perceptions, (acid, LSD, PCP, detail, anxiety, panic, nausea,synacsthesia MDMA, Ecstasy, (simultaneousperception,for example psi locyhin, mushrooms,smelling colors, seeing sounds) peyote) needle marks on arms, needles,syringes, euphoria, drowsiness, insensitivity topain, NARCOTICS spoons, pinpoint pupils, coldmoist skin (heroin, junk, dope, nausea, vomiting, watery cycs,runny nose Black Tar, China White, Demerol, dilaudid, D's, morphine, codeine)

10 8 PRENATAL DRUG USE IN PINELLASCOUNTY

WHAT: A recent study was conducted by theNational Association for Perinatal Addiction Research and Education (NAPARE), inconjunction with Operation PAR, a St. Petersburg, Florida drug treatment program.

W11Y: The purpose of the study was to look at theprevalence of drug use during pregnancy in a sample of pregnant womenin Pinellas County, Florida, as well as aspects of the reporting of such cases. Florida has a policy thatrequires hospitals to notify local health departments when an infant is born with drugs inits system or the mother is an addict. WHO: 715 pregnant women from both public and privatehealth care sectors were1 involved.

HOW: From January I , 1989 until June 30, 1989, a urinesample for toxicology was collected from every woman at her first prenatal visit as sheentered care at any of the 5 public health clinics or in 12 of 20 private obstetricoffices in the county. Urine samples were tested for cocaine, marijuana, opiates and alcohol.

FINDINGS:

14.8% of all women tested positive for cocaine,marijuana, opiates and/ or alcohol.

'There were no significant differences in the ratesof public or private patients. 13.1% of women receiving private care, and16.3% of women receiving care in a public clinic, tested positive for alcoholand other drugs.

Though white women (15.4%) had a slightly higher ratethan black women (14.1%), differences in the ratesof those testing positive for alcohol and other drugswere not significant.

Marijuana was the drug used most often in theoverall group.

Cocaine was used by 7.5% of black women and1.8% of white women.

Because alcohol is metabolized and excreted eighthours after consumption, it is likely that the use of alcohol was morefrequent than the urine tests could determine.

Although white women were 1.09 times as likely asblack women to have used drugs or alcohol, black women were 9.58times as likely to be reported to county health authorities for substanceabuse during pregnancy.

:1? rammaim ADDICTED INFANTS ANDTHEIR MOTHERS led by The National Select Committee onChildren, Youth and Families Congressman George Miller talkedwith hospitals in largemetropolitan areas The results of their about damage caused bysubstance abuse during pregnancy. survey were released athearings on April 27, 1989.

FINDINGS:

Fifteen of the 18 hospitalssurveyed reported three tofour times as many drug-exposedbirths since 1985.

Drug-exposed babies are morelikely to be born prematurelyand have low birthweight,dramatically raising their risk ofinfant mortality and childhood disability.

Women who seek help during pregnancycannot get it. Two- thirds of the hospitals reportedthat they had no place torefer substance-abusing pregnant womenfor treatment.

Hospitals in Los Angeles andWashington, D.C. reported the re-emergence of maternaldeath during labor anddelivery directly attributable to drug abuseduring pregnancy.

Eight hospitals reportedgrowing numbers of "boarderbabies" who remain in hospitals becausetheir parents abandon or cannot care for them.

Rep. George Miller of Californiawrites: they "While the number of drug-exposedbabies remains relativey small, And, these children have the are among the mostexpensive babies we care for. chili protective ability to swamp every systeminvolved with their care - hospitals, services, foster care, andschools. Hospitals we surveyed cautionedthat their estimates vastlyundercount well, that these the number of women andchildren affected. They indicated. as newborns stay in the hospital up to13 days longer than healthyinfants, at a cost which can reach nearly$1,81X1 a day. These problems are no longerconfined to inner cities. In mysuburban and these chil- district in California, 40 babies amonth are born drug-exposed, the country." dren now represent 60-75%of foster care caseloads in Chapter 2 Iit

WHAT ARE THE EFFECTSOF PRENATALEXPOSURE TO ALCOHOL AND OTHERDRUGS?

Categories of Effects

Effects on the Fetus andInfant

Effects on Toddlers and OlderChildren Chapter 2 WHAT ARE THE EFFECTS OF PRENATALEXPOSURE TO ALCOHOL AND OTHER DRUGS ?

The effects of prenatal exposure to alcohol and otherdrugs vary according to the particular circumstances of each child's pre- and postnatal experiences. Thefrequency, quantity and timing of use, for example, all influence the extent of damage to the fetus.Poor maternal nutrition and inadequate health care can compound the harmful influence of the toxicsubstances used by the mother during pregnancy.Further, prenatally-exposed babies may fail to thrive after birth as aresult of poor feeding habits, inadequate care or disturbed bonding and attachmentbetween mother (or caregiver) and child. In spite of these problems, however, if parents, teachers andother helping professionals meet the substance-exposed child's special needs as early as possible, thelong-term consequences of prenatal exposure to alcohol and other drugs can besignificantly reduced.

CATEGORIES OF DRUG AND ALCOHOL EFFECTS 6

Not all babies exposed to drugs and alcohol in the womb are born"hooked." Some babies are born "clean," but may have sustained injury as a result of exposure to somelevel of alcohol and/or other drugs.Others look perfectly normal at birth, but gradually display symptomsthat hint of previous exposure. This variety of possible effects makes identificationand intervention even more challenging.

The three categories of effects suffered by infants affected by prenatal exposureto alcohol and other drugs are:

1) ADDICTION The newborn undergoes withdrawal, afterwhich it may grow and develop more or less normally, as if addiction had notbeen part of his or her short life experience.

2) TOXICITY - Toxic effects cause direct injury to thedeveloping fetus.

3) TERATOGENICITY - More complex than addiction ortoxicity, teratogenic effects may or may not appear at birth.Teratogenic effects involve structural damageof some sort. Drugs that act on metabolic, endocrine, or central nervous systemfunctions may not cause symptoms to emerge until childhood oradolescence.

"..if parents, teachers and other helping professionals meet the substance-exposed child's special needs as early as possible, the long-term consequences of prenatal exposure to alcohol and other drugs can be significantly reduced."

Cy THE FETUS AND NEWBORN THE EFFECTS OF ALCOHOLAND OTHER.v+M.*VelnvewM,*vw..~...%...W.MOfl.r*Wnew... DRUGS ON nnvollnenv

Some people believe that the fetusis protected from dangerous substancesby the mother's and other drugs flow rapidly and easilyfrom the placenta.Actually, the opposite is true. Alcohol mother's bloodstream through the placenta tothe baby. Because the fetal liver is notfully developed, such substances also remain in thefetus for a much longer timethan in the mother. Cocaine, for three days before example, has been found in six day-oldinfants who were exposed to the drug two to birth.

COCAINE

How does COCAINE affect thedeveloping fetus?

When a pregnant woman uses cocaine,the risks to mother and child immediately increase. Cocaine decreases blood flow tothe fetus, cutting off the passage of growth- enabling nutrients and oxygen. In addition,studies have found that women who use cocaine during pregnancy are more likely tosmoke cigarettes and have poor weightgain- factors that also inhibit the developmentof the fetus.

In the early months of pregnancy, the useof cocaine can cause a spontaneous abortion.Used later, cocaine may result in prematurelabor, a fetal stroke causing irreversiblebrain damage, or a stillbirth delivery.In some cases, neurological and respiratory problems may result,or organs may beunderdeveloped or malformed. Sometimes the placenta pulls away from thewall of the uterus before labor begins, causing extensive bleeding. This condition, known as"abruptio placentae," can be fatal to both mother and child.

How does COCAINE affect the infant?

Babies exposed to cocaine in utero mayremain irritable for six to eight weeks after birth and may not respond well to theirenvironments for two to three months. Other signs of exposure to cocaine include: tremors,usually stiff muscles , irregular sleeping patterns, poor feeding patterns, increasedrespiratory and heart rates, and difficultysucking and swallowing. Persistence of symptoms beyondthe first few weeks of life suggests to some authorities a more lasting central nervous systemchange rather than a withdrawal pattern. of In addition, some researchers havefound that substance exposed infants have a rate Sudden Infant Death Syndrome (SIDS) tentimes greater than non-substance exposed infants. Neurobehavioral evaluations at 3 dayshave revealed that prenatally-exposed infants are largely unable to respond tothe human voice and face, deficientin the ability to interact with others,and highly unstable emotionally.Very sensitive to even the They do not fall mildest environmental stimulation,newborns affected by cocaine cry a lot. asleep readily and once asleep areeasily awakened. According to Dr.Diana Kronstadt of "The distress of these the Far West Laboratory forEducational Research and Development, newborns is obvious and yet they areunable to calm themselves."

2 14 A normal infant can shut outunwanted stimulation andtake inpositive stimulation. Newborns affected by cocainecannot. Withdrawnand difficult to comfort, develop normal they are unable to respond to theirmothers in the ways necessary to along with the guiltthe mother-child attachment.The infant's unresponsiveness, mother may feel for using drugs, makesbonding even more difficult. Asthe mother's vulnerable feelings of frustration and inadequacy build,the infant becomes increasingly to child abuse and neglect.

COCAINE AND INFANTCOMMUNICATION

Soonafter birth,normal babies enter the give- and-takeof human cannt unicat ion .Normally, the biologically-programmed responseof an infant to his or her primarycaregiver cements the relationshipbetween them. This is the process of bonding.

Newborns affected by cocaine, however, arephysiologically unable to respond to their caregivers in the way natureintended. Compared with non-exposed infants, cocaine affected infants have"depressed interactive abilities."They are easily disturbed, difficult to comfort, andunable to provide positivefeedback to the caregiver.

As a result,the relationship can be veryunsatisfyingfor caregivers particularly for parents who continue to usedrugs. A negative cycle maydevelop in which the caregiver is unable orunwilling to provide the helprequired for recovery to an infantexhibiting difficult behaviors.Feelings of inadequacy and frustration on the part of parents may, in turn,lead to further abuse andneglect of the child.

Source: Schneider, J.W., Griffith,D. and Chasnoff, I. (1989,July). Infants exposed to cocaine inutero:Implications for developmental assessment and intervention.Infants and Young Children,25-36. ALCOHOL 11

How does ALCOHOL affect the developingfetus?

Frequent or heavy drinking throughout pregnancy mayresult in various serious birth defects. The most severe constellation of effects is known asthe Fetal Alcohol Syndrome (FAS). Childrenwith FAS demonstrate three kinds of impairments: I)Growth retardation before and/or after birth, 2) A particular pattern of abnormal features of the face andhead, and 3) Evidence of a central nervous system abnormality (brain damage) often resulting in intellectualimpairment. FAS is the third most common cause of mental retardation.

Some babies are affected prenatally by alcohol,but lack the full set of characteristics of FAS. Research indicates that there are approximatelytwice as many of these "mildly affected" children as there are "severely affected" children with FAS.Fetal Alcohol Effects (FAE) is the term used to describe the variety of potential impairments associatedwith lower levels of maternal alcohol useduring pregnancy than that found in mothersof children with FAS. FAE include any of thefollowing: ear and eye defects, heart defects,physical deformities, joint and limb malformations,hemangiomas (a kind of birthmark), cerebral palsy, mental retardation, andneurological abnormalities.

How does ALCOHOL affect the infant?

Prenatal exposure to alcohol may result in subtle central nervous system(CNS) deficits that may cause behavioral and learningabnormalities. Carefully controlled studies haveidentified a number of these functional Fetal Alcohol Effects: hyperactivity,decreased learning ability, poor locomotion, lack of coordination, developmental delays, suckingand feeding difficulties and response inhibition.

Infants with FAE may also show signs of braininvolvement in impaired motor development, decreased capacity to self-regulate physiological states,and sleep problems.Irritable and restless sleepers, infants of heavy drinkers may havedifficulties with bonding and provoke abuse from parents. Further, at eight months of age, infants of heavydrinkers showed significant decrements in height, weight, and head circumference.

16 How do OTHER DRUGS affect the developingfetus and infant?

MARIJUANA

Marijuana can cause premature delivery and even withdrawal symptoms.Like babies born to cigarette-smoking pregnant women,newborns who have been exposed to marijuanain utero may be significantly lower in birthweight and shorter in length.As babies, they may be irritable and tremulous, and deficient in visual functioning. They are also atincreased risk for Sudden Infant Death Syndrome (SIDS).

HEROIN AND OTHER NARCOTICS

A mother using heroin and other narcotics is at greater risk forhepatitis (both acute and chronic), endocarditis, and AIDS, if the substance is used intravenously. Thechance that the baby will be lost due to miscarriage or stillbirth is also increased. The infant islikely to have low birthweight and small head size (a sign of diminished brain growth).Other problems include withdrawal symptoms, difficulty in responding to human voice and touch, and increasedrisk of Sudden Infant Death Syndrome (SIDS).

TRANQUILIZERS

Babies of mothers who use tranquilizers often go through withdrawalafter birth, suffering such symptoms as reduced ability to nurse, hypothermia,and breathing abnormalities. In addition, some tranquilizers are suspected of causing congenital abnormalities.

BARBITURATES

Sudden withdrawal from barbiturates by the mother orbaby may result in seizures or even death. The withdrawal symptoms resemble those ofheroine-addicted babies, but tend to be more prolonged and severe.

17 THE EFFECTS OF ALCOHOLAND OTHER DRUGS ONTODDLERS AND OLDER CHILDREN other drugs vary considerably, The long-term consequences ofprenatal exposure to alcohol and reflecting differences in the child'srearing environment as well asthose present at birth. Some children classroom. Many others, typicallywith with severe symptoms areunable to function in an average associated with prenatal exposure to normal intelligence, demonstratesubtle impairments not easily investigate the less obvious deficits ofthese alcohol and other drugs.Researchers are just beginning to significantly help to remediate learning children. All agree that earlyidentification and intervention can and behavioral problems.

Highlights of Major ResearchStudies

INTELLECT, PLAY, AND ATTACHMENTIN POLYDRUG-EXPOSED CHILDREN AT 18 MONTHS

compared 18 prenatally drug-exposed18-month-old toddlers with Dr. Judy Howard and associates quality of play, a comparable,non-exposed group. The researcherslooked at intellectual functioning, and security of attachment tothe parent or parent figure.

FINDINGS: tests, but fell Drug-exposed toddlers hadsignificantly lower scores on developmental within the low-average range. self-initiation, and In an unstructured, free playsituation requiring self-organization, follow-through without the assistanceof an examiner, the drug-exposedtoddlers showed striking deficits. scattering, batting and For the majority of drug-exposedtoddlers, play consisted of play (sustained picking up and putting down toysrather than the representational in the combining of toys, fantasy play, orcurious exploration) more common comparison group. acquisition, problems in Because representational playis associated with language language development areanticipated for drug-exposedchildren. goal-directed behavior than the The drug-exposed toddlershad more impulsive, less comparison group. their caregivers than the The drug-exposed toddlers wereless securely attached to comparison group. n -- 4 ;) 1 8 The rearing environment, throughfostering secure attachment, lessenedthe impact of prenatal drug exposure, but did noteliminate its effects entirely.

Source: Howard, J., Beckwith, L., Rodning, C.,and Kropenske, V. (1989, June).The development of young children of substance-abusing parents:Insights from seven years of intervention and research, Zero to Three, p. 812. (See Appendix A)

DEVELOPMENTAL ABILITIES OF COCAINE/POLYDRUG-EXPOSED CHILDREN AT TWO YEARS

At thePerinatal Center for Chemical Dependenceat Northwestern MemorialHospital, the developmental progress of 263 prenatally drug-exposed children wasevaluated over two years and compared with a control group of children whose mothers had notused drugs during pregnancy. The mothers of the children were categorized as cocaine/polydrug usersbecause most used cocaine plus other drugs such as marijuana and alcohol.

FINDINGS:

Evaluation at birth revealed the infants of thecocaine/polydrug using mothers were more likely to be barn prematurely andgenerally weighed less, were sliorter,and had smaller head circumference.

By 3 months of age the mean infant weight had caught upwith that of the drug-free control group.

By 12 months of age the two groups were notsignificantly different in length.

Z `trough 2 years of age, the head circumference measurementremained smaller in the drug-affected children. Smaller head circumference isthought to be a marker of risk for long term developmental difficulties.

This study and others indicate that drug-exposedtwo-year-olds score poorest on developmental tests that measure abilities to concentrate,interact with others in groups, and cope with an unstructuredenvironment.

The drug-exposed children scored within the normal rangefor cognitive development and are not, as some people have stated,brain damaged. They will require a structured learning environment and patient, one-on-oneattention from teachers and caregivers in order to achieve their maximumlearning potential.

Source: National Association for Perinatal AddictionResearch and Education, 11 E. Hubbard Street, Chicago, Illinois, 60611, (312) 329-2512. LEARNING DISABILITIES IN CHILDRENOF NORMAL INTELLIGENCE EXPOSED PRENATALLY TOALCOHOL

Children referred to the LearningDisorders Unit of the Yale-NewHaven Hospital were evaluated hypothesis that, even for indications of prenatal exposure toalcohol. The researchers tested the alcohol may be a frequently in children of normal intelligencewithout Fetal Alcohol Syndrome, overlooked cause of behavioral and learningdifficulties.

FINDINGS:

Of 87 children referred for learningproblems, 15 were found to havebeen exposed prenatally to large amounts of alcohol.All were of normal intelligence. Syndrome, but None of the children displayed the severesymptoms of Fetal Alcohol all showed the deficits in growth,facial anomalies and "soft" neurologicalirregularities that would suggest prenatal exposure toalcohol.

Although the children prenatally exposedto alcohol had normalintelligence, subtle central nervous system impairmentsresulting from exposure to alcoholcaused behavioral and learning deficits.

Children born to alcoholic mothersshould be followed carefullythrough the early school years for the possibility oflearning difficulties.

Children experiencing school failureshould be evaluated for indicationsof prenatal exposure to alcohol. Behavior and learning Source:Shaywitz, S., Cohen, D. and Shaywitz,B. (1980, June). difficulties in children of normalintelligence born to alcoholic mothers.The Journal of Pediatrics, 96, 978-982. (SeeAppendix A)

2 20 POSSIBLE EFFECTS OF PRENATALEXPOSURE TO COCAINE:

In the fetus: WMVIAMM.4000...1110,..le.

Miscarriage Premature labor "Abruptio placentae" Cerebral stroke Stillbirth delivery

In the infant:

Low birthweight Small head circumference Impaired motor development Seizures and strokes Abnormally formed internal organs Rapid respiratory and heart rate Irritability Frequent startles Hypertonicity Unresponsiveness Tremulousness Difficulty in being comforted Irregular sleeping patterns Poor feeding patterns Abnormal sucking and swallowing Disorientation Frequent gaze aversion Atypical motor development Poor interactive capacities Alterations in bonding and attachment Increased risk of child abuse and neglect Increased risk of Sudden Infant Death Syndrome(SIDS) Increased risk of AIDS and syphilis (from mother)

In the child: 101,l,t1SM,WS:4404 SIX,SX-:.,,,,,,Vet.V.1~46165.V.KOW,XOSSX9356:00.^.W.M.X.X.:30W0~04.1WWWWWWVICIX00,0462KKPX Impaired play skills Irritability Small head circumference Speech and language delays Impaired ability to concentrate Poor task organization and Impaired social; skills processing difficulties Difficulty coping with an unstructured environment Problems related to separation and Impulsivity and hyperactivity attachment Heightened response to internal and external stimuli Motor development delays Tremors POSSIBLE EFFECTS OFPRENATAL EXPOSURE TOALCOHOL:

In the fetus: vemworftworm,...... *

Miscarriage Premature labor Stillbirth delivery

In the infant:

Low birthweight

Fetal Alcohol Syndrome, including: 1) growth retardation beforeand/or after birth 2) a particular pattern of abnormalfeatures of the eyes, face and head,includin,* small head circumference (suggestingdiminished brain growth), small eyes, ;. evidence of a retarded formation ofthe midfacial area including aflattened bridge and short length of nose andflattened vertical groove between themouth and nose 3) evidence of central nervous systemabnormality

Fetal Alcohol Effects, like: Physical deformities Heart defects Ear and eye defects Joint and limb malformations Mental retardation Cerebral palsy Neurological abnormalities Hemangiomas Irritability Sleep problems Impaired motor development; poorlocomotion State regulation disorders Increased risk of child abuse Sucking and feeding difficulties Response inhibition

In the child: Hyperactivity Attention deficit disorder syndrome, Reduced body weight, height and expressed as restlessness, short attention head circumference span, distractibility,longer reaction time Facial abnormalities Learning difficulties Mild hearing loss Development delays

22 ' LOW IHRTHWEIGHT: WHAT DOES ITMEAN? ""m""41,

One of the most common consequences of prenatal exposure to alcohol and other drugs is low birthweight. What does lowbirthweight actuallymean? Whatsignificance does it have forachild's development? A baby is considered to have low birthweight if he or sheweighs less than 5.5 pounds at birth. Having failed to thrivein the mother's womb, the low birthweight baby faces significant risks whichshould not be underestimated.For example, compared with infants of normal weight, low birthweight babies:

are 40 times more likely to die in thefirst year of life. account for two-thirds of all neonatal deaths. are still five times more likely to die evenif they survive the first month of life.

In addition, the educational outlook for low birthweightbabies is compromised. Low birthweight infants:

often have neurodevelopmental handicaps, includingcerebral palsy and seizure disorders, which are linked withlearning disabilities and behavioral problems in the classroom. . are alsosusceptible to chronic respiratory problems that can interfere with school attendance.

Finally, these and other potential impairments putfamilies of low birthweight babies in an emotional and financial crisis.

Source: Preventing Low Birthweight. (1985). Instituteof Medicine. DRUGS AND BREASTFEEDING

In the same way they pass freelythrough the placenta to the developingfetus, alcohol and other drugs pass readilyinto the breastfeeding mother's milk.Dr. Ira mother Chasnoff of Northwestern UniversityMedical School reports on the case of a who breastfed her infant whilesnorting cocaine over a 4-hour period.The infant dilated was brought to the emergency roomwith signs of cocaineintoxication: pupils, hypertension, tachycardia,and extreme irritability.

Source: Chasnoff, I. (1987, May).Perinatal effects of cocaine. ContemporaryOBI GYN, p. 163-179.

WITHDRAWAL: The Neonatal AbstinenceSyndrome

Sixty to ninety percent of infants born tomothers with a recent history of narcotic abuse show clinical signs ofwithdrawal. The characteristic sequenceof withdrawal show effects is called the neonatal abstinencesyndrome (NAS). Newborns with NAS increased sensitivity to noise,irritability, poor coordination, excessivesneezing and yawning, and uncoordinated suckingand swallowing reflexes. Abstinence symptoms last for four to six months afterbirth, often with a peak in symptoms atabout six weeks of age. NAS has also been seenit newborns exposed prenatally todrugs other than narcotics, including phenobarbitol,diazepam, marijuana, cocaine, and alcohol.

Source: Chasnoff, 1. (1988, March).Newborn infants with drug withdrawal symptoms. Pediatrics in Review,..2, 273-277. 1 Chapter 3

WHAT IS THE ROLE OF THE CHILD'SENVIRONMENT? 400mt,roomt~er.... ,IMINVOMI~MMIMMONIMMMI10/

.Profile of the Pregnant Substance Abuser

.The Child's Place in the Drug-AbusingFamily

Substance Abuse, Bonding and Attachment Chapter 3 WHAT IS THE ROLE OF THECHILD'S ENVIRONMENT?

Environment plays a critical role in the life of thesubstance-exposed child, since it can lessen or exacerbate the damagethat took place in the womb. The child who ismoved from one foster care placement to another or who is neglected or abused athome, for example, is unlikely to thrive emotionally, intellectually, socially, or physically . Asetting characterized by structure, consistency, and love, on the other hand, can go a long way towards amelioratingthe difficulties faced by children prenatally exposed to drugs.

Though substance abuse in pregnancy is found in rural, suburban,and urban settings, among women of all races and economic strata, moststudies of substance-abusing pregnant women have involved low socioeconomic status women seeking public aid.These women are alike in several ways. First, they themselves tend to be victims of unresponsive or traumaticrearing environments, without positive role models for parenting. Second, they have great difficulty inmeeting the special needs of their drug-exposed children, at least without help. Finally, even whenmotivated to seek treatment, these substance-abusing pregnant women have few options, since drug treatment programstraditionally exclude pregnant women.

Professionals who face the painful reality of substance-exposed children mustavoid demeaning appraisals of drug-involved mothers. The most effective effort is onegrounded in empathy for the entire family of a substance-exposed child. According to Dr. Judy Howard atthe University of California at Los Angeles (UCLA), the work of she and her colleagues is successful,in part, because of the "stance of respect" from which all staff approach the substance-abusingfamilies engaged in her research and service project. Essential to the cultivation of this respect is a deepunderstanding of the struggles of substance-abusing families.

PROFILE OF THE PREGNANT COCAINE ABUSER The following characteristics are drawn from studies of highlyimpoverished, substance-abusing pregnant women: Most have a history of physical, sexual, or emotionalabuse. They have the disease of chemical dependency and need treatment. Their mothers and fathers probably abused alcohol andother drugs. They are likely to live with a drug-using partner. They may come from the poorest, most deprived, mostchaotic environments. They feel guilty and responsible for their plight. Their orientation to life is often characterized by lowself-esteem and powerlessness. Denial is part of their disease process. They tell themselves"a little won't hurt," or"I'll do it just once more". Blaming, reprisals, and attempts to criminalize them keepthem from using systems and services that could help. Their ability to be a good parent is compromised by theirdisease of chemical dependency and the often difficult behavioral characteristics of their infants.

Source: Kronstadt, D. (1989, March). Pregnancy andcocaine addiction: An overview of impact and treatment. Far West Laboratory forEducational Research and Development,Sausalito, CA.

27 THE CHILD'S PLACE INTHE SUBSTANCE - ABUSINGFAMILY

The following is excerpted from"The development of youngchildren of substance-abusing parents: Insights from seven yearsof intervention and research", anarticle on substance-abusing families involved in aresearch/treatment project at theUniversity of California at Los Angeles (UCLA), under the direction of Dr.Judy Howard:

Substance-abusing parents are unstable, movefrequently, lack telephones, fail to keep appointments,and drop out of sight when abusing illicit drugs.Friends and often family colludewith the substance- abusing person's flight fromrepresentatives of authority structures such as universities,medical and legal systems. We havefound, therefore, that it is very important notonly to provide clinical services but to provide them through an intervenorwho isable to establish an ongoing,stable, nurturing, and non-threateningrelationship with the subject.

Substance abuse undermines normal patternsof interaction and alters conventional priorities(Howard, in press). The families we have worked with, who are poor and arechronic polysubstance abusers, have multiple legal, social and medicalproblems. They often come from a history ofimpoverishment, abuse, and intergenerationalchemical dependence. One mother, for example,told us how her mother taught her to shoplift and then to sell thestolen goods on the street. This mother was introduced to heroinby her own father. (In fact, a significant number of parents experienced their first exposure todrugs and alcohol through their own parents' encouragement.)Another mother told us that when she was upset as a child her motherwould mix her a drink and say, "Drink this; it will make you feel better."A third mother stated that her own father "shot me up with heroin when Ithreatened to call the cops on him."

Parents who are addicted to drugshave a primary commitment to chemicals, not to their children.Disruption and chaos in the household often result in the neglect or disregardof the child's needs. For example, a three-month-oldbaby in one of our researchprojects was found underneath a bed by a neighbor.The baby's parents and friends were high and consequently not merelyinattentive to the baby's needs but completely unaware of the baby's presence.Another mother explained her inability to keep medicalappointments for her child because she was out "chasing the bag" -that is, looking for drugs. Yetanother mother explained her pregnancy by statingthat "I need this baby to slow me down, to keep me off the streets."

Chronic drug use can impair anddistort a parent's thoughts and interfere with perceptions.Chronic use of mind-altering drugs can memory, attention, andperception. Mothers in our studies havehad difficulty remembering their ownchildren's birthdates.

26 Safety is an issue for family members, for professionalstaff who make home visits, and most of all for the childrenof substance- abusing families. Drive-by shootings and violence wheredrugs are used and sold are daily occurences in theirneighborhoods.Further, children are often in danger because theiraddicted parents do not function as protectors and advocates. Infancy professionals who have been trained to acknowledge and respect that parents have a primary leadership role in their children's lives must learn to understand that the substance-abusingparent is often unable to assume thisprimary protective role. The first goal of professionals, therefore, is to keep the child visible in the community in order to monitor the child's safety in a dangerous drug culture."

Source: Howard, J., Beckwith, L, Rodning, C., Kropenske, V. (1989, June). The development of young children of substance-abusing parents: Insights from seven years ofintervention and research. Zero to Three, 9, 8-12.

Aelle11SUBSTANCE ABUSE AND TEENAGE PREGNANCY1111 In a 1989 study of 253 pregnant adolescents conducted at Boston City Hospital, the use of alcohol and illicit drugs was found to be "a common andsometimesfrequentexperience." According to the researchers, the group under study reflected the poor, predominantly black andHispanic,unmarried population served at Boston City Hospital. Among their findings:

one in six used cocaine during their pregnancies.Slightly over half* used alcohol and just under a third used marijuana during their pregnancies. adolescent drug users had more of their social support provided by their male partners than nonusers. adolescent women who used drugs were nearly three times more likely than nonusers to report being threatened,abused, or involved in fights during pregnancy. drug use among pregnant adolescents was closely tied totheir partner's drug use. For this reason, it is recommended that intervention and prevention efforts address both the adolescent mother and hermale partner. the mother's drug use is often an attempt to cope with unhappiness and stress resulting from such difficulties as depression, poverty, poor social supports, and a variety of negativelife events.

Source: Amaro, H., Zuckerman, B. and Cabral, H. (1989, July). Drug use among adolescent mothers: Profile of risk.Pediatrics, BA, 144- 150.

29 THE RISK OF AIDS

In addition to other potential problems,the child exposed to drugs in utero is at greater risk Rd the HumanImmunodeficiency Virus (HIV) infection, a precursor to AIDS. This is because womenwho use cocaine are at high risk for theAIDS virus, as a result of a life-style often characterized by promiscuous sexual behavior andexchange of sex for drugs. In addition, crack cocaine maybe injected in order to sustain a lasting high, enormously increasing the riskof HIV infection by a contaminated needle. Studies suggest that 50%of infants born to mothers infected with AIDS or AIDS Related Complex(ARC) become infected. These children will require extensive medicaland psychosocial care for as long as they live.

Source: Falloon, J., Eddy, J., Wiener, L.and Pizzo, P. (1989). Human immunodeficiency virus infection in children. Journalof Pediatrics, 114 1-30. and The Far West Lab for Educational Researchand Development, The Center for Child and Family Services,Sausalito, CA.

SUBSTANCE ABUSE, BONDING, ANDATTACHMENT

Bonding, the process by which an infant develops a senseof trust and attachment to a consistent caregiver, is essential for healthy psychologicaldevelopment. Attachment is defined by Kennel),(1976) and time and serves to join as " an affectionate bondbetween two individuals that endures through space them emotionally." Attachment helpsthe child to:

- attainhis full intellectual potential; sort out what he perceives; - thinklogically; develop a conscience; become self-reliant; - copewith stress and frustration; - handlefear and worry; develop future relationships; and - reducejealousy (Fahlberg, 1979).

Bonding is often extremely problematicfor newborns affected by alcohol and otherdrugs.These children typically face lengthy hospital stays, returnto chaotic drug environments, or enterthe foster relationship between care system, all circumstancesinterfering with the development of a strong, secure infant and mother or primary caregiver.

30 In addition, drug-affected babies are likely to have health problems, be difficult and demanding, and are less responsive and rewarding than even "difficult" babies. The inability of these babies to communicate their needs effectively, combined with frequently inadequate parenting skills on the part of the caregivers, makes bonding even more difficult. Magid and McKelvey (1987) describe this as the "vicious cycle of the non-responsive infant": When a child is not physically responsive, the mother wonders what she is doing wrong. As the mother's feelings of nervousness and anxiety grow, the child becomes more nervous and anxious, and withdraws even more from the mother. Thus, the cycle begins again.

Magid and McKelvey assert that the "vicious cycle" begins when "the infant has failed, sometime during the first year, to develop a strong internalized parent. As this cycle continues, babies fail to gain a sense of trust." In their review of the work on bonding and attachment, they found that the extent of psychological damage resulting from a failure to bond with a primary caregiver depends on three main factors. They describe them as:

1) The age of the infant when the bonding cycle is broken. The younger the infant, the more disastrous the break will be. The first months of an infant's life are the most important for the attachment process, although the process does not seem to be fully complete for about two years.

2) The length of time the cycle is broken. if a primary caregiver is gone from the child a relative few hours, little damage is done. But repeated day-long breaks, or breaks of several days or more, can result in an unattached child.

3) The basic genetic predisposition of the particular child. Just what role this plays has not been determined at this time." (p. 68)

The many problems facing babies prenatally exposed to alcohol and other drugs greatly threaten the establishment of a strong, secure bond and sense of attachment to a primary caregiver. The importance of this relationship between the infant and mother or primary caregiver cannot be understated, since it impacts on the child's physical, intellectual, emotional, and moral development. Clearly, the answer to the question of substance abuse during pregnancy lies in prevention. Researchers, praction- ers, legislators, and other citizens must work together to build a society in which the future of our children is everyone's top priority. Only in this way can the cycle of substance abuse and pregnancy end.

Sources: 1)Kennell, J., Voos, D. and Klaus, M. (1976). Parent-infant bonding. In R. Helfer and C.H. Kempe (Eds.), Child abuse and neglect. Cambridge, MA: Ballinger Publishing. 2) Fahlberg, J.V. (1979). Attachment and separation: Putting the pieces together. Michigan Department of Social Services, DSS Publication 429. 3) Magid, K. and McKelvey, C. (1978). High risk: Children without a conscience. New York: Bantam Books.

31 [Chapter4-11

,.v.4*ve**Wo,4.Av.A***1.4*.v.+.*...... WHAT IS THE ROLE OF THE SCHOOL? Roles of the School Staff

Identifying At-Risk Children

A Model Program ,...... ,.,...... 4., Chapter 4 WHAT IS THE ROLE OF THE SCHOOL?

Experts suspect that our educational system already containssignificant numbers of substance- exposed children. Because these children are of normal intelligence,however, the subtle deficits affecting their performance may remain undetected. Early research withsubstance-exposed preschoolers, the oldest group of children being followed by researchers, shows they areunable to function effectively in.a traditional school setting. Thus, without assistance, substance-exposedchildren appear to be at great risk for school failure and for dropping out of school.

Yet the proper school setting can make a great difference in the lives of childrenaffected by their parents' substance abuse. Structure, consistency, and concern are important componentsof this optimal learning environment, along with a good deal of individualized attention. Teacherswho work with substance-exposed children must be familiar with related neurological impairmentsthat affect learning and behavior. Rather than working in isolation,they must also be willing to work as part of a multidisciplinary team. In model early intervention programs, the first substance-exposedchildren under study are responding to such an approach by learning and growing.

WORKING WITH SUBSTANCE-ABUSED CHILDREN: ROLES OF THESCHOOL STAFF

The Teacher should:

be supportive of various intervention techniques that work with drug-exposedchildren (see "Teaching Strategies" in this chapter). be open-minded and willing to try new and different methods to meet thechild's needs. be ready to coordinate with a variety of different resources and agencies toassist the child's cognitive, physical, emotional and behavioral development. through patience, love and understanding, provide the environment in whichthe child can progress comfortably and in which sometimes reluctant parents can be encouraged toparticipate in their child's development. coordinate with other school-level support staff to provide a team approachfor each child. be provided with information related to identifying and assistingsubstance-exposed children.

The Counselor should:

be able to identify signs and symptoms of drug-exposed children. be aware of assessment techniques and instruction for use with thechild and the family. be able to provide specialized guidance and counseling in the schoolsetting. be able to provide support and guidance for other staff members. be ware of community resources for information and referral.

35 The Principal should: drug-involved children. be knowledgeable aboutsigns and symptoms of be sensitive to special needsof drug-involved children. for use with these children. be aware of special curriculumand instructional techniques necessary be knowledgeable about theaffective as well as academic needsof drug-involved children, drug-involved children (see below). be aware of sources of trainingfor staff in dealing with

Director should: The Child Care Center,Pre-kindergarten, and Kindergarten special consideration in both practice and be able to recognize thatdrug-involved children will need curriculum. arrange to providefor such special consideration asfar as possible within the center's means pay special attention tostaffing. use innovative waysof involving parents or guardians. be willing to refer drug-involvedchildren for diagnostic screening if necessary. make arrangements for outsideassistance if deemed important to thechild's overall development. outside source since make it his or her responsibility tofollow through on a child's referral to an continuity of care is critical.

Source: Kate Howze, M.S. andWendell Howze, Ed.D., personalcommunication.

Some Sources of Training inFlorida: of Student Services, Linda Delapenha, Supervisor,Primary Diagnostic Services, Department Hillsborough County Schools, 411 EastHenderson Avenue, Tampa, FL 33602,(813) 272-4576.

Shirley Davis, Director, ChildDevelopment Center, Operation PAR,10901-C Roosevelt Blvd., Suite 1000, St. Petersburg,FL 33176, (813) 577-9728. of Pinellas County, 4140 Kate Howze, Community RelationsSpecialist, Juvenile Welfare Board Forty-Ninth St. N., St.Petersburg, FL 33709, (813)521-1853 . 1717 54th Avenue, St. Petersburg, FL Wendell Howze, AssistantPrincipal, Northeast High School, 33714, (813) 527-8441.

36 IDENTIFYING AT-RISK CHILDREN

The following list of behaviors was compiled by thestaff of Los Angeles' Program for Children Prenatally Exposed to Drugs (PED). Substance-exposedchildren displaying these behaviors are at risk for school failure and a variety of related problems.

Perinatal Substance Abuse: Indicators for Early InterventionServices

Mo and Neurological Development

tremulousness, tremors when reaching, increased startling poor quality of visual following r visual attention to people and objects ing out, staring spells, bizarre eye movement motor dexterity difficulty gross motor clumsiness

Affective and Behavioral Development

lability of emotion, rapid shift from apathy to agressiveness. irritable, hyper-sensitive, explosive and impulsive behaviors depressed affect, decreased laughter difficulty in comforting self and being comforted marked difficulty with transitions and changes increased testing of limits -insists on doing tasks on own terms -persistent refusal to comply to simple commands inability to self-regulate or modulate own behavior (easily becomesover-excited, cannot calm down)

Social /Attachment Development

decreased use of eye contact to initiate social interaction decreased use of gestures to initiate social interaction decreased/absent stranger and separation anxiety indiscriminate attachment to new people aggressiveness with peers decreased compliance to verbal direction decreased response to verbal praise decreased use of adults for solace, comfort and object attainment decreased use of adults to gain recognitionfor accomplishments Problem Solving, Attention andConcentration Strategies

poor on task attention increased distractability to extraneoussounds and movements inability to accommodate in problemsolving situations - impulsive responsesbefore "reflecting" persistent use of ineffective problem solvingstrategies, or easily "gives up" without trying otherstrategies - decreasedvisual scanning of all components inproblem solving situations decreased use of trial and error strategies delay in acquisition of sense task completion

Language Development

fewer spontaneous vocalizations fromearly infancy delayed acquisition of words decreased use of acquired words/gestures tocommunicate wants and needs prolonged use of "in-class" errors inpicture/object identification at preschool level prolonged infantile articulation at thepreschool level difficulty in "word finding" at the preschoollevel

Play

shows decreased spontaneous play withincreased aimless wandering does not apply acquired adaptive skillsin spontaneous stacking, marking andcontainer play cannot organize own play, appearsperplexed and confused, cannot selectmaterials and focus adaptively shows delays, discontinuity anddisorder in representational play easily overstimulated by too many thingsand people and by too much noise, has difficulty with peer relationshipsin unsupervised play

Source: Program for ChildrenPrenatally Exposed to Drugs (PED) Team, Los Angeles Unified School District,Division of Special Education PED Team: Carol Cole, Teacher Victoria Ferrara, Teacher Teresa Garcia, Psychologist Deborah Johnson, Psychiatric SocialWorker Marci Blankett Schoenbaum, Teacher Rachelle Tyler, M.D. Valerie Wallace, Psychologist

Marie Poulson, Ph.D., UniversityAffiliated Program, Children's Hospital

33 A MODEL PROGRAM

The following is excerpted from "Today'sChallenge: Teaching Strategies forWorking with Young Children Pre - nasally Exposed toDrugs/Alcohol", a booklet developed in July1989 by the staff of the Children Prenatally Exposed to Drugs(PED) Program of the Los Angeles UnifiedSchool District. The booklet was designed to provide guidelinesfor preschool programs wishing to meetthe needs of substance-exposed children. The teaching strategies areorganized in the areas of learning, play,social/ emotional communication and motor development, andhome/school partnership. In addition to specific teaching strategies, there are descriptions of normaldevelopment as well as behaviors that place prenatally-exposed children at risk.

Overview

Background

The Los Angeles Unified School District, Division ofSpecial Education, has initiated a pilot project serving twenty families in two classrooms at SalvinSpecial Education School and one at 75th Street School. The pilot serves children ages 3-6 who havebeen prenatally exposed to drugs (P ED ). Using a transdisciplinary approach, a team consistingof teachers, psychologists, socialworkers, speech and language specialists, adapted physicaleducation staff, a physician, and a nurseoffer services to children and families.

Purpose

The pilot is designed to determine the educationalstrategies that will be necessary to serve this high riskpopulation.Ongoing assessments and documentaionhelp to identify the learning styles, behavioral characteristics anddifficulties with bonding that are oftenfound in these children. To promote understanding of these young children,special emphasis is placed on strergthening the home /school partnership, gathering andimplementing data from related research,developing curriculum guidelines, providing parenticaretakereducation and disseminating information tothe conununity.

Entrance Criteria

I.Age: Three years, zero months to four years, zeromonths 2. Cognitive Ability: Overall functioning within average range 3. Medical: Prenatal exposure to drugs such as cocaine,PCP, heroin, etc. Children who have a medical conditionsuch as a) seizures, b) deafness, c) blindness,d) severe mental retardation, e) severe physical disabilities, f)chromosomal abnormalities, that would qualify themfor services on a special education site are noteligible for services in the PED program. 4. Behavioral Characteristics: Children may exhibit anyof the following: tremors, perceptual disorganization, blankingout, speech and languagedisorders, minimal development delays, disorganized play, difficulty with transitions, poor peerrelationships and poor coping skills.

39 Characteristics of ChildrenPrenatally Exposed to Drugs/Alcohol

of a drug-exposed child,and as such each child must be There is no "typical profile" vulnerabilities. Because the effects of educated as an individual withparticular strengths and children are varied, the continuumof impairment can range prenatal alcohol or other drug use on child's development. from minimal symptomology to severeimpairment in all areas of the Characteristic behaviors include aheightened response to internaland external stimuli, irritability, speech and language delays, poortask organization and processing agitation, tremors, hyperactivity, social and play skills, and motor difficulties, problems related toattachment and separation, poor development delays. always he remediated, While organic deficits caused byprenatal exposure to drugs cannot adverse child rearing conditions cannotalways be created, high quality and while immunity against self-control, and child /family intervention services cansignificantly improve a child's self esteem, ability to solve problems in thereal world.

Goals of the PED Program family focus, systematicinterdisciplinary 1. To develop aeschool program that incorporates a staff, and program assessments, individualizedprogramming, consistent teaching, support evaluation. and provide structured learningexperiences to promote the 2. To develop effective strategies of children prenatally exposed cognitive, communicative,psychosocial, and motor development to drugs includingalcohol. and developmental learning 3. To identify preschool childrenwho are at-risk for behavioral other drug exposure. problems due to prenatal alcohol or To Drugs, PED, children to a 4. To facilitate the succesfultransition of Prenatally Exposed regular education setting or totheir least restrictive specialeducation program placement. have been prenatally exposed to 5. To promote a betterunderstanding of young children who drugs including alcohol andwho are at-risk for school failure.

Philosophy of Program alcohol or other drugs are the result The behaviors seen in thepreschooler prenatally exposed to organic damage. early insecureattachment of a constellation of riskfactors resulting from possible environmental instability. The childis particularly vulnerable to manystresses patterns, and ongoing hyperactivity, The extremes ul".FPrved in achild's behavior, he it passivity or that impact on daily living. fear and suspicion, must heunderstood in the apathy or aggression,indiscriminate trust tit extreme context of the child'sexperience. drugs is more favorable Research has shown that the progress achild prenatally exposed to and stable environment; therefore,intervention when the child is placedin a predictable, secure with defined programs for thesechildren must include thedevelopment of protective environments and boundaries, as well asthe provision of on-goingnurturing and support. structure, expectations, emotional and cognitive well-being.Establishing Early positive, responsive careis crucial for children's is a teacher's major attachment with each childthrough understanding and acceptance a strong child's true potential he realized. priority. Only in the contextof a good attachment will a

40 Intervention strategies, to be effective, must attemptto counteract prenatal riskfactors and stressful life events. To accomplish this, the teacher mustbuild in protective factors within the classroom environment and provide facilitative ways for youngchildren to cope appropriately with stress.Self- protective factors are coupled esteem, self-control, andproblem solving mastery is best achieved when with a facilitative approach in the acquisitionof better coping skills. These protectiveand facilitative factors are similar to those built into anygood preschool program, but becausechildren prenatally exposed to drug are more vulnerable, these program componentsare essential.

The following are protective factors to bebuilt into a classroom for at-risk children:

A. Respect Children at-risk need a setting composed of nurturingadults who are respectful of children's work and play space and who do not make unrealisticdemands nor unpredictably appear and disappear. B. Routines & Rituals At-risk children need a setting which is predictable.Providing continuity and reliability through routines and rituals and scheduling activities to occurin a predictable order over time strengthen a child's self-control and sense of mastery over theenvironment. In staffing programs for children at-risk, not allprofessionals (speech and language therapist, psychologist, social worker, etc.) come into theclassroom weekly to interact with the children. These adults should develop a routine for reintroducingthemselves and predicting for the children when they will appear again. Consistent personnelwho help a child understand the visiting adult's schedule enhance the child's sense of security. C. Observation & Assessments The manner in which the child uses these skills duringplay, at transition time, and while engaged in self-help activities is equally important.Close observation of a child's behavior at these times allows for the understanding of how thechild experiences stress, relieves tension, copeswith obstacles, and reacts to change. It provides valuableinformation on how the child uses peers and adults to meet needs and solve problems. D. Flexible Room Environment Children at-risk need a setting in which classroommaterials and equipment can he removed to reduce stimuli, or added, toenrich the activity. E. Transition Time Plans At-risk children need a setting in which transitiontime is seen as an activity in and of itself and as such has a beginning, middle, and end.Special preparation is given to transitiontime, recognizing that it is one of the best times of the day toteach the child how to prepare for and cope with change and ambivalence. F. Adult:Child Ratio Children at-risk need a setting in which theaa'ult:child ratio is low enough to promote attachment, predictability, nurturing, and on-goingassistance in learning appropriate coping styles. for children prenatally exposed The following are facilitativefactors to be built into a classroom to drugs: A. Attachment Children at-risk need ateacher who accepts the childwith a history of both positive and that for a high-risk child, there mayhe a history of poor negative experiences. It is assumed world depends, to a attachments and lack of trust. The degree towhich a child comes to trust the inconsistent, inadequate, or rejecting, great extent, upon the qualityof care received. When care is world and people in particular. it fosters mistrust, fear, suspicion,apathy, or anger towards the These feelings will carry through tolater stages of development. B. Feelings Children at-risk need a teacher who acceptsthat children have negative andpositive misbehave for a reason, feelings. Feelings are real, important, andlegitimate. Children behave and misbehavior, the first priority should be even if it cannot befigured out. In responding to a child's the child seems to want, before dealingwith the misbehavior. Doing so allows to acknowledge what understood facilitates self- the child to recognize that his/herfeelings are real and valid. Being esteem and promotes awillingness to function within prescribedlimits. Different children respond to stress(internal or external) in different ways.Individual need to children show different responses to the samestressful events on different days. Teachers the individual child and develop a sensitivity to the particularmeaning different stressors have for child behavior. not have a predetermined setof expectations for or responses to C. Mutual Discussion feelings and At-risk children need a teacher whoacknowledges that children's behavior, with empathy experiences are open to mutual discussion.Talking about behavior andfeelings , (done accepting atmosphere. rather than judgment) validates thechild's experiences and sets up an distinguish between wishes and Permission to have these feelingsleads to the increased ability to the other. Verbal expression allowsthe integrating process fantasies on the one hand, and reality on self-control, and express that leads to the child's increasedability to modulate behavior, gain feelings. D. Classroom Rules limited. By Children at-risk need a setting in whichthe number of explicitly stated rules are encouraged to explore and actively engagein their social and limiting classroom rules, children are by relying on rules to control physical environment. While it ispossible to teach specific objectives problem solving capacity, and the child, it may be at the expenseof the child's intrinsic motivation, self-mastery. E. Role Model Children at-risk need ateacher who understands that byestablishing an individual, trusting teacher models is more relationship, the teacher becomes animportant person. and behavior the likely to be imitated. F. Peer Sensitivity At-risk children need ateacher who realizes that childrenbecome sensitive and aware of the needs and feelings of others onlyby repeatedly having their ownneeds met.

42 6 G. Decision-Making Children at-risk need a teacher who recognizes that itis important that they he allowed to make decisions for themselves. Freedom to choose and to assumethe responsibility for those choices gradually expands the in view of the child's physical,social, emotional, and intellectual growth and promotes self-esteem, problem solving mastery,and moral values. H. Home The home is recognized as an essentia! part of the curriculum.Facilitating parental! caregiver goals helps to establish a close workingrelationship between home and school. Intervention strategies that strengthen the positive interactionbetween child and family increase parental confidence and competency. I. Program Program intervention is best achieved when all professionalsconcerned with the child and family are coordinated. To accomplish this successfully, time musthe allotted for teachers to meet and plan with assistants and for support services of socialworkers, psychologists, speech and language, and adaptive physical education to come together in atransdisciplinary model.

43 Teaching Strategies

A. Learning framework. Development is aninternal process in which Learning occurs in a developmental experiences within a continuumof stages. the child is consistentlyorganizing and reorganizing automatic passive activity. Frombirth, a child who has not been Movement through the stages is not an respond to selected stimuli andtake the exposed to drugs /alcohol hasthe potential to attend and initiative to explore and controlthe environment. explore the environment canhe damaged in the childprenatally Competency to perceive and decision-making and problem solvingwithin a exposed to drugs/alcohol.Concrete experiences, for positive interactive communicationhelp to build the foundation nurturing environment as well as a motivation for new learning. development. This foundation promotesself-esteem, competence and

NORMAL LEARNINGDEVELOPMENT The child: learns to focus on tasks inplay situations. uses numerousproblem-solving strategies. shows sustained attention inindividual and small group activity. develops a sense of taskcompletion. of skills. steadily progresses in the acquisition expectations of the classroonz. learns to delay immediate needsand to conform to the social is able to end a preferredactivity and start a teacher -directed activity. demonstrates sporadiclintermittent masteryof skills in new learning situations. acquires pre-academic conceptsthrough incidental learning.

LEARNING BEHAVIOR OFAT -RISK CHILDREN The child: may easily bez'istracted by sounds, people,and movement. may have poorvisual scanning. may showdecreased trial and error. may showdecreased problem-solvingstrategies. may have decreasedattention and concentration. may showperseverative behavior in problemsolving. may show decreasedtask completion. may need longertime to complete task. may give upeasily when confronted byproblem-solving situations. may he easilyfrustrated and become irritablein problem-solving situations. may he unable todo task previously mastered. may be unable totake turns. seated in circle or at the tablewith the other children. may not remain envirotunetzuzl stimulation and marlearn to become may withdrawfrom a lack of social and non-responsive. may not haveregular playlrest cycles or patterns. may become upsetwith changes in routine. may havedifficulty with changesltransitions. end or let go of preferredobject or activity. may be unable to skills over prolonged period oftime. may demonstratesporadiclinzermittent mastery of may not learnincidentally.

44 TEACHING STRATEGIES FOR OPTIMALLEARNING

Teaching staff: provides support and emotional reassurance. reduces classroom interruptions as much as possible. limits number of objects in room. establishes classroom routines with minimum numberof transitions. models alternative strategies. directs child to watch another child who is using asuccessful strategy. considers developmental level of child. recognizes preschoolers may need to sit in adult's lap. recognizes preschoolers may need to sit next to anadult. uses physical, concrete, andverbal cues to direct or redirect child in task or activity. recognizes and consistently praises child's attempts andaccomplishments. asks child to verbalize steps of a task. provides verbal cues (talks the child through task) if child is unable toverbally give steps of task. provides the child with an opportunity to take turns with peersand adults. models taking turns. provides attention and time to children who are behavingappropriately. protects child from the over-stimulation ofintrusive persons or noisy environments andfrom the under-stimulation of a bland social and environmentalexperience. provides the child a schedule of play and rest activities to helpdevelop regular patterns. alerts the children routinely 1-2 minutes ahead of time thatthe activity will soon be over. talks about the next activity before entering into the activity. allows adequate time for the transition activity. guides the child through the transition and into the next activity. B. Play integrates learning, communicationand social /emotional and Play is the area where a child others and play, a child can learn tounderstand him/herself and the relation to motor skills. Through play involves increased communication the world around him/her. As achild grows and matures his/her because a and concept development.Strategies for play are important skills, attention, concentration, play skills. child prenatally exposed to alcoholand other drugs is at-risk for poor

NORMAL DEVELOPMENT PLAY The child: learns to organize his/her ownplay. can independentlyselect materials and focus onthem in an appropriate manner. progresses from parallel tointeractive play. joins in play with other children. initiates interactive play. takes part in and initiates dramaticplay.

PLAY BEHAVIOR OF AT-RISK CHILDREN The child: wandering. may show decreased spontaneousplay with increased aimless and may not organize ownplay, appear perplexed andconfused and cannot select materials focus adaptively. people and by too much noise, move- may be easilyover-stimulated by too many things and ment and excitement. play. may show delay,discontinuity, and disorder in representation may have difficultyjoining others in play. may not initiateappropriate interactive play. may not initiatedramatic play.

TEACHING STRATEGIES FOROPTIMAL PLAY DEVELOPMENT

Teaching staff: alone, and do not have to he gives child toys and/or areas inthe classroom that are child's shared. recognizes that the child may nothave had consistent play objectsin his /her environment. finds out whet is available forthe child in child's home. decreases /regulates amount of toysfor child. responds to and follows thechild's lead in play. models toy choices for childwith correct verbal cues. play with toys. verbally and physically models safe environment with the adult provides opportunities for thechild to play interactively in a available for assistance and reassurance. provides child with opportunities totake turns with peers and adults. provides time to modelinteractive play. provides child with support and encouragementduring play. play with child. initiates and models dramatic or by playing with the responds to child when childinitiates dramatic play by verbal responses child.

46 C. Social /Emotional When interactions between the drug exposed infantand caregivers result in lack of attachment rejecting or inconsistent care, this child is at greaterrisk for developing mistrust. suspicion and fear. These attitudes may carry through to later stages ofdevelopmentand manifest themselves beluiviorally. Exaggerated behavior patterns are often the way a child copeswith a situation that is overwhelming. Each child must he made to feel emotionally safe to attempt newlearning. It is important to establish a responsive, nurturingenvironment conducive to active learning in which the child maybuild a positive self-concept. NORMAL SOCIALIEMOTIONAL DEVELOPMENT The child: develops and maintains healthy attachments. separates from parent when trust has been established. learns to look for and respond to adult approval. learns to respond to gestural/ verbal praise and setting of limits by teacher. forms attachment to teacher. learns to socially signal desires and needs. learns to interpret and respond to social cues of adults. learns to read and respond to social cues of peers. shows broad range of emotions, including pleasure, anger, fear, curiosity,and assertiveness. shows a balance in emotions. learns to regulate own inner-state. reponds to emotions of others. learns to develop an independent sense of self and responsible behaviorresulting in self- esteem. develops a strong self-interest.

SOCIALIEMOTIONAL BEHAVIOR OF AT-RISK CHILDREN The child: may not use adults for comfort, play, approval, orobject attainment. may go from one to another showing nopreference for a particular adult. may not look to adult for recognition of a jobwell done. may not respond in any way toverbal praise from adult. may ignore verballgestural limitsetting. may show decreased compliancewith routine simple commands. may show indiscriminate attachment toall adults. may not signal desires by giving eye contact,gesturing, or vocalizing. may not read teacher's cuellook. may show a restricted range of emotion. - overreacts to"no" by total withdrawal. - rarely smiles,laughs, or show joy. - lethargy,listlessness, lack of affect. - clingybehavior with adult. may not express fear, grief, worry. may withdraw, seem todaydream, or not be there. may have poor inner controls(giggles turn into screams). may remain clingy anddependent on teacher for decisions and daily living activities for extended periods of time. may overreact to separations fromprimary caregiver. may show some lack of self-awareness as anindividual. may not show concern for hurt peers. TEACHING STRATEGIES FOR OPTIMALSOCIALIEMOTIONAL DEVELOPMENT

Teaching staff: provides opportunities for contact, mutualtouch, and smiling throughout the day. responds to specific needs of child withpredictability and regularity. addresses child by name, elicits eye contact,and/or touches child before giving verbal command. talks child through to consequence ofchild's action. provides the child with explicitly consistentlimits of behavior. takes every opportunity to developteacher child relations. uses close proximity and gestures. responds to muted signals and gives child averbal explanation of child's behavior. moves close to the child,looks at the child, and helps the child to readteacher's cues by explaining to the child what the teacher'slook, body language, or gesture means. labels expression of emotions so child learns toidentify those emotions. uses books, pictures, dollplay, and conversation to explore and helpchild express a range of feelings. allows, identifies, and reacts to child'sexpression of emotions: - pleasure - protest excitement - anger self-assertion -curiosity dependency - love - fear models full range of emotions for child. communicates with caregiver and finds outif there has been an upset in the home or any change of routine in the home, any family emergency orif the child's sleeping pattern has changed. assists child in gaining control by: - getting eye contact. - sitting next tothe child. - verbal reassurance. - physicalcomfort, (i.e., teacher rubs child's back). uses stories, puppets,and role play to develop empathy forothers. provides daily opportunity for the child topractice independent feeding, dressing,bathing, toileting, and play skills with tolerancefor messiness and dawdling. provides child with a daily opportunity tomake small decisions and limited choices inplay and/or self-help activities. has activities centered around thechild as an individual. provides spaces and objects in the classroomthat are for each child (cubbies with names, personal toys from home, and individualpicture hooks).

48 D. Communication evolves from early mother-childinteraction. The development of The child's capacity to communicate receive, understand, integrate, and express a child's languagedepends on the child's ability to learns to use gestures/ words to expressfeelings, communicate wants, meaningful experiences. The child interaction with significant and describe experiences. A childlearns language best through social individuals and through activeexploration of his/her environment.

NORMAL COMMUNICATION DEVELOPMENT The child: is able to follow directions appropriatefor his developmental level (simplecommands, multiple commands). learns to communicate simple wants andneeds, name objects, express feelings at appropriate developmental levels, and describeexperiences and events. is able to use pragmatic language. learns to initiate appropriate interactions with peers.

COMMUNICATION BEHAVIORS OF AT-RISKCHILDREN The child: may have delayed receptiveand expressive language. may be unable to followdirections that are appropriate for the child'sdevelopmental level. may have prolonged infantilearticulation at the preschool level. may not use attained language tocommunicate feelings, wants, and needs. may he unable to verbalizehis /her needs, wants and fears, and expressesthem through behavior such as hanging, stomping, shouting. may show listlessness, passivity,and/or lack of social awareness. may observe rather thanverbally engage with peers in play. may inappropriately initiateinteraction with peers by: - hitting - pushing - biting swearing negative verbal remarks.

TEACHING STRATEGIES FOR OPTIMALCOMMUNICATION DEVELOPMENT

Teaching staff: and needs. creates a stable environmentwhere child feels safe to express feelings, wants, uses "hands-on" activities toreinforce the child's language. uses eye contact, givessimple one step directions, and graduallyincreases the number of steps in a direction. maps language in the contextof the activity. provides names of people, pets, food items,body parts, objects, feelings, and events inthe process of conversation. immediately responds to beginning attempts atverbal communication. investigates child's behavior by askingchild questions to discover what child needs, wants, or fears. acknowledges the needs, wants or fears of thechild. provides strategies to enable the child toappropriately express needs, wants, or fears. acknowledges attempts by child to cooperateand interact with other children. recognizes negative behavior may be asignal of child's unmet needs. reflects child's feelings.

49 verbally directs child's behavior. praises child's attempts toward adaptivebehavior. ignores inconsequential verbal behavior. verbalizes expected behaviors. redirects behavior. removes child and helpschild calm self provides child verbal language to use withother children. intercedes with extra support for childwho has used best developmentalskills to resolve conflict without success. expression of feelings. sets consistent limits oninappropriate behavior, but allows for provides time to talk with child about emotions.

50 E. Motor of factors beginning Motor and spatial development stemsfrom the interplay of a number along this continuum can prenatally and continuing through earlychildhood. Any major interferences and other drugs. the child result in motorl spatial impairment. As aresult ofprenatal exposure to alcohol relationship delays. may exhibit varyingdegrees of fine, gross motor, and spatial

NORMAL MOTOR /SPATIAL DEVELOPMENT The child:

has Awareness of child's body placement inrelationship to his/her environment. has age appropriate gross motor skills. has awareness of space relationships amongobjects in relationship to sell has awareness of space relationship amongobjects in relationship to each other. is able to manipulate objects, age appropriately.

MOTOR /SPATIAL BEHAVIOR OF AT-RISKCHILDREN The child:

may trip or stumble without apparent cause. may have difficulty with gross motorskills (e.g., swinging, climbing, throwing,catching, jumping, running, and balancing). may walk into stationary ormoving objects. may move too close or toofar away from another object. may show splaying offingers, immature grasping skills. may have difficultymanipulating objects (stacking, stringing, cutting, anddrawing). may exhibit tremors whenstacking, stringing, or drawing.

TEACHING STRATEGIES Teaching staff:

verbally reminds child of obstacles. guides child through motor activities that emphasizethe skills of rhythm, balance, and coordination. models and guides child in learning to controlchild's body through songs, games, andplay. provides child with opportunities to experience spatialrelationship through motor mazes, out- door play, and indoor play. provides a variety of tactile and small motor activities(water and sand play, pegboards, puzzles, blocks, legos, etc.). observes child and notes tremor occurrences andduration and Iww child compensatesfor tremors. F. Home-School Partnership indicated that early The home is recognized as an essential partof the curriculum. Research has intervention programs are essential inproducing long-term positive resultsonly when parents! design. interactions between teachersand parentslcaregivers must caregivers are part of the program expression of mutual be professional, sensitive, and flexible.This relationship must be based on the Parents of children at-risk may themselveshave past and/or present experiences concern and goals. which may include which can compromise their ability toeffectively parent their children. Factors, poverty, depression, a historyof child abuselnegkct, family instabilityand violence, history of psychiatric problems, drug abuse, etc., aretaken into consideration when staff isaddressing the child's needs with the parent. placed with extended family members areparticularly Children who reside infoster homes or are require on- vulnerable to the consequences of separation,loss, and poor attachments. These children going support and coordinated case managementplans with the goal of maximizing the child's success within the home and in the school. Theemphasis on strengthening the positiveinteraction between caregiver and child increases the caregiver's awarenessand understanding of the child'sindividual needs and assists in promoting feelingsof confidence and competency withinthe caregiver. This empowerment of the caregiverwill benefit the child far beyond his/herformal school program. Having the knowledge of school /community resourcesand a genuine interest in the parent's well-being are essential to tidging thehome-school partnership.

HEALTHY HOME ENVIRONMENT The child: will have a mother who receives properprenatal care. is provided consistent, responsive primarycaregiver from birth. is provided predictable, safe, stableenvironment. has regular eating and sleeping patterns. will have a mother /primary caregiverwho sees herself as child's first teacher. is provided with atablished familyrituals around daily living activitiesand special events. is provided appropriate developmentalactivities. is encouraged to express feelings. is encouraged to be self-sufficient andindependent.

AT-RISK ENVIRONMENT The child: with prenatal exposure to drugs/alcohol may: - be premature - besmall for gestational age - gothrough withdrawal and/or - sufferdamage to gastrointestinal, endrocrine,respiratory genito-urinary, cardiovascular central nervous systems. may have multiplehome placements. may have multiplecaregivers. may live with other youngchildren who are at-risk. may be abused andneglected. may receive inconsistentand intermittent nurturing. may have caregiverwho is emotionally unaviailabk. may have caregiverwho is overwhelmed or untrainedin dealing with the child's emotional needs. may be exposed tochaotic, unpredictable, and unstableenvironments.

52 TEACHING STRATEGIES OPTIMAL HOME-SCHOOLPARTNERSHIP

Teaching staff: identifies family constellation and primary caregiver. develops relationship with caregiver and lines ofcommunication. schedules on-going visits to: develop a child's history (number of placements, medical history,family history, other agency involvement). - explore whatthey are doing about child's behavior. discuss observations of child's behavior and progress. - observeand discuss caregiverlchild relationship. identify parental concerns and assess family needs. - developindividual family service plan. facilitate referral to other agencies as services are needed. - encourageparticipation in parent education classes. discusses and models the importance of predictability and organization: - by developing atransition plan with caregiver for entering school (books, toys,expected parent attendance). by establishing regular patterns of communications with home (phonecalls, classroom newsletter, informal notes, notebook back and forth). - by anticipating,discussing and integrating events at home and school (daily routine,special events). by discussing implications of prenatal exposure to drugs /alcohol (short-termand long-term effects). - by promoting anunderstanding of psychosocial risk factors (abuse, neglect, mutipleplace- ments). A Teacher's Personal Account

Young Children Prenatally Exposed to Drugs in the School Setting by Carol Cole, M.A., Teacher, Los Angeles UnifiedSchool District

Children prenatally exposed to drugs entering the preschool settingbring with them a constellation of risk factors. The behaviors seen in the classroom may be theresult of possible organic damage, early insecure attachment patterns, and often ongoingenvironmental instability.These children are particularly sensitive to the many stressors that impact ontheir daily lives. The extremes observed in a child's behavior, be itpassivity, hyperactivity, apathy or agression must be understoodin the context of the child's experience. The average child in our pilot programhad approximately three placements by three years of age.

When we began three years ago, we were aware that theliterature described babies prenatally exposed to drugs as having a poor arousal response, beingdifficult to soothe, showing poor organization to environmental sounds, and being poor eatersand sleepers. We read that drug using mothers had a history of poor prenatal care, dysfunctional relationships,chaotic lifestyles and poor parenting skills.

What we didn't know was how the developmental line of vulnerabilities orimpairments would manifest themselves in the three and four year old child in theschool setting. We thought we could pinpoint different behavior and attribute it to a particular drug. We alsothought we might be able to tease out the effects of the drugs from thoseenvironmentally induced difficulties. We could not. The children

e 53 occurring at different times during the pregnancy, are the product of polydrug abuse in utero, the abuse Perhaps, more importantly, we could fordifferentdurations and at differentintensity while in the womb. impact of the drug and the impact of theenvironment. riot clearly distinguishthe difference between the

Three year old C. was reported to havebeen exposed to cocaine. pcp, and alcohol in utero.In school, he knew his colors,and was beginning to read. Yet, often, his response tosimple teacher demands to participate in chassroom activitiesand routines would result in temper tantrums, foul language,drooling, spitting, and undressing. C.lived in a group home forsix children, all under the age of five.There was a rotating staff of nine caregivers. This wasthe 8th placement that C. had experienced in his short three years.Was the inappropriate behavior we saw in the classroomthe result of the drugs or becauseof the multiple placements .. or wasit both? and that We have learned that these children are morealike than different from their typical peers while we know drug exposure can cause acontinuum of impairments, from severehandicapping generalization that can conditions to risk factors, there is no typicalprofile. Likewise, there is no typical served with sensitivity to their be made about the families andcaretakers of these children. Both must be atypical or dissimilar unique strengths as well as needs.Children prenatally exposed to drugs are not and environmental insults from other vulnerable children.However, the combination of both organic leaves these children in need ofspecialized curriculum and services.These children's cognitive competence is often notenough to protect them from schoolfailure. Therefore, specialized, but not necessarily separate from other high risk ortypical children, early intervention is necessaryfor these children.

The intervention strategies, to be effective, mustattempt to counteract prenatalrisk factors and children must incorporate the stressful life events. School curriculumand social services provided these basic principles, of buildingattachment and trust. which they learn The beginning of moral developmentforchildren rests in part with the degree to Attachment is the word we use, the to trust the world ...and of course the people in that world. building block for all shorthand, to convey that a child has thatbase of trust. Attachment is the initial and effect learning: cognitive, emotional,behavioral. . .It is fundamental for extending simple cause knowledge into the more complex realmof socially appropriate behaviorand abstract thinking. influence in the outcome Research indicates that one person,advocating for a child can have tremendous of that child.

Our experience is that a majorityof children coming into our programhave a history of poor establish a strong relationship attachment and lack of trust.Therefore, it is a major priority for teachers to skills, but rather on relationships with each child and family. Amajor focus is not just school readiness predictable interaction with respect for and attachment. Teachersmodeling concerned nurturing, size and shape. That is: feelings can teach a lesson far moreimportant that colors, numbers, letters,

adults can be trusted needs will be met children are valued

54 geomms HillsboroughCounty's Response: The Drug-Exposed Children'sCommittee am%

The Drug-Exposed Children's Committee (DECC) in HillsboroughCounty, Florida, investigated the needs of young childrenexposed.to alcohol and other drugs to see if modifications were neededwithin regular education/pre-school programs. An informal assessment was conducted in May 1989, to see if there werechildren in kindergarten Head Start and other pre-kindergarten programs who werethought to be drug-exposed, and to see the kinds of problems they were experiencing.Schools with "at risk" populations did have drug-exposed students and hypotheses weregenerated about possible problems.

A five year longitudinal study of children from three to six yearsof age is currently being implemented.If we are successful in validating our pre-K and kindergarten checkl is, for symptomatic behaviors, children will be selected for thestudy based on teacher observation. The Committee has developed a checklistof behavioral characteristics associated with prenatal exposure, compiled from data from LosAngeles City Schools, research, and our own observations. Drug exposure will bevalidated by a parent interview. Initial funding for the study isprovided by the University of South Florida Institute for At-Risk Infants, Children, and Their Families. Thenumber of children identified for study during the 1989-90 school year will be determinedby the level of funding received. Descriptive data will then be collected for all childrenin the study, such as screening test scores, promotion/retention data, teacher observations, etc., over a five year period of time.

This Committee is actively providing inservice to teachers and otherschool personnel to allay their fears of this problem, and to present current researchand information. A staff development component has been written to addressTeaching Strategies for Children Pre-natally Exposed to Drugs. The syllabus is beingdeveloped with September 1990, as a target date for offering the course throughthe Teacher Education Center for re-certification credit.

Source: Linda Delapenha, Member Drug Exposed Children's Committee (DECC) of Hillsborough County Supervisor, Primary Diagnostic Services Hillsborough County Schools, Florida

55 Operation PAR's Child Development and Family GuidanceCenter

Since 197I. Operation PAR hasaddressed the problems of drug andalcohol abuse in Pinellas County, Florida. OperationPAR's Child Development and FamilyGuidance Center provides innovative, comprehensive,community-coordinated services designed dependency. Working with to serve infants andchildren affected by parental chemical the local county health unit.pediatricians. child protection teams, stateprotective the program services, juvenile court services, andchemical dependency treatment teams, strives to prevent multigenerationalchemical dependence.

One component of the program is aspecial center serving children of twomonths to five years whose parents areserious drug abusers, especially parentsabusing cocaine. Tne children participate in a wide variety oflearning experiences designed to assessand develop their physical, emotional, social,creative, cognitive, language andself-help skills.

Infants and pre-school children areassisted to:

feel secure in a healthy and safeenvironment.

develop or enhance primary and trustrelationships.

nurture and grow in a positivesocial environment where satisfyinginterpersonal relationships can be developed through interactionwith peers and adults.

develop effective verbal and non-verbalcommunication skills.

improve self-concept and self-esteem.

improve perceptual motor activity.

express feelings and perceptions,and enhance creativity throughmusic, art, drama and dance therapy.

Each child is given a comprehensive screening todetermine his or her developmental competencies. Children who have indicatorsof serious development deficits arefurther All children tested in order to determine appropriateeducational and intervention plans. have personalized learning objectivesdeveloped with their parent(s) andongoing participate evaluation to determine progress towardmeeting individual goals. All parents potential skills and in seminars and educationalclasses designed to enhance their competencies. Development and Family For more information, callShirley Davis, Director, Child Guidance Center, (813) 896-2672.

56 Chapter 5

WHAT IS THE ROLE OF OTHERHELPING PROFESSIONALS?0..X108WWW,

Florida's Reporting Requirements

A Continuum of Services in Florida

Legal Issues Chapter 5 WHAT IS THE ROLE OF OTHERHELPING PROFESSIONALS?

Florida's new reporting requirements (see below)increase thelikelihood that prenatally- exposed children and their families will comeinto contact with a wide range of helpingprofessionals by the time these children reach school age.In Florida, sustained and systematic effort toassist high-risk children below age five is generally considered"early childhood intervention". Studiesshow that children affected by prenatal exposure toalcohol and other drugs are significantly helpedby early intervention designed to meet their particular needs.Such intervention is particularly effective when interagency cooperation and coordination of servicesexists.According to Samuel Meisels of the University of Michigan:

"...early intervention incorporates a host ofservices and service providers that cut across several disciplines andorientation...medicine, education, social work, social services, child care, respite care,public health,speech and language, occupational and physical therapy, nursing and psychology.Indeed, in order to achieve a thorough understanding of early intervention, one mustadopt a set of assumptions that emphasize this plurality."

Bothstate and federal governments havemadeearly intervention a priority through legislation which emphasizes the importance of timely andcoordinated care.Althoughsuch postnatal intervention is essential to preventing even greaterproblems, prevention is, of course, best achieved prior to me conception of the child throughactivities such as teen parent and dropout prevention programs and curriculum courses that buildself-esteem and healthy practices in future parents. Early childhood experts point outthat this kind of proactive education is the mostfundamental approach to the problem of substance abuse during pregnancy.

SUBSTANCE-EXPOSED NEWBORNS: FLORIDA'SREPORTING REQUIREMENT

Between 1963 and 1965, all fifty states enactedlaws requiring physicians and otherhealth care workers to reportknown or suspected child abuse to local protectiveservices departments. States receive federal funds contingent on theexistence of such statutes. In Florida, thedefinition of "child abuse" extends to instances in which anewborn has been exposed in the womb todrugs other than those administered as part of adetoxification program Cr in conjunction withmedically-approved treatment procedures. (FloridaStatutes, 415.503)

The means for reporting and referring newbornswhose mothers used drugs during pregnancy is specified in the Florida Departmentof Health and Rehabilitative Services (HRS)regulation 150-6: Substance Abused Newborns. Excerpts fromHRS Regulation 150-6 explain the procedure:

HRS Regulation 150-6: Substance AbusedNewborns

I. Purpose. This policy provides for a systemof identification, reporting and provision ofneeded services to drug or alcohol involvednewborns, and babies born to mothers who areaddicted to or abusing drugs or alcohol.

59 2. Effective Date. October15, 1988 Services shall be informed ofall newborn 3. Scope. The Departmentof Health and Rehabilitative have abused drugs duringthe childbearing infants who are born tomothers who are addicted to or period in the following manner:

Physically Drug DependentNewborn a. Report of newborn is physically drug (1) If anyone has reasonable causeto suspect that a suspicion must be of actual or threatenedharm exists, this knowledge or dependent or a situation 415.504 (1)). the FLORIDA ABUSEREGISTRY (required by F.S., reported immediately to Protective Investigation Unit (2) The abuse registry shallnotify the district Child investigation. The child protectiveinvestigator which will commence animmediate child protective conduct a separate homeevaluation and family will inform the countypublic health unit which will assessment. Substance Abuse Concerns. b. Referral of Other AtRisk Newborns with Related harm suspected, If no child abuse is threatened,physical drug dependency or newborn or family, the attendinghealth professional but there is a substanceabuse concern with the health unit for a family assessmentand service should make a referral tothe district or county public of the client is required forthis referral. provision through the districttelephone network. The consent families will be assumed by thepublic health The primary responsibilityfor the health care of these nurse.

4. Explanation of Terms in which a child's physical,mental a. Child Abuse.This team refers to situations with harm by the acts oromissions of a parent, and emotional well-beingis harmed or threatened institutional staff; it includessexual abuse.(F.S., other person responsiblefor the child's welfare or 415.503 (3)) authorized agent located Child Protective Investigator(CPI). The department's b. protection investigations of the state and responsiblefor conducting child in each district within parent or other personresponsible for allegations that children havebeen abused or neglected by a staff. their welfare or institutional injury of a newborn Children. This term includes,but is not limited to an c. Harm to drugs and infant's being born physicallydependent on certain controlled infant evidenced by that shelter, failure of a parent to supply achild with adequate food,clothing, actual or potential offered financial or other means todo so. (F.S., supervision or health care,although financially able or 415303 (8)) manager, who isusually the d. Health Care CaseManager. The health care case referrals, follow-up, monitoring,education, public health nurse,plans and provides nursing care, other activities necessary toenhance the wellbeing of thefamily. counseling and coordinates network is the system for e.District Telephone Network.The district telephone directly from health careproviders and child receiving referrals ofsubstance-abused newborns that every hospital and birth centerhas the protective investigators.Each district should ensure district or in some areas, the countypublic health appropriate telephonenumber for referrals to the maintain a plan for timelyreferral to the county public health unit. The districtoffice shall establish and unit.

60 newborn is Dependent Newborn. Aphysically drug dependent f. Physically Drug abnormal neurological patterns or, 28 days of age whoexhibits abnormal growth or, an infant under documented evidence thatthe mother used abnormal behavioral patterns,and for whom there is Documented evidence forthis condition is:Admission Schedule I or II drugsduring her pregnancy. maternal drug screenduring pregnancy or the by the mother of drug useduring pregnancy, a positive early postpartum period or apositive newborn drug screen. to suspect that a g. ReasonableCause to Suspect.Indicators for reasonable cause dependent are: newborn is physically drug is using drugs. Thisshould 1. Directly observing the pregnantwoman while she be by a relative, householdmember or other reliable source.

2. Admission by the motherof drug use during pregnancy.

3. A positive drug screenof the newborn. period. 4. A positive maternal drug screenduring pregnancy or the postpartum FLORIDA ABUSE REGISTRY'S h. Reports to the FLORIDAABUSE REGISTRY. The utilized for the reportingof all suspected child statewide single number(1-800-96 ABUSE) should be abuse or neglect.

REPORTING AND REFERRINGSUBSTANCE- ABUSEDNEWBORNS THE REPORTING AND/ORREFERRAL OF SUBSTANCE ABUSED NEWBORNS

REQUIRED ABUSE AND RF.COMMENDED REFERRAL. NEGLECT REPORT FOR FOR AT RISK INFANTS DRUG DEPENDENT NEWBORN HOSPITAL or Other Place of Birth

DIS1RICTI TEL,. NETWORK

CHILD cPHU FLORIDA PROTECTIVE 111.1C REALM NURSE ABUSE INVESTIGATOR REGISTRY

GUIDE: CPT Child Proistuan Team PS Pesiactiva Services VES Voissramy Family Supra AFDC Aid to Families with Depandiet Ouldree DS Developwrieal Service( CMS Osibleen's Medical Same: COM A.D.MCamenunity Alcohol. Drugs and Mensal Ilsaldi CPI RI. Cuomo, public heath mu VS Yakima Services Source: Florida Department of Ilealth and Rehabilitative Services

61. A CONTINUUM OF SERVICES IN FLORIDA ..140011.1010~~A~INOWOMM.444.K.MVA.:.**".14.*:l4C.W.NOKOX:lt.X1`,NON.X44C.X.34CW:::::**X1V.40,6(.00:<.:X

Increasingly, legislators and citizens are turning to prevention as a solution to many social problems. Such is the case with Florida's 1986 Handicap Prevention Act, which asserts that 50 percent of handicapping conditions in young children can be prevented or minimized by "focusing preventive efforts on high-risk pregnant women and high-risk and handicapped young children, in the formative years of 0 toy, and their families"(F. S., 411.102). Interagency and intraagency programcoordination are seen as indispensible means of achieving this goal.

The Act directs the Departments of Education (DOE) and Health and Rehabilitative Services (HRS) to work together to identify and refine a continuum of early assistance services that contribute to the prevention of handicapping conditions in young children. The resultis Florida's Handicap Prevention Report, which, among other things, describes a full array of prevention and intervention services currently provided at the state and local levels. As such, it is an extremely valuable resource for educators and other helping professionals working with drug-involved parents and prenatally- exposed children.

The Continuum of Services

The continuum of preventive and early assistance services described in Florida's Handicap Pre- vention Report serves as a guide for a comprehensive statewide approach to services for high-risk pregnant women and for high-risk and handicapped children and their families. The continuum includes the following categories of services:

1. Education of the Public and Professionals 2. Family Support Services Prior to Pregnancy 3. Maternity and Newborn Services 4. Health Services for Newborn Children 5. Early Intervention, Education and Related Services for High-Risk and Handicapped Preschool Children 6. Support Services for High-Risk or Handicapped Children and Their Families

Definition of High-Risk Children

Beginning July 1, 1989, the definition of the "high-risk" or "at-risk" child was broadened as part of the Florida Prevention, Early Assistance, and EarlyChildhood Act (CSHB), a major rewrite of the Handicap Prevention Act (F.S. 411). In relation to prenatal substance exposure, a "high-risk" or "at-risk" child means a preschool child who: - is a victim or asibling of a victim in a confirmed or indicated report of child abuse and neglect. - is a graduateof a perinatal intensive care unit. - has a parent or guardianwho is developmentally disabled, severely emotionally disturbed, drug- or alcohol-dependent, or incarcerated and who requiresassistance in meeting the child's developmental needs. - has no parent orguardian. - is drug-exposed. (F.S., 411.201-205)

62 For More Information

To obtain a copy of Florida'sHandicap Prevention Report orfurther information contact:

B.C. Parker Program Specialist - Infants andToddlers Office of Early Intervention Department of Education Tallahassee, Florida 32399-0400 (904) 488-6830 Sun Com: 278-6830

Diane Lincoln Prevention Coordinator Office of Program Policy Development Department of Health and RehabilitativeServices 1317 Winewood Boulevard Tallahassee, Florida 32399-0700 (904) 488-2761 Sun Com: 278-2761

LEGAL ISSUES

The following is excerpted from a paperentitled "Drug Addiction, AIDSand Childbirth: points to the difficulty in Legal Issues for the Medical and SocialServices Communities". The paper The authors balancing the rights of the pregnant woman,the unborn child, and society atlarge. emphasize the role of the medical communityin the prevention of substanceabuse during pregnancy, and in early intervention withaffected children:

Clearly, there are many new legal issuesemerging as a consequence both of the largenumber of women who abuse drugsthrough pregnancy and of the AIDSepidemic.[This paper's] purpose is to focus attention on the conflicting interestsand rights involved and to offer some concrete ideas as to howthese interests might be balanced.

In sum, although the state courtshave granted unborn children some rights in other contexts, anyattempt to grant unbornchildren greater protection againstactions taken by their mothersduring pregnancy will be subject tostrict scrutiny. Only very narrowlytailored restrictions on maternal conduct with theminimum intrusion necessary will have any chance of survivingconstitutional challenge...Moreover, before any legal action is taken, themedical community must consider it whetherstate intervention willreally serve the purpose for which would be designed or whether itwould simply deter pregnant women from seeking any prenatal care.Attention must also be given to

63 ensuring that there are adequatedrug and alcohol treatment centers before any mandatory treatment isinitiated.

In the meantime, states should moveahead to strengthen child abuse and neglect reporting requirementsand to extend them to infants born drug dependent. Sanctions forwillful failure to diagnose and report drug dependency among newbornsshould be considered. At the same time, greater protections must begiven to the mandatory reporters to ensure that they will bewilling to provide all of the informationneeded by state agencies to act on the reportsreceived.

The medical community should take greatersteps to advise women of the consequencesof actions taken .during pregnancy. Brochures should be developed to give toall women who come in for prenatal care which describe the consequencesof continued drug and alcohol use during pregnancy.If a woman cannot read the brochure, someone should read it toher.By informing the woman of the consequences of her conduct,the physician will be limiting his or her liability.

Physicians and hospitals must also developprotocolsfor obtaining informed consent of a parent orlegal guardian before drug tests are run on newborns andfor reporting cases of infants born drug dependent.

Source: Walter B. Connolly, Jr. andAlison B. Marshall Miller, Canfield, Paddock and Stone 2500 Commerce Building Detroit, Michigan 48226 (313) 963-6420

64 Chapter 6 I

WHAT RESOURCES ARE AVAILABLE TO AID THE HELPING PROFESSIONAL? ....

Hotlines

Sources for Information, Consultationand Training

Selected Bibliography Chapter 6 WHAT RESOURCES ARE AVAILABLETO AID THE HELPING PROFESSIONAL?

HOTLINES

Cocaine Baby Help Line, 1-8(X)-327-BABE, in Indiana,Michigan, Minnesota, Missouri, Wisconsin, Kentucky. Outside these states, call (312) 908-0867.

1-8(X)-COCAINE, 24-hour toll-free information and referral service.

SOURCES FOR INFORMATION, CONSULTATION, ANDTRAINING

AIDS Project, Prevention Center, Office of Policy Research andImprovement (OPRI), Florida Department of Education, 414 Florida. Education Center, Tallahassee,FL 32399 0444, (904) 488-7835, SunCom 278-7835. Contact: Mae Waters, Director,AIDS Project.

Alcohol and Drug Abuse Program, State of Florida Department of Healthand Rehabilitative Services (HRS), 1317 Winewood Boulevard, Tallahassee, FL 32399-0700,(904) 488-0900, SunCom 278-0900. Contact: Terri Goens, Senior Human ServicesProgram Specialist.

Arnold Palmer Hospital for Children and Women, 92 West MillerSt., Orlando, FL 32806, (407) 841-5111 ext. 6029. Contact: Dr. Frank A. Lopez, Assistant Directorof Medical Education, and Specialist in Development, or Dr. Robert L. Maniello,Co-Director of Newborn Nursery, and Director of Ambulatory Pediatrics.

Children's Home Society of Florida, 370 Office Plaza,Tallahassee, FL 32301, (904) 877-5176. Contact: John Haynes, Director.

Department of Health and Rehabilitative Services(HRS), State Health Office, Family Health Services, 1317 Winewood Blvd., Tallahassee, FL 32399- 07(X),(904) 487-1321. Contact: Donna Barber, Director.

Drug-Exposed Children's Committee, Hillsborough CountySchools, 411 E. Henderson Ave., Tampa, FL 33602, (813) 272-4577, SunCom 547-4577.Contact: Linda Delapenha, Supervisor, Diagnostic Services, Hillsborough County Schools.

Drug-Free Schools Program, Prevention Center (OPRI), FloridaDept. of Education, 414 Florida Education Center, Tallahassee, FL 32399-0444, (904) 487-8771,SunCom 278-8771. Contact: Nancy Fontaine, Director, Drug-Free Schools Program.

The Family Center, Thomas Jefferson UniversityHospital, 11th and Chestnut Streets, Suite 6105, Philadelphia, PA 19107, (215) 928-8850. Contact: Terry Hagen.

67 Pregnancy Project , 180 Educational Research andDevelopment, Drug-Free Far West Laboratory for 331-5277. Contact: Diana Kronstadt. Harbor Drive, Suite 112,Sausalito, CA 94965, (415) North Paul Russell Road,Tallahassee, FL 32301, Florida Alcohol and DrugAbuse Association, 1286 (904) 878-2196. Contact:Cindy Colvin. Dependent Families, UCLA Interdisciplinary Training forProfessionals Serving Chemically Avenue, Los Angeles, Department of Pediatrics, 23-10Rehabilitation Center, 1(XX) Veteran Investigator. Contact: Vicki CA 90024-1797, (213) 825-4622.Dr. Judy Howard, Principal Kropenske, Project Director. Petersburg, FL 33709, Juvenile Welfare Board of PinellasCounty, 4140 49th St. N., St. (813) 521-1853. Contact: KateHowze, Community RelationsSpecialist. Department, 1275 Mamaroneck March of Dimes Birth DefectsFoundation, Community Services Avenue, White Plains, NY10605, (914) 428-71(X). Seealso local chapters. Education (NAPARE), 11 E.Hubbard National Association forPerinatal Addiction Research and Eileen Ward (for scheduling) St. Suite 200, Chicago, IL60611, (312) 329-2512. Contact: or Pat O'Keefe(public information). Office Box 2345, Rockville,MD National Clearinghouse for Alcoholand Drug Information, Post 20852, (301) 468-2600. CA 900()7, (213) 731-0703. Salvin Education Center, 1925S. Budlong Avenue, Los Angeles, Contact: Gayle Sadofsky,Principal.

Snowbabies, Inc. P.O. Box162856, Altamonte Springs, FL32716-2856, (407) 331-5577.

SELECTED BIBLIOGRAPHY M.Y3C:*:.,,,F,OM.N...... :44.14.N...3.:}XITS.W.41*tio.X.:44.X..K..:0~....7.1,0:*C.:00011.1t. 3.1.:***X41.4140NOPPNOMMICW4034010001414MOMMIWOK704~XONVADOOON.:44WASVAVni,XWAVNJX....::<:iMIVAti. mothers: Profile Amara, H., Zuckerman, B.and Cabral, H. (1989, July).Drug use among adolescent of risk. Pediatrics, 84,144-150. Maternal cocaine use: Neonatal outcome. Chasnoff, 1. and Griffith, D.(1990; exact date pending). Company. Theory and Research in BehavioralPediatrics. Plenum Publishing

A. Drug addiction, AIDSand childbirth: Legal issuesfor the medical Connolly, W. and Marshall, Paddock and Stone, 25(X) and social service communities.Available from: Miller, Canfield, Comerica Building, Detroit, Ml48226, (313) 963-6420.

alcohol syndrome: implicationsand counseling Elliott, D.J. and Johnson,N. (1983, October). Fetal considerations. The Personneland Guidance Journal,67-69.

the fetus. Exceptional Children,49, 30-34. Furey, E. (1982, September).The effects of alcohol on

68 I Ioward, J., Kropenske, V. and Tyler, R. The long-termeffects on neurodevelopment in infants exposed prenatally to PCP. National Institute on Drug Abuse, ResearchMonograph Series #64.

Howard, J. (1989, January). An approach to early intervention:Birth to 3 years. Infants and Young Children, 1, 77-88.

Howard, J., Beckwith, L., Rodning, C. and Kropenske, V. (1989, June). Thedevelopment of young children of substance-abusing parents: Insights from seven years of interventionandresearch. Zero to Three, 2, 8-12.

Kronstadt, D. (1989, March).Pregnancy and cocaine addiction: An overview of impact and treatment. Far West Laboratory for EducationalResearch and Development, Sausalito, CA.

Lewis, K.D., Bennett, B., Schmeder, N.H. (1989, Sept/Oct). The care of infantsmenaced by cocaine abuse. MCN, 14, 324-329.

McCracken, J.B. (1986). Reducing stress in young children's lives. National Associationfor the Education of Young Children, Washington, D.C.

Meisels, S. (1989, July). Meeting the mandate of public law 99-457: Early childhood interventionin the nineties. American Journal of Orthopsychiatry, 59, 451-459.

Mendelson, J. and Mello, N. (1985). Alcohol: Use and Abuse in America. Little, Brown andCompany, Boston.

Miller, G. (1989, June). Addicted infants and their mothers. Zero to Three, 9,20-23.

Rogan, A. (1985, Fall). Issues in the early identification, assessment and managementof children with fetal alcohol effects. Alcohol Health and Research World, 10, 66-67.

Ronan, L. (1985, Fall). State strategies for prevention of alcohol-related birthdefects. Alcohol Health and Research World, 10, 60-65.

Schneider, J. and Chasnoff, I. (1987, July). Cocaine abuse during pregnancy:Its effects on infant motor development A clinical perspective. Topics in AcuteCare and Trauma Rehabilitation. 2, 59-69.

Schneider, J., Griffith, D. and Chasnoff, I.(1989, June). Infants exposed to cocaine in utero: Implications for developmental assessment and intervention.Infants and Young Children, 2, 25-36.

Shaywitz, S., Cohen, D., and Shaywitz, B. (1980, June). Behavior and learningdifficulties in children of normal intelligence born to alcoholic mothers. The Journal of Pediatrics, 26,978-982. of Health and RehabilitativeServices. State of Florida Departmentof Education and Department Prevention Report. Officeof Program Policy Development, (1989, April). Florida's Handicap lahassee, Department of Health andRehabilitative Services, 1317Wi ne wood Boulevard, Tal FL 32399-0700.

Barr, H.M., Sandman, B.M.,Kirchner, G.L. and Darby,B.L. Streissguth, A.P., Martin, D.C., and reaction time in 4-year-old (1984). Intrauterine alcohol andnicotine exposure: Attention children. Developmental Psychplggy,20, 533-541. behavioral effects in children Streissguth, A.P. and LaDue, R.A.(1985, Fall). Psychological and World, 10, 6-12. prenatally exposed to alcohol.Alcohol Health and Research

R., Amaro, H., Levenson, S.,Kayne, H., Parker, S., Vinci,R., Zuckerman, B., Frank, D., Hingson, (1989, March 23). Effects of Aboagye, K., Fried, L., Cabral, H.,Tim peri, R. and Bauchner, H. Journal of Medicine, 320, maternal marijuana and cocaine use onfetal growth. New England 762-768.

70 APPENDIX A: SELECTED RESEARCH ARTICLES

711 " NAPARE A First: National HospitalIncidence Survey National Association for Perinatli Addiction Researcn 11 E. Hubbard St.. Suite 200 Chicago, IL 60611 Substance abuse in pregnancy is maternal-fetal medicine in each (312) 329.1512 one of the most commonly missed of hospital. all obstetric and neonatal diagnoses. Initially, we found the overall Prj.;:1,01 according to the first national incidence of diagnosis of substance hospital incidence survey conducted by abuse in the 36 hospitals was II Ai National Association for Perinatal percent with a range of 0.4 percent Addiction Research and Education to 27 per cent; Chasnoff said 'To (NAPARE). As many as 375,000 find the reason for this wide varia- He pointed out that if one or infants may be affected each year, tion, we examined the results in more children in every ten bora are said Ira J. Cbasnoff, M.D., relation to the proportion of public affected by their mothers' substance President of NAPARE. aid patients. We found the rates abuse during pregnancy, the impact In a keynote address to a na- were similar in all the hospitals, on health care. social services, and tional training conference on drugs, so this did not explain the differ- public education would be dramatic alcohol, pregnancy and parenting owes.' (See Table 1) and costly. which was held in New York City The researchers then categorized Among' the 36 hospitals, nine had August 28 to 31. Chasnoff said, the hospitals according to the thor- conducted formal studies of the in- *Many of these cases are unrecog- oughness of the substance abuse as- cidence of illicit drug use in preg- nized until after birth when the sessments conducted during prenatal nancy. (See Table 3) baby is born addicted, often with or perinatal period. The hospitals severe physical or neurological were divided into three groups: damage' This lack of recognition, those at which no assessment by Hospitals Interviewed for NAPARE he said, accounts for the high rate history or mine tcaicology was Incidence Survey of infant morbidity and mortality in conducted during or after preg- Allevart Cesare liesmisL ritutwo. r these infants. nancy; those that had a policy that 111m1 bred Medical Cutter. New You. S'Y all pregnant women would be ques- Reese Cep Messrs& Demos. MA COMW.°Impede Howe. Cetsee. ft. Major Conclusions: tioned about substance abuse, but Chases Miesmal. Mersa. DE did not have an established proto- &lessees. Hew& Poetised OR Epees's' MespootaL Flasetipee.PA I. The high rate of pregnancies or col and did not monitor compliance; Emmet Nowa Emsocet. births in which drugs are present is and hospitals that had a protocol Hares Metteek Mee YOtL !4Y Islam Menem' Mapusl, Meat. Ft not confined to the largest urban for assessing every pregnant woman Jeff paw MespiaL Hemet TX areas; the rate is similar in hos- and/or newborn for substance abuse JeeweY HRWRISL S. Lem MO Jeer lieptees Mepes/ Itaiuwen. pitals across the country. or exposure. (Sec Table 2) Kee Cleary Itimena iteeehe 2. The high rate is not confined to ChasatAT said. in this phase of Mane West Keg Hwptal. Lou ANttlel. CA the study, we found that the inci- Men Heeptet. Radek Caster. "I'Y hospitals with high rates of low kftrnabra Mssesesi Heepetai. Manna. CA income or public aid patients. dence ia hospitals with established Neursestera Memssisl liestesk Cheap. n. Hospitals with small or moderate protocols and monitoring was three Oliabesss Hull C. Okla'.. Om OK Chew Hula Seism Ussesrecy Howe. For-Atte. :.!ct rates of public aid patients to five times greater than in the Pa used. Heiteal. OsIka TX reported an incidence of substance two groups of hospitals with no Pee wees's Hespeel. PtiorlelMia. PA Reitotal Magma Owe, Meopir. Tm abuse similar to hospitals with monitoring or incomplete monitoring. IteseiTtesbeensedl. Lake's Matetal. agar& IL greater than half their patients on The number of public aid patients St. Elislietb's Hass& Ream MA was sot a factor.' St. Rues Flteptel Pittebst PA public aid. SI. Lee +Assam. Fleessusl Crest. `fee Vett. Pr 3. The incidence reported by each The substances included in the St. Matteters Hammel fur Wanes. Bettes. MA hospital correlates with the thor- sunny were heroin, methadone, Set IMMO* GssuraL Set teressa. CA UNA 4t.upl. G.L.eser Pt. oughness with which the hospital cocaine, amphetamines, PC?, and Stesised Useenry liespost. Snaked, CA staff screens and/or tests pregnant resetes hams Uswereim Meassue FIrlatleIeue PA Tiede Me w& Toledo. OH women patients. The results of the study, Useermy of Calker Wee Meseni. Sseresgetee Ct. Included in the study, which was Cbasnoff said, mean there is an thwerteet d Tesiesiss Medial Ciao. Kneseat. funded by pants from the Office for urgent. need for physicians, curses, *ease lad Islam titarpsal. Preseieses. RI Substance Abuse Prevention (OSAP) social workers, and other health and the March of Dunes Birth Defects care professionals to establish protocols for early recognition of Foundation. were 36 hospitals from The study trim supported by grams from the substance abusing woman and for across the country, accounting for the Office for Substance Abuse Prevention providing treatment and interven- 134,856 births. The responses were (OSAP) and the March of Dimes Birth supplied by the chairman of obste- tion programs for both mothers and DefectsFOUIWINSOIL. trics, pediraies, neonatology, or their children. 4

BEST COPY AVAILABLE Infants exposed to cocaine in utero: Implications for developmental assessment and intervention

Findings of developmental assessment in the newborn and early infancy periods are presented. The implications of abnormal state control and orientation as well as dysfunction in motor control are discussed as the basis for intervention. Intervention in the newborn phase includes information on positioning, handling, and feeding. Parent education to improve the infants' ability to interact with caregivers is emphasized. Improving the infants' movement patterns through play, carrying positions, and handling techniques is the focus of intervention in infancy. While intervention with cocaine-exposed infants is presently possible, these children should be followed by health care professionals through preschool and early school years to identify any behavior or learning disorders that may be associated with intrauterine cocaine exposure.

II Jane W. Schneider, MS, PT DRUG ABUSE in the United States is begin- Assistant Professor ning to be recognized and acknowledged as Northwestern University Medical School a significant societal problem. The use of cocaine Programs in Physical Therapy and its derivatives occurs in all segments of US Senior Physical Therapist society regardless of race, ethnicity, or socioeco- Childrens Memorial Hospital nomic status. Furthermore, cocaine use during Chicago, Illinois pregnancy is no longer an unusual phenomenon. In Dan R. Griffith, PhD fact, it appears to be increasing." A recent study by Developmental Psychologist the National Association for Perinatal Addiction Perinatal Center for Chemical Dependence Research and Education4 surveyed 36 hospitals Clinical Associate around the country and found that at least 1196 of Department of Psychiatry and Behavioral women in the hospitals studied had used illegal Sciences drugs during pregnancy. Based on those figures, an Northwestern University Medical School Chicago, Illinois estimated 375,000 newborns per year face health hazards from their mothers' prenatal drug abuse. Ira J. Chasnoff, MD Specific hazards of prenatal cocaine use include Associate Professor of Pediatrics and Psychiatry increased rates of spontaneous abortion, abruptio and Behavioral Sciences placentae, intrauterine growth retardation, and in- Northwestern University Medical School utero cerebrovascular accidents. Attempting to Director determine the impact of prenatal cocaine exposure Perinatal Center for Chemical Dependence Chicago, Illinois on development, however, is a complex issue. Many women whose drug of choice is cocaine are abusers of other drugs as well.Itis often difficult to ascertain the frequency and amount of drug use. It is also acknowledged that the infant's environment as well as prenatal exposure to drugs will have a profound effect on subsequent development. Cur- rently, data from both a research and an empirical

The research on which this article is based was supported by a grant from the National Institute on Drug Abuse, National Institutes of Health (DA04-103.01). Inf. Young Children, 1989, 2(1), 25 -36 ©1989 Aspen Publishers, Inc. L 25 BEST COPY AWAKE 26 INFANTS AND YOUNG CHILDREN/JULY 1989

perspective are being gathered to help clarify the the physiologic effects of cocaine on the adult have only now effects of prenatal cocaine exposure. been well documented,' researchis American society has begun to more readily showing that the same and perhaps more severe acknowledge drug abuse. Health care professionals effects may be experienced by infants exposed to can now begin to gatherinformation concerning cocaine in utero. development following prenatal drug exposure, and at the same time begin appropriateintervention on DESCRIPTION OF THE behalf of exposed infants. This article describes COCAINE-EXPOSED INFANT motor development of cocaine-exposedinfants, the impact on other areas of development during the As health care professionals encounter more newborn and early infancy stages, and intervention newborn infants exposed to drugs prenatally, the strategies appropriate for cocaine-exposed infants initial taskis to identify drug-exposed infants. and their caregivers. Withdrawal syndromes are well-documented in infants born to heroin-addicted mothers; however, COCAINE: PROPOSED MECHANISMS some controversy exists concerning the presenceof OF ACTION IN UTERO a cocaine withdrawalsyndrome." Whenever prenatal exposure to drugs is suspected, urine toxicology The placenta does not protect the fetus from screens of both mother and infantshould be cocaine exposure. Cocaine readily crossesfrom performed. Common clinicalsigns of prenatal maternal to fetal circulation and may remain in the cocaine exposure include hyperirritability, poor infant's system long after it has been excreted by feeding patterns, high respiratory and heart rates, the mother because immature liver andkidneys increased tremulousness and startles, and irregular metabolize the cocaine more slowly. As cocaine is sleeping patterns." Relating these signs to a with- metabolized, it is broken down into norcocaine, a drawal syndrome may be a misnomer, since the highly active metabolite with a high level of infant may in fact still be experiencing the direct penetration into the central nervous system (CNS). effects of cocaine exposure. Al so, because some of of Because norcocaine is water soluable, it does not these effects persist beyond the first few weeks readily pass back into the mother's systemfor life, they may be indications of a more lasting CNS excretion. It is theorized that an infant may con- change rather than a withdrawal pattern. tinue to be exposed to cocaine and its active Full-term cocaine-exposed infants have been metabolites by reingestion of norcocaine through tested as newborns and at one month of age using the amniotic fluid.5 the Brazelton Neonatal Behavioral Assessment Cocaine acts centrally on the CNS as a stimulant Scale." Infants at both ages show depressed interac- compared while peripherally causing vasoconstriction, tachy- tive abilities and poor state control when ages.2.1"6 While cardia, and a rapid rise in blood pressure." These to drug-free infants of the same physiologic effects are thought to occur in both these behavioral characteristics are not unique to mother and fetus, and therefore may explain in- cocaine-exposed infants, they have been noted as that describe a creased rates of spontaneous abortion, abruptio part of the cluster of characteristics placentae, and in-utero cerebrovascular accidents large percentage of these infants. 1.2.9.10 associated with cocaine use during pregnancy. Beyond the newborn period, the Movement Documentation of specific CNS damage has been Assessment of Infants (MAI)" has been used to reported by Dixon and Bejar" on a sample of 28 assess motor developmentof full-term cocaine- cocaine-exposed infants. They found that 3956 of exposed infants at four months of age.This test was and a that sample showed hemorrhagic cerebral infarcts chosen since it provides both a quantitative documented by cranial ultrasound at birth. While qualitative assessment of motor development in the Infants Exposed to Cocaine in liter° 27

first year of life. Ongoing results of research suggest however, do not show organized behavior states or that many symptoms noted on the Brazelton exam- smooth state changes, but rather tend to change ination in the newborn cocaine-exposedinfant rapidly from one extreme stare (eg, deep sleep) to remain at four months of age on theMA1.18" For another (eg, frantic crying). example, frequent tremors, especially in the upper Four common behavioral patterns have been extremities, are still noted at four months of age. observed clinicallyin newborn cocaine-exposed These infants display increased extensor muscle infants.1"6 Some infants, in response to any sort of tone. especially in the lowerextremities. Primitive stimulation, will pull themselves down into a deep reflexes normally integrated by four months are sleep. These infants will not awaken in response to often still present. Using previously establishedrisk handling of any sort. While this is a protective categories, approximately 40% of the cocaine- mechanism for their fragile nervous system,it exposed infants studied were designated "high risk" precludes any caregiver-infant interaction. for motor developmental dysfunction as opposed A second pattern presents as an agitated sleep to 2% of a control group(JW Schneider and If state. These infants seem stressedby external Chasnoff, unpublished data, 1989). This means that stimulation (as evidenced by startling, color changes, cocaine-exposed infants were approximately 40 whimpering) but do not wake up to attend to the times more likely to be designated "high risk"for stimulation. motor developmentaldysfunction than nonex- Newborn cocaine-exposed infants demonstrate a posed infants.18" third behavioral pattern by vacillating between Preliminary results of eight-month-old cocaine- extremes of state (sleeping or crying)during exposed v nonexposed infants suggest that while handling:J16 For example, when unwrapped from a motor abnormalities have lessened bythis age, they blanket they immediately cry and show agitation, have not totally disappeared. Some of the cocaine- but when wrapped up again, they quickly fall exposed eight-month-old infants, while able to asleep. crawl, were slow in moving, and stood bearing The fourth common behavioral pattern resem- weight on their toes with stiff extension of their bles a panicked awake state.".16 This is seen in an lower extremities. Future studies are needed to infant who can achieve an alert state for short document motor development of cocaine-exposed periods but appears quite stressed while doing so infants in the first year of life and beyond. and requires a lot of help from the caregiver to stay calm. DEVELOPMENTAL IMPLICATIONS OF The descriptions of these four behavioral states COCAINE EXPOSURE make it clear that many newborn cocaine-exposed infants may be initially incapable of responding State control appropriately to their caregivers. Because they have The physiologic effects of cocaine on the new- such difficulty reaching and maintaining an alert auditory or born nervous system make state control difficult. state, their abilities to attend to either Newborns have a variety of behavior states avail- visual stimuli may be quite limited. Those cocaine- exposed infants who do reach alert states usually able to them and cycle through periods of sleeping (deep or light sleep), wakefulness (drowsy, quiet need outside assistance to stay calm, and then only of alert, active alert), and crying." It is expected that attend to a stimulus briefly before showing signs newborns will spend some time in each of these distress such as gaze aversion, increased respira- behavioral states, that they will move smoothly tions, or disorganized motor activity.'5'I6 from state to state, and that as they grow they will The reciprocity normally present in the process spend more time in quiet alert states and less time of bonding may be very difficult for theseinfants.'" sleeping or crying. Many cocaine-exposed infants, Thus if inadequate behavioral interaction between 28 INFANTS AND YOUNG CHILDREN /JULY 1989

infant and mother results, it places their relationship stiffness in their lower extremities prevents them at risk, since studies have shown that the behavior from exploring their lower body either visually or of the newborn affects the caregiving he or she with their hands. Visual and tactile exploration of receives.2225 In effect, a negative cycle may be set up body parts are important in the development of in which the behavior of the poorly organized. body image and contribute to the ability to move high-risk infant may suppress the optimal caregiv- well in the environment (ie, motor planning). ingpattern necessary tofacilitatehisor her The increased extensor muscle tone noted in the recovery.24'2' The feelings of frustration and inade- supine position is noted in other positions as well. quacy that parents may experience in dealing with Many cocaine-exposed infants display an exagger- their fragile yet unresponsive infants may predis- ated positive support reaction when held in an pose them later to physical child abuse, as has been upright position." This reaction is characterized seen in other high-risk infant groups' by stiff extension of hips, knees, and ankles and weight bearing on the toes. This type of standing Motor behavior posture encourages abnormal alignment of the body parts and would impede development of Looking beyond the newborn period to the age appropriate balance control. of four months, it is important to remember some The above descriptions of the motor abilities of of the key characteristics of normal four-month-old some cocaine-exposed infants suggest that they are motor behavior. When supine, four-month-olds are mildly hypertonic infants with dystonic movement very active. They can reach out easily to midline and patterns. It is important that health care profession- finger one hand with the other. The infants' lower als oe able to identify these characteristics in the extremities are also very active. They can flex and cocaine-exposed infant and understand the effect of extend their legs and kick reciprocally. The infants any detected behavioral or motor abnormalities on flex their legs in order to begin playing with and later development. Health care professionals can exploring their knees and feet. This is an important also provide appropriate intervention to mother and part of learning and contributes to the proper infant both before and after birth. development of body image. Flexibility is a key descriptor of four-month-old motor development. They are developing control of both the flexor and INTERVENTION extensor muscle groups without being dominated by either one. Even though a four-month-old Intervention will be addressed by considering the cannot stand independently, when held in sup- infant's developmental phases from before birth ported standing this flexibility is seen by a relaxed through infancy. Within each phase, the focus is on standing posture that incorporates both flexor and enhancing infant development, and intervention extensor muscle control. with parents will be addressed from this viewpoint. The flexibility so evidentinnormal four- month-old motor behavior is often less apparent in some cocaine-exposed infants. When supine, these Prenatal program infants often lie in excessively extended postures, Drug abuse programs now exist in most major and movements of their extremities may be jerky cities across the country. Programs for the pregnant and stiff." While they do reach out for objects, addict, however, are less prevalent. As awareness of the presence of tremors in the upper extremities the problem increases, programs such as the Perina- may have an impact on their development of good tal Center for Chemical Dependence (PCCD) at eye-hand coordination. Many cocaine-exposed in- Northwestern University Medical School in Chi- fants are less able to round their buttocks off the cago, Illinois, should become more available to supporting surface or kick reciprocally." This drug-abusing pregnant women. Infants Exposed to Cocaine in Utero 29

The PCCD is a comprehensive program staffed the infant freedom to move within the posture. by a number of medical personnel, including Covering the infant with a blanket tucked in on physicians, nurses, a developmental psychologist, a each side of the mattress will help maintain this physical therapist, a social worker, and drug depen- relaxed posture and thus encourage a more relaxed dency counselors. The PCCD provides prenatal and behavioral state. postnatal addictive care, obstetric care, and psychological care, as well as pediatric care for the infant. Handling There is a heavy emphasis on education throughout A caregiver's first impulse might be not to handle the program, including topics such as Lamaze the cocaine-exposed infant for fear of setting off training, family planning, nutrition, having a healthy irritable response from the hypersensitive infant. baby, parenting, infant-toddler series, a woman's However, proper handling is essential to help the issues and the law. It is hoped that programs such as infant improve state control and appropriate motor this will provide more information about the effects patterns. Initially an infant may need to be swad- of drug exposure on infant development while dled in a blanket in a semiflexed position. The providing comprehensive care for those who seek warmth from the blanket appears to cause inhibi- it. tion of motor behavior.'9 In addition, the flexed position breaks up the extensor tone, decreases Newborn phase tremors and overshooting, and facilitates normal The therapeutic techniques described below were hand-to-mouth activity. In conjunction with swad- chosen to address the specific needs of the cocaine- dling, slow rocking may be necessary to calm the exposed infant." These same techniques would be infant. Studies have shown that such vestibular equally appropriate for any infant who displays proprioceptive stimulation frequently has the imme- similar clinical manifestations. The overall interven- diate effect of arresting crying, reducing irritability. tion goals of this period are to increase periods of and bringing the infant to a visually alert state.'° alertness so that appropriate infant-caregiver inter- This produces a sense of effectiveness in the actions can occur. This broad goal can be accom- caregiver that encourages social interaction. plished by meeting each of the subgoals listed in While vestibular-proprioceptive input appears to Table 1. have a strong effect on the infant's motor control, other forms of slow rhythmical input (eg, visual, auditory, tactile) could be used to "pacify" the Positioning infant.' Once the infant has become calm, he or she Even in the newborn nursery, cocaine-exposed can be held in the en face (face -to -face) position to infants can be positioned to improve their posture encourage visual tracking, vocalization, and playful and movement patterns. The infant can be posi- interaction with the caregiver (Fig 2). Initially, this tioned on hisor herside to overcome both face-to-face interaction may be brief, since cocaine- increased extensor tone and the effects of gravity. exposed infants often have difficulty processing The spine, including the head, should be flexed, complex combinations of stimuli such as looking at bringing the infant away from the hyperextended the mother's face and listening to her voice at the position (Fig 1).28 Upper extremities should be same time. The infant may signal this sensory protracted at the shoulder girdle to encourage overload by crying or averting his or her gaze. midline orientation. Lower extremities should be Another unique form of handling the cocaine- flexed somewhat to break up pelvic and lower exposed infant to reduce irritability and improve extremity extensor tone. Rolled-up cloth diapers motor control is the use of neonatal hydrotherapy. can be placed between the legs and along the spine This consists of placing the infant in a small tub or to support and maintain the posture while allowing bassinette filled with water 99°F to 101 °F. Hydro- 30 INFANTS AND YOUNG CHILDREN/JULY 1989

Table 1. Summary of intervention goals and management related to period of development

Period of development Intervention goals Management Newborn Increase periods of alertness and interaction Prevent hyperextended posture Positioning in sidelying Decrease irritability, tremors, and Swaddling and rocking overshooting Hydrotherapy graded auditory and visual stimuli Improve feeding patterns Positioning handling Improve feeding posture Decrease facial and oral hyper- Tactile stimulation to facial and sensitivity oral areas Improve parent handling Observe Brazelton Model for appropriate behavior Demonstration and return demonstration of appropriate handling Infancy Improve movement patterns to enhance interaction and exploration Decrease extensor tone Supine flexion with lower extremity rotation Prevent extensor thrusting in sitting and standing Discourage supported standing Discourage use of jumpers and walkers Carry inflexed position Slow, gentle movement through space Increase antigravity strength Prone positioning Pivoting in prone position Sitting with support for short periods Improve parent handling Demonstrations and return demonstrations of appropriate play and carrying positions and handling techniques

therapy techniques include handling to facilitate in improving posture, muscle tone, behavioral state, head in midline, hand-to-mouth activity, and flexion and feeding behavior in premature infants. These and rotation of the trunk. An overhead radiant outcomes are also appropriate for cocaine-exposed heater should be used to decrease temperature loss infants. If the infant responds well to this form of during hydrotherapy. Vital signs should be carefully state control, it could easily be taught to the parents monitored for any signs of physiologic instability. and adapted for home use. Sweeney27.52 has used hydrotherapy in an intensive While swaddling, rocking, and other methods of care nursery setting and has found it to be effective calming may initially be necessary, it is important to

-1441111Prr Infants Exposed to Cocaine in Utero it

Fig 1. Infant in flexed sidelying position used to decrease extensor tone. Reprinted from Schneider JW, Chasnoff IJ: Cocaine abuse during pregnancy: Its affects on infant motor developmentA clinical perspective. Top Acute Care Trauma Rehabil 1987;2(1):63. use these methods only as needed and to begin to Feeding withdraw these additional techniques as soon as Poor feeding has been mentioned as a symptom possible so that the infant learns to gain control in cocaine-exposed newborns.'3 Problems in oral over his or her state. For example, swaddling may motor control are again most probably related to initially be necessary every time the infantis abnormal extensor tone, disorganized movement handled. As the infant responds more to calming patterns, and poor state control. Proper positioning measures and begins to show self-calming abilities, and handling techniques described above should swaddling should only be done when the infant prepare the infant motorically and behaviorally to seems unable to respond without this intervention. assume and maintain a more relaxed, flexed posture during feeding. Cocaine-exposed infants may also display oral hypersensitivity. Gentle but firm tactile stimulation around the face as well as within the mouth should help to decrease sensitivity and increase appropriate sucking behavior.

Parent education This component of the intervention program is of paramount importance in enhancing normal infant development as well as ensuring a strong parent-infant bond. Parent education should begin early enough so that parents can learn appropriate and effective caregiving and avoid compounding the problems of the already at-risk infant. Having the parents observe the Brazelton Neonatal Behav- ioral Assessment appears to have a positive effect on later interaction with their infants.33 This is probably because parents are able to see the positive Fig 2. Swaddled infant in en face position with characteristics and the strengths their infant pos- mother. Reprinted from Schneider JW, Chasnoff IJ: sesses rather than focusing only on the weaknesses. Cocaine abuse during pregnancy: Its affects on While it appears that some drug-abusing mothers infant motor developmentA clinical perspective. continue to deny their infant's problems, pointing Top Acute Care Trauma Rehabil 1987;2(1):64. out positive attributes as well as ameliorating

BEST COPY -AVAIUZE 32 INFANTS AND YOUNG CHILDREN/JULY I')89

problem behaviors will serve to strengthen the Whenever an infant does become distressed, mother's bond with her infant. parents are encouraged to see this as an attempt of Many cocaine-abusing mothers may not be the infant to ask for help and are taught the calming physically or psychologically ready to observe the techniques (swaddling, pacifier, vertical rocking) initial assessment done on their infants a few days discussed earlier. Repeated demonstrations of posi- after birth." Information gained during this assess- tioning and handling techniques to relax and begin ment, however, can be used to educate the mother interacting with the infant, as well as return demon- about the competencies and needs of her infant. stration by the parents, are all part of the educa- Most important to understand is how easily the tional process. cocaine-exposed infant can become overstimulated. More than teaching dos and don'ts, parents are Parents are taught to recognize common distress taught to pay attention to their infant's cues during signs from overstimulation such as yawning, sneez- interactions and to respond as quickly as possible. ing, hiccuping, gaze aversion. spitting up, color Modeling of appropriate handling and feedback to changes, and crying." parents on their handling and interactions help the When the infant is alert, they are instructed to try parents to expand the infant's range of appropriate to engage the infant en face without speaking or behaviors. Regardless of how competent a parent moving too quickly. If the infant is fixing on them may seem, a follow-up session after the infant has comfortably, they may try either speaking to the been in the home setting for at least one week is infant in a soft rhythmic voice or moving slowly in recommended. Follow-up visits at one week and front of the infant without speaking. For some one month of age allow the infant's improvements infants, any direct visual input may prove too in state control to be highlighted for the parents. stressful initially. In this case, parents are instructed Suggestions for appropriate progression of interac- to hold the infant in a vertical position against their tions with the infant to increase his or her responsive- chest with the infant facing away from the parent ness to more complex stimuli for long time periods (Fig 3)." In this position, the infant may be held are also given. These sequential intervention ses- securely to prevent uncontrolled movements and sions help determine how appropriate the parent- can hear the parent's voice without needing to infant interactions appear and how well the infant interact visually. has fit into the family unit.

,fit r

441P4*

Fig 3. Infant held securely facing away from parent.

_BEST COPY AVAILIDIE Infants Exposed to Cocaine in Utero 33

Infancy The goal of intervention during this period is to have the infant move appropriately throughout his or her environment. By moving well, he or shewill be able to interact well and explore his or her environment appropriately. Thus, infant motor abil- itiescanhave an impact on psychosocia.1 and cognitive development. Since cocaine-exposed infants beyond the newborn period demonstrate increased muscle tone and retention of primitive reflexes, they may require intervention to move normally. This intervention can be in the form of practical suggestions for appropriate play and carrying positions or ways to handle infants to decrease Fig 4. Lower extremity rotation in supine flexion muscle tone while encouraging normal movement. 3° position. Reprinted from Schneider JW, Chasnoff IJ: Cocaine abuse during pregnancy: Its affects on infant motor developmentA clinical perspective. Play positions Top Acute Care Trauma Rebabill987;2(1):66. When supine, cocaine-exposed infants show increased extensor tone. This tone causes decreased beside them, which prompts pivoting in the trunk pelvic mobility and limits the infant's ability to lift to reach the toys. the legs up to play with his or her knees or to kick Sitting is an appropriate developmental activity Parents can be taught toliftthe reciprocally. from approximately five months ofage,and, in infant's pelvis up and flex the legs toward the chest, addition, infants may sit with the support of their enabling the infant to overcome the extensor tone parents from birth onward. One caution to parents and to begin increased kicking movements with the is not to place infants in the sitting position for long lower extremities (see Table 1). From this position periods of time, since newly developing trunk of supine flexion, the lower extremities can be extensor muscles will not be capable of sustaining rotated from side to side to further decrease the erect position. In addition, cocaine-exposed extensor tone (Fig 4). The upper extremities may infants often push backwards into extension when need to be brought down and forward (depressed sitting (or standing). This extensor thrusting should and protracted) at the shoulder girdle to allow the be prevented by bending the infant forward at the arms to reach out to grasp objects. Parents should hips whenever thrusting occurs or is anticipated. If be warned against leaving their infants supine for thrustingis allowed to continue, extensor tone long periods, since increased extensor tone and the (already abnormally high) will be further facilitated. effects of gravity make movement difficult in this Supported standing allows infants to experience position. upright weight bearing throughout the lower extrem- Prone is a good position for infants to develop ities. Cocaine-exposed infants characteristically en- antigravity extensor strength. Because cocaine- joy standing because it allows them to use their exposed infants have a preponderance of extensor abundance of extensor tone. They can frequently be tone, they usually enjoy this position and perform observed in rigid stand positions, including going well init. The infants should be encouraged to up on their toes or thrusting head and trunk move in prone by placing colorful stimulating toys backward into extension. Despite their obvious

BEST CSPV UM PIKE 34 INFANTS AND YOUNG CHILDREN /JULY 1989

enjoyment of standing, this position should not be encouraged since it reinforces their abnormal tone and movement patterns. Use of infant assistive devices such as jumpers and walkers should be discouraged. Parents should be informed that thousands of injuries each year are related to the use of these devices.' As importantly, infants placed in these devices are riot exercising their muscles appropriately, since they do not yet have the ability to hold themselves in proper postural alignment when placed in the upright position.' The leg actions of an infant in a walker have little relationship to walking skills. Rather than training an infant to walk, the walker may actually impede progress by inhibiting the infant from crawling around.' Walkers encourage hypertonic Fig 5. Infant in flexed carrying position. Reprinted infants (like the cocaine-exposed infants) to further from Schneider JW, Chasnoff IJ: Cocaine abuse increase their extensor tone by pushing their feet during pregnancy:Itsaffects on infant motor against thefloor and archingtheir trunks developmentA clinical perspective. Top Acute backwards." Care Trauma Rehabil 1987;2(1):67.

Carrying and may respond by stiffening their bodies or Since cocaine-exposed infants display primarily crying. Slow, gentle swinging through theair extensor tone, they should be carried in a more should replace rapid movements in space during flexed position to counteract this. Fig 5 illustrates rough-house play. In all cases, the infant's reactions how the infant sits on the parent's hip while being (physically and behaviorally) should guide parents supported by the parent's arm under the infant's in assessing the appropriateness of their handling. thighs. The infant's arms are kept forward, which Parent education, which includes appropriate facilitates the hands coming to midline. This posi- play, carrying, and handling techniques, changes tion controls the infant's tone while facilitating according to the infant's needs. While many cocaine- head and trunk control and the ability to reach and exposed infants may not require intensive physical grasp objects. therapy, monthly sessions may be necessary to demonstrate developmentally appropriate activities and to teach parents new handling skills. As always, Handling return demonstrations from parents are important Parents who have been taught to handle their to confirm their level of skill and understanding. infant so as to optimize interaction in the newborn period can now expand on those abilities as their infant grows and changes. The cocaine-exposed Itis clear from present research findings that infant should no longer require swaddling to stay cocaine exposure in utero is not an innocuous calm; he or she may, however, require more sensi- phenomenon. Physical and behavioral findings exist tive handling than normally required of a growing that are worrisome to the pediatric health care infant. For example, while rough-house playis professional. Clinical experience has shown that enjoyed by most infants, cocaine-exposed infants some of these findings can be ameliorated with may be more sensitive to quick rough movements appropriate intervention.

BEST COPY AVAINLE Infants Exposed to Cocaine in Der° 35

Because of the tremendous potential for plastic- mal nervous system reorganization that may result ity that exists within the human nervous system, it in behavior and learning difficulties.;' -'0 may be expected that hard neurologicalsigns and Studies are needed to document motor develop- gross motor dysfunction may not be apparentafter ment of cocaine-exposed infants later in the first 12 months of age. However, the early effects of year of life. Follow-up of these infants through cocaine on the developing nervous system may preschool and early school years will help to place the drug-exposed infant at high risk for identify any behavior or learning disorders that may minimal brain dysfunction, which involves an abnor- be associated with intrauterine cocaine exposure.

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Special Children Special Risks: The Maltreatment of 33.Widmayer SM, Field TM: Effects of Brazelton Children with Disabilities.New York, Aldine De demonstrations for mothers on the development of Gruyter, 1987. preterm infants.Pediatrics1981;67:711-714. 27. Schneider JW, Chasnoff IJ: Cocaine abuse during 34.Newsbriefs: Ban sale of baby walkers, CMA urges. pregnancy: Its effect on infant motor developmenta Can Mtd Assoc.'1987;136(1):57. clinical perspective.Top Acute Care Trauma Rehabil 35.Vzrious notes from readers: More on infant walkers. 1987 ;2(1):59 -69. Pediatr Notes1987;26:46. 28. Sweeney JK: Neonates at developmental risk, in 36.Simpkiss MJ, Raikes AS: Problems resulting from the Umphred DA (ed):Neurological Rehabilitation.St excessive use of baby-walkers and baby bouncers. Louis, Mosby, 1985. Lancet1972;1:747. - 29. Umphred DA, McCormack GL: Classification of 37.Touwen BC: Examination of the child with minor .V! common facilitory and inhibitory treatment tech- neurological dysfunction, ed 2, inClinics in Develop- niques, in Umphred DA (ed):Neurological Rehabilita- mental Medicine,no. 71. Spastics International Medi- tion.St Louis, Mosby, 1985. cal Publications, Lavenham Press Ltd, Lavenham- 30. Korner A: Interconnections between sensory and Suffolk England, 1979. affective development in early infancy, in Powl J (ed): 38.MacGregor SN, Keith LG, Chasnoff I), et al: Cocaine Zero toThree.Washington, DC, Bulletin of the use during pregnancy: Adverse perinatal outcome. National Center for Clinical Infant Programs, 1985. AmJ Obstet Gynecol1987;157:686-690. 31. Wilhelm IJ: The neurologically suspect neonate, in 39.Oro AS, Dixon SD: Perinatal cocaine and metham- Campbell SK (ed):Pediatric Neurologic Physical Ther- phetamine exposure: Maternal and neonatal corre- apy.New York, Churchill Livingstone, 1984. lates. JPediatr 1087;111:571-578. 32. Sweeney JK: Neonatal hydrotherapy: An adjunct to 40.Drillen CM, Thomason AJ, Burgoyne K: Low birth- developmental intervention in an intensive care nurs- weight children at an early school age: A longitudinal ery setting.Phys Occup Ther Pediatr1983;3:39-52. study.Dev Med Child Neurol1980;22:26-47.

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Bulletin of hree JUNE 1989 ISSN01A OM I NATIONAL CENTER FORCLINICAL INFANT PROGRAMS VOL. IX. NO.5, Drug Exposed Babies:Research and Clinical Issues by Donna R. Weston, Ph.D., Children's Hospital Oakland, California Barbara Ivins, Ph.D., Children's Hospital Oakland, California

Barry Zuckerman,M.D.,Boston City Hospital Caryl Jones, Ph.D., National Institute on Drug Abuse Richard Lopez, Ph.D., I.D., D.C. General Hospital Specialists in drug treatment know well the pervasive destructive effects of drug addiction or drug abuse on an individual's capacities tofunction in daily life. In recent years, however, the drugabuse problem has developed a new facethe face of a baby.Drug-exposed infantsarea large and still growingpopulation requiring treatment in newborn nurseries,neonatal intensive care units, and early intervention programs.The increasing prevalence of drug use or addiction among womenof childbearing age is redefining the drug treatment problem, bringing new challenges andcomplexities to professionals working with infants,children and families. Changes in prevalence aredue in large part to increasing use of cocainewith its very high addictive potential. We can no longer view drugabuse or drug addiction as problems of individuals; these areproblems infants, children and with a devastating impact on Representatives, May, families. drugs in utero (U.S. House of Four facets of babies' exposure todrugs deserve 1988). A recent nationwide hospital surveyconducted Perinatal Addiction special mention. by the National Association for rirst is the sheer increase in thenumbers of babies Research and Education (NAPARE)found that the born in the United States who havebeen exposed to overall rate of deliveries affected bysubstance abuse

BEST COPY AVARITIE___ with drug-exposed infants (ADAMHA News, Practitioners who work newbornsaffected annually and their families face issuesthat are as intellectually, Oetopei, 1968),.with the variation in rates among emotionally and ethically difficult as anythat have 27 percent) relatedchiefly to hospitals (0.4 percent to used. confronted our field and our society. This article the thoroughnessof the substance abuse assessment Theliroblem of substance abuseduring pregnancy does is it Zero to Three Staff not seem to beconfined to urban settings, nor EditorJeree Pawl Associate EditorEmily Schrag Fenichel limited to low income women. A1989 survey conducted Consulting Editor in PediatricsJack Shonkoff Children, Youth and by the Select Committee on Zero to Three is a publication of the National Center for Clinical Infant Families (see p. 20) found 15 of 18hospitals reporting Programs. Unless otherwise noted, materials published in Zero to Three 3 to .4 times as many drugexposed births since 1985. may be reproduced by health professionals oremployees, officers or Second, HIV (human immunodeficiencyvirus) board members of non-profit organizations for non-commercial use, linked to drug provided they acknowledge the National Center for ClinicalInfant infection in young children is inextricably Programs as the source and copyright owner of this material. use in adults: Ofall HIV-infected children under 13 years of age in the UnitedStates, about 80% have a NationalCenter for Clinical Infant Programs Related Complex or who Boar/of Directors . . . parent with AIDS or AIDS Kathryn BarnardUniversity of Washington is at risk for AIDS. (Falloon,Eddy, Warner and Pizzo, Peter Bloc, Jr.University of Michigan Medical Center 1989) Little is known about the timingof mother-to- T. Berry Brazelton Children's Hospital MedicalCenter, Boston child transmission, and reported transmission rates Amy S. CohenCenter for Preventive Psychiatry,White Plains that approximately 50 Robert N. EmdeUniversity of Colorado Schoolof Medicine vary, but evidence suggests Linda GilkersonThe Evanston Hospitaland Erikson Institute, percent of infants born to infectedmothers are infected. Chicago The most common route of maternalinfection is Morris GreenIndiana University Schoolof Medicine intravenous drug use or sexual contact with an StanleyI. GreenspanGeorgeWashington University School of Medicine intravenous drug user. (For a detailed discussion of Robert J. HarmonUniversity of ColoradoSchool of Medicine transmission, diagnosis, etiology and medical manage- Irving B. HarrisPittway Corporation,Chicago ment issues of HIV infection inchildren, see Falloon, Asa Grant Hilliard, IllGeorgiaState University, Atlanta Eddy, Wiener and Pizzo, 1989) Anneliese KornerStanford UniversityMedical Center J. Ronald LallyFar West Laboratory,San Francisco Third, the explosion in numbers of drug exposed Bernard LevySmart Parts, Inc.,NYC babies and drug using parents is threatening to Samuel MeiselsUniversity ofMichigan overwhelm already overtaxed foster care systems. Dolores NortonUniversity ofChicago University School of Medicine Newborns who test positive for drug exposure are often Robert NoverGeorge Washington Joy OsofskyLouisiana StateUniv. Medical Center, New Orleans removed, from the mother's custody before they even Jeree PawlUniversity of California,San Francisco go home, but drug use is alsodestroying families who GeorgeH. PollockNorthwesternMemorial Hospital had been making it together, struggling against the Sally ProvenceYale UniversitySchool of Medicine odds, families on the margin for whom involvement Kyle PruettYale University Schoolof Medicine Julius B. RichmondHarvardUniversity Medical School in the drug use lifestyle is the last straw.Infants and Arnold Sameroff Brown UniversitySchool of Medicine very young children are enteringfoster care at a Lisbeth SchorrHarvard University disproportionately high rate. Children under three Rebecca Shahmoon Shanok JewishBoard of Family and Children's years old constituted 53 percentof children in placement Services, NYC Jack ShonkoffUniversity ofMassachusetts Medical School in San Francisco county in 1986.Data from Alameda Albert J. SolnitYale University Schoolof Medicine County in 1988 indicated that new intakes forchildren Lynn StrausMamaroneck, NY through age 12 included 48 percent in the 0-3 age range. Ann TurnbullUniversity ofKansas fragile Judith Viorst Washington, D.C. More importantly, the number of medically Bernice WeissbourdFamily Focus, Inc. infants entering foster care is creating a new setof G. Gordon WilliamsonJFK MedicalCenter, Edison, New Jersey demands upon foster families and socialworkers. Many Edward ZiglerYale University of these infants are remaining inhospitals for lack of Life Mnoirrs medical Mary D. Salter-Ainsworth-Universityof Virginia homes deemed adequate to meet their extensive William FriedmanNew York City needs. Peter B. NeubauerNew York City Finally, drug-exposed babies are beingborn in times Arthur H. ParmeleeUniversity of CaliforniaMedical Center Los that are difficult for mental health andsocial services Angeles Mary RobinsonBaltimore. Maryland programs. Federal or statefiscal policies have resulted Pearl RosserSilver Spring. Maryland in budget limitations for stateagencies, for drug Executive Mutter:Eleanor Stokes Szanton treatment programs, and for programsdesigned to Associate Director:Carol Berman healthy parent-child Associate Dewier:Ems;/ Schrag Fenichel support families or promote David Chavkin and Peggy Pizzo relationshhips. Programs and staffhave been caught Senior Prosrato Associates: between fiscally driven cutbacksand need-based This publicationwas made possible inpart by grants from the demands for more services. Theyhave also been Commonwealth Foundation, Johnson and Johnson Baby Products challenged by the need for new programmodels to treat Company, and the New Land Foundation infant-parent dyads or families who arefeeling the s:t National Center for Clinical Infant Programs 1930 June 1080Zero to Three 2 87

BEST COPY AIT1.7 1E help practitioners evaluate represents an effort to Editors' note research information and tothink about clinical and Practitioners who workwith drug-exposed treatment issues. face issues that are as effects of maternal drug use on infants and their families Direct and indirect _:intelleCtually, emotionally andtechnically difficult the infant "is any that haveconfronted our field and our A review paper (Jones &Lopez, 1988) prepared for articles in this issue of Zero toThree Health's Expert Panel on society. The the National Institute of reflect the work ofclinicians, researchers and Prenatal Care points out thatdirect and indirect effects policymakers who are trying tounderstand this of maternal drug use onthe fetus and infant must be of children and families simultaneously. One must heterogeneous population understood and addressed and to addresstheir.complex needs., consider the effects of drugs onthe fetus consequent The reader will notice aninevitable tension to transfer of thedrug through the placenta(e.g., fetal to make useful One must consider the belween 'authors' attempts infarcts attributable to cocaine.) generalizatiOns concerningdrug-exposed babies effects attributable to changes inthe fetal environment about stereotyping. retards placental develop- and their families and cautions (e.g., the THC in marijuana Contributors also differabout the most promising ment, which reducesblood flow to the fetus). One must approacheialthough all agreethat consider the effects of abuseddrugs on the mother's service parents simply as place the fetus at risk. treating substance-abusing central nervous system which criminals is agraveclisservice to them and their young children.Missing from this issueentirely whose Investigators must reconceptualizethe effects of drug is a discussionof drug.L'using parents developing fetus and infant. Directand affluence allows them toavoid detection through exposure on the and whose indirect effects of maternal drug use mustbe understood hospital urine assays and other means, infants' developmentaldifficulties are unlikely to and addressed simultaneously. be attributed to drug exposure. society have much indirect fetal risks of Clearly, our field and our Summaries of the direct and to learn about supportingthe optimal development maternal drug abuse for eightclasses of the most and their families. As in drugs produced a 'of drug-exposed infants commonly abused psychoactive any work withchildren and parents, weneed to lengthy list with many effects commonto several of empathic attention to the studies demonstrat- be guided by careful, the classes of drugs. 5ecause many .unique experience ofeach infant .and parent.This ing or suggesting arelationship between specific drugs is, we believe, the research design flaws, quality of thoughtful attention and specific fetal risks have hallmark of the articles inthis issue. inferring causal relationshipsbetween specific drugs thank Donna R. Weston The The editors wish to and specific fetal risksis uncertain business. their invaluable contribu- effects aside, the research does and Barbara Ivins for question of specific drug tions to this issue ofZero to Three. Dr. Westonand indicate that it is in behavioraland neurobehavioral December, 1988 NCCIP that effects Dr. Ivins organized the domains, rather than growth parameters, Fellows' symposium thatinspired this special issue; of prenatal drug exposure aremost consistently clinical and research ap- assessments are they also identified documented if adequate developmental proaches to be reportedand coordinated the bi- made. produced the lead article. the research suggests that coastal collaboration that Jones and Lopez' review of The editors welcomeletters from readers that investigators must reconceptualizethe effects of drug research, practice developing fetus and infant. For reflect their own experiences in exposure on the and policy developmentrelating to drug-exposed example, infants exposed todrugs in utero are To the extent possible infants." This may infants and their families. frequently referred to as "addicted these will be published infuture issues of Zero be the case. Some drugs areaddictive. Some or may not to Three. are toxic. Some areteratogenic. Both addictiveand toxic be sick, small for drugs can cause the newborn to withdrawal. These symptoms,however, may actually gestational age, low birthweight,andlor premature. The effects of drugs on thedeveloping the neonate will undergo be the result of the addictive model assumes that endocrine or central nervoussystem. (Thesebehavioral withdrawal, after which theinfant will grow and effects of drugs are of addiction had not been part and developmental teratogenic develop ciore or less as if particular concern to childdevelopment and human of his rice short lifeexperience. The toxicmodel if thresholds of pain inthe infant have services nractitioners; assumes thatdirect injury to the infant may if the capacity for stateregulation, are modified, or bonds occurred. attention, interpersonalrelationships and human Teratogenicity is more complex.Unless there are at risk). are compromised,the future of that child is identifiable anomalies at birth,the infant can appear reside in the genito-urinary infant Teratogenic effects can also to be free of symptoms.On the other hand, the andlor cardiovascular system.These effeits are may look like asick, inconsolable babyundergoing drug

June 1989 Zero to Three 88

BEST COPY AVAILABLE the basis of a urine dosage of exposure, the systems drugs and were identified solely on influenced by, time and assay. Had the investigatorsrelied only on self-reported which are undei developmentat the time of exposure, found no significant of individuals. Those drugs drug use, they would have and genetic vulnerability differences between the supposedly"drug-using" and that act on metabolic,cldocrine and central nervous system functions may not causethe appearance of "non-drug-using" groups. The interaction of drug use, healthand mental health symptoms until specificdevelopmental stages occur in status, sociological, and ecologicalvariables is seldom childhood of adolescence. examined in perinatal research, but thereality is that The infant is not only at direct riskfrom the effects intensified by of the drug(s) used by his mother in pregnancybut the consequences of drug exposure are an array of maternalhealth behaviors which tend to also at indirect risk from the mother'sbehavior. The drug abuse. For Diagnostic Statistical Manual of MentalDisorders, Third be associated with the lifestyle of example, although drug users tend tohave a "drug of EditionRevised (DSM-111-R 1987) definesand examines substances they can behaviors caused by each class ofpsychoactive choice", they also tend to take the get, and to mix alcohol, cigarettes,and illicit drugs, substance. The types of maternal behaviorsassociated type of drug disorders (psycho- rather than rely on any one class or with drug-induced organic mental exclusively. Thus, studies of theeffects of cocaine logical or behavioral abnormalitiesassociated with brain most likely are, dysfunction and caused by psychoactivesubstances) can exposure, or studies of heroin exposure in reality, studies of polydrug exposure. place infants at grave risk. Jones and Lopez(1988) report the infant can also doses, some- The effects of drug exposure on maternal seizures following large drug factors. For example,drug- times resulting in death; paranoidand suicidal ideation; be compounded by postnatal exposed infants who experienceadequate parenting in violent or aggressive behavior,particularly with better developmen- stimulants such as cocaine or with PCP; the commission an adequate environmentmay have tal status than drug-exposedinfants whose experience of harm to self or others while reacting todelusions; of neglect and other stresses. accidents caused by impaired motor coordination;and postnataliy is comprised death from respiratory depression following high doses. Clinical and treatmentissues Lack of any treatment isthe foremost issue for drug- Reading the research pregnant women. Mostsuch A rapidly growing research literaturestrongly using or drug-addicted women are receivingneither prenatal care nor drug suggests that drug use during pregnancy islinked to during outcome, infant treatment services.Women who seek help a multitude of problems in pregnancy get it, according tothe 1989 Select status, and individual development. As isoften the case pregnancy cannot Committee survey;two-thirds of the hospitals queried in a new area of research, reports mayconflict in their place to refer substance- findings regarding the impact of drug exposure on the reported that they had no abusing pregnant womenfor treatment. fetus, neonate and developing child. Clinicianswho programs concerned provide care for drug-exposed infants and their families In their 1980 effort to survey with the provisionof services to drug-abusing women, would do well to keep in mind three important identified only 25 programs considerations as they read interpretations of data from Beschner and Thompson nationwide serving 547 women.Roughly half were experiments, whether these are wellcontrolled and family counseling, and a laboratory trials or unfortunate natural experiments providing psychological third provided skills assessmentand education coun- such as the "crack" experience. Theseconsiderations making an attempt to serve usefulness of animal studies; 2) seling. Few programs were are: 1) limits on the the children of drug-abusing women.The disparity the validity of self-reported drug use; and 3)failure and services required was variables affecting between services offered to take account of many interacting highlighted by Beschner andThompson's findings that this population. likely to by women enteringtreatment programs are Animal studies can elucidate the mechanisms and complicated psychosocial which drug exposure damages the fetus(teratogenicity) present chronic medical and that the provide early information problems demanding special attention, in humans and can possibly higher levels of personaldistress and lower levels of about the effects of a previously unidentified teratogen. compared and individual differen- self-esteem found in drug-using women, as But because of species, strain, to male drug abusers,indicate the need for special ces, generalizingresults of animal studies to humans seldom found in false positives and counseling and support services can also involve important errors, existing drug programs.Eight years later, although false negatives. Thalidomide testing,for example, efforts exist, Jones and 10 strains some pioneering treatment showed only occasional teratogenicity among Lopez (1988) report that "nopreventive intervention of rats, 15 strains of mice, 11 breedsof rabbits, two targeted hamsters, and eight programs havebeen located which are breeds of dogs, three strains of specifically on (drug abusing) womenand prenatal care." species of primates (Lewis, 1987). The challenge fur the field is todesign programs that Reliance on self-report to determinedrug use can of a recent study can be preventive infocus and comprehensive in design, lead to spurious findings. Results involving prenatal care, drug treatment,and infant- (Zuckerman, et.al., 1939) indicatedthat women who and cocaine had parent support. had positive urine assays for marijuana Practitioners and programplanners currently face infants with impaired fetal growth.Among these two formidabletasks: 1) applying whatever treatments women, 16 percentof the marijuana users and 24 available while 2) simultaneously percent pf the cocaine usersdenied the use of these are currently (one Mg Zero to Three 4 89 *: /

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assimilating the growing clinical andresearch data in them have different implications for parentingcapacity. order to develop more apppropriate newmodels for Moreover, not all babies exposed to drugs in uterowill service programs and treatmentapproaches. Clinical be affected, nor will those who areaffected be affected issues and treatmentconsiderations that must be in the same way. Stereotypes canblind us to the unique the danger of characteristics that both infants and mothersbring to addressed in this process include: 1) of drugs. stereotyping; 2) focusing the treatmenteffort; 3) the their relationships despite the impact Treatment efforts must recognize, respectand support impact of the work uponhelping professionals; and 4) the very real framework that assists individual differences while addressing the development of a conceptual risks that these mothers and infantsface. clinical and research efforts. Focusing the treatment effort The danger of stereotyping Whether she is treating a singledrug-involved dyad Available information about the impactof specific in a mixed practice or is working in anenvironment and polydrug use onphysiology, behavior, and where drug use is the norm, the clinician mustmake development tends to cite commonalitiesin the a series of decisionsabout the type and focus of characteristics of drug-using mothersand their babies. treatment. The complexityof drug use virtually Mothers are likely to be described ashaving a history guarantees that these decisionswill have to be made of poor prenatal care, dysfunctionalrelationships, in the absence of sufficientinformation. chaotic lifestyles and poor parenting.Drug-exposed First come decisions about whom andwhat to treat. infants tend to be described in termsof irritability, Whatever their specific drug exposure experience,drug- hyper- or hypotonicity, depressedgrowth parameters, exposed infants are likely to have-healthproblems (low compromised state regulation andpossible developmen- birthweight, complications of prematurity)and to be tal delays. Emphasizing onlycommonalities, however, more difficult anddemanding, and less responsive and suggests that ahomogeneous group of drug-using rewarding, than even "difficult" healthybabies. Drug- babies exists. In fact, the exposed babies tend to be compromisedin their mothers and drug - exposed the subtle opposite is the case. Drug useincludes many patterns capacities fur state regulation, participation to casual use of low do',es to give-and-take of interaction, and comnittnit amenabout that range from occasional their states and needs through smite.,frowns, Cries episodic intake at high doses orthe compulsive use vulnerable infants associated with drug dependency.The differences and eye contact. These biologically are born to motherswho face Health and emotional between use and addiction andthe causes underlying

June 1989 Zero to Three 90 tiLt BEST COPY AVAILABLE schizophrenic and is addicted to cocaine,for example, problems of their own andwho are also compromised obstacle and ability to understand may find that herpsychiatric condition is an in their relational capacities to her effective participation indrug treatment. and respond to their infants'needs. Thus these infants with experience a double jeopardy:biologic vulnerability due Although she will have difficulty communicating that is exacerbated by inadequate and relating to others, staff in most drugtreatment to drug exposure identify her difficulties caret.iking (Parker, Greer, andZuckerman, 1988). The programs may not be able to multiple needs of infants and mothersproduce a strong as signs and symptomsof schizophrenia; her mental impetus to treat mother and babyseparately. However, illness will go untreated, and her drug treatment may interventions also be ill-fated. Women with borderlinepersonalities the true clinical challenge is to provide well. The to support the mother and protectthe infant, while frequently have difficulties with drugs as additionally promoting positive mother-infant interac- Detoxification Program at the Districtof Columbia percent of patients tion and the formation of a positiverelationship. General Hospital estimates that25 Treatment strategies are further complicatedby the treated have dual diagnoses. of When drug use isin fact addiction, intenseand cumulative occurrence and complex interaction needed. Jessup and mothers' health behaviors and psychosocialfactors. comprehensive intervention is Depressed mothers and those with "dualdiagnosis" others (cited in Jessup, 1983) suggestthat pregnancy calls for even and motherhood are psychologicallyloaded issues for require special attention. True addiction of whom fee/ that more intense and comprehensiveintervention. chemically addicted women, many Observations from a recent study (Zuckerman, et al., motherhood is the onlysocially acceptable role 1959) suggest that depressive symptoms in women and remaining to them andthe only avenue open to associated health behaviors may be an important link achieving feelings ofself-worth (Finnegan, 1979; between the social environment and infant outcome. Rosenbaum, 1981). The mostdifficult psychological task Not surprisingly, the study found that depressive during pregnancy for chemicallyaddicted women, who symptom., were more likely to occur among women tend as a group tohave poor self - esteem, is the with a low level of social support and a high number management of guiltand regret about drinking ordrug of life stresses. Women with more depressive symptoms use. If a woman'schild is born ill or inwithdrawal and were found to be more likely tosmoke cigarettes, drink the mother attributesthe abnormality to her drug use, alcohol, and use cocainepossibly as a form of self- her guilt may be very greatindeed, but it may not be medication, a way of coping with unhappiness and expressed directly. In addition,actions including failure stress. These women also had poor weight gainduring to form an affectivebond with the infant, neglect, abuse, pregnancy Such pour healthbehaviors in combination and abandonment mayeach be products of unconscious are likely to lead to poor outcomesfor newborns, and, processes (Fraiberg,1975). Practitioners must be well of course, sick, difficult babies may further stress trained and caring individualswho can support mother- parents and increase depressive symptoms,which have infant interaction and promotethe mother's capacity a,lverse effects on the developing child. to become the protectorof her infant. Intervention must l..! forts to interrupt such a process must consider a acknowledge the simultaneousneeds for drug treat- woman's emotional and mental health, economic ment and good infant care.It must recognize individual rirc tn-ns tanee:, and social context.Well-intentioned but dynamics that may impair themother-infant relation- unrealistn interventions may simply set women up to ship (Fraiberg). It mustaddress barriers to formation fail. it a potentially harmful health behavior serves as of a working alliance.(Seligman and Pawl, 1935). a means of copingwith depressive symptoms or life stresses or is, as in poor weight gain,itself a symptom Impact on helping professionals The increased concentrationof drug-exposed infants of depression, providing informationabout the risks in neonatal nurseries,early intervention programs and vf pow health behaviors during pregnancyis unlikely problems for helping and pregnancy foster homes has created new by itself to improve women's health professionals. The prevalence ofdrug-exposed babies outcomes. Interventions thatidentify women's existing of many human services healthful ones, and has changed the very nature coping strategies, help develop more jobs, with interventions that were oncelimited to focus on reducing stress and depression inthe context becoming the norm,. help women master infrequent, high risk situations of a therapeutic relationship may The already difficult care ofmedically fragile, ill, or feelings of helplessness and changetheir behavior. life with heavy developmentally delayed infants who may start Efforts to reduce alcohol consumption among extended hospital stays is furthercomplicated by issues drinkers during pregnancy that haveused this kind of the home, and basic beneficial of parenting ability, resources in counseling approach have demonstrated safety. Follow-up is ofen difficult.Protective service effects to the newborn. An interventioncharacterized (often involving by emotional support and behavioral strategies tohelp referrals and out-of-home placements frequent moves and a series of primarycaregivers for pregnant women reduce cigarettesmoking resulted in interventions. Social birthweight among their newborns the infant) become routine an increase in workers, NICU staff, dischargeplanners, and early (Zuckerman et al,1989). intervention specialists copewith heavy caseloads, The "dual diagnosis" woman hasboth a drug problem of time searching for arid a psychiatric problem. A pregnant womanwho is spend a disproportionate amount June 1084Zero to Three 6 91 BEST COPY AT. """ that A "risk model," onthe other hand, recognizes and contacting parents,and struggle to establish some compromises or jeopardizes alliance with them. For manyprac- fetal exposure to drugs and sort of working and in their developmental processesbut that organismic titioners, the changein responsibilities environmental forces cancontribute to positive perceived effectiveness oftheir work bring high stress, Prospective studies of risk the need for new coping developmental outcomes. decreased job satisfaction and have repeatedly indicatedthat developmental outcomes strategies. product of both constitutionalmake-up and Recognition and ongoingdiscussion of the special are the professionals who treat drug- environment, and that adynamic, transactional model difficulties faced by and Chandler,1975;Werner and exposed infants and theirfamilies are critical to the is needed (Sarneroff 1982). delivery of quality care. The arrayof feelings aroused Smith, researchers and practitioners by the work must beacknowledged. Early rescue The challenge for feelings of helplessness and becomes one of learninghow better to help drug- fantasies can give way to compromised capacities reach out work with infants, thesefeelings exposed infants with anger. Particularly in support their families increating are compoundedby a sense of urgencyrelated to the to the world, and to awareness that thebabies stranded in hospitals or a worldworth reaching for. bouncing between foster homes arein developmental References (1987) Diagnostic and statistical manual of attachment, Americ:n Psychiatric Association.Revised. Washington, D C. American periods critical for the development of mental disorders, Third Edition. affect, self-regulation, and cognition.Professionals may Psychiatric Association. attachment to babies Beschner. G., and 1 hnmpson, P.(1980) Women and drug abuse wrestle with their own feelings of National Institute on Drug Abuse who have been entrusted totheir care, and find it treatment. Needs and services. empathy, concern or Monograph Series Rockville, MD. difficult to maintain feelings of Fannon, J., Eddy. J.. Wiener, L.and Pizzo, P., (1989) Human helpfulness for mothers withoutbecoming judgmental Immunodeficiency Virus Infection inChildren: journal of Pedratries or even,unknowingly, punitive. Forprofessionals Vol. 114, 1.30 Eraiberg. S (1075) Ghosts in the nursery.A psychoanalytic appro.', h accustomed to feeling effective intheir work, these relationships recognizing them is a to the problems ofimpaired infant-mother child feelings can be intolerable. But Journal of Ihe American Academy ofChild Psychiatry, 14. 387-421. working relationship dependency in pregnancy: Clinical critical first step toward forming a Finnegan, L. (1970) Drug Monograph wail a family or implementing atreatment plan. management of motherand child. Servu es Research Series, National Institute onDrug Abuse Whatever their emotional state,few professionals dependrrtt pregnant women in San Francisco: Jessup. M. (1983) Chemically have adequate preparation or resourcesto handle such Substance Abuse Services. Department delivery A stains report. Community a large proportionof high risk cases. Service of Public Health, City and Countyof San Francisco. progi airs mustallow for ongoing supervision,consul- Jones, C L. and Lopez, R (1988)Direct and indirect effects on the miont that problems, feelings, and of maternal drug abuse. U.S.Department of Health and Human tation, and peer support so Services/National Institute on Health. particularly troublesome treatmentissues can be for teratogenocity: Their relevance Lewis, P.T. (1987) Animal tests Y.: shared. Caseloads must bemonitored by supervisory to clinical practice. In D.F.Hawkins (Ed), Drugs and Pregnancy. N staff and staff members' concernsabout their caseloads Churchill Livingston. National Association for PerinatalAddiction Research and Education re4t-cted if feelings ofineffectiveness and burnout are found (1988) Innocent addictsHigh rate of prenatal drug abuse to he prevented. Asfrontline workers, foster parents ADAMHA News. (October, 1989). a!.: need support.In-service training and staff Parker, S.. Greer, S., Zuckerman,B. (1988) Double jeopardy: The education on drug effects,drug treatment, infant- impact of poverty on earlychild development in children at risk, essential B. Zuckermam, M. Weitzmanand ). Alpert (Eds). Pediatric Clinics parent interactionand high-risk dyads are Saunders Co. Vol 35.1227-1240 supporting babies and their of North America, W.B. supports for those who are Rosenbaum, M. (1981) Women onheroin. New Brunswick, NJ: Rutgers families University Press (1973) Reproductive risk and the Sameroff, A. and Chandler, M.J. A conceptual framework toassist clinical and research continuum of caretaking casualty.In F. D Horowitz (Ed ), Rcrinv Vol. IV. Chicago. Universityof Chicago efforts of child development research, "Deficit models" arc as dangerousin addressing the Press. Children Youth and Families (1089) and their families as they Select Committee Hearing on needs of drug-exposed infants Addicted Infants and their Mothers.Washington, D C about any group of children oradults. Seligman, S. and Pawl, I. (1965)Impediments to the formation of are in thinking Call, E A deficit model fordrug exposure in utero assumes a working alliance ininfant-parent psychotherapy In J iieurochemical or Galenson, and R. Tyson, (Eds.)Frontiers of Infant Psychiatry. Vol. 11 that the baby has experienced some New York: Basic Books. other fundamental damage tothe organism's capacities (May 21, 1988). PlacingInfants at U.S. House of Representatives, Select self-righting (Washington, risk. Parental addiction anddisease. Hearing before the for self-organizing and and Families Washington, D C : 1975). Symptoms ofdrug exposure such asimpaired Committee on Children, Youth, U.S Government Printing Office. self-regulatory capacities,hypertonicity, and respira- Vulnerable bat invincible New York. otherwise Werner, E. and Smith. R. (1982) tory difficulties arealso observed in full-term, McGraw Hill been exposed to drugs. Zuckerman, B , Frank, D Htngson,R.. Ammo, II , Levenson, S.. healthy babies who have not ,Cabral, infant is Kayne, H., Parker, S, Vinci, R.,Aboagye, K , tried. I Yet any difficulty ofthe drug-exposed H (1980) Eflciis of 111Ail.111.11 of drug exposure, and H. Timperi, R., and Bauchner, Journal attributed to the single cause marijuana and cocaine use onfetal growth. New England the complexities of the impactof drugs on parents and of Motion,. .120. 762 -7o5 and H , and Cabral. II Depressive children are deemedbeyond understanding 7.uckerman, B . Ani.vro, /-I , Bauchner, The symptoms during pregnancy.Relation-hip to poor health preventive interventions,beyond professional help. and Gynecology. Vol 1n0.1107- deficit mode: can be used torationalize giving up on behaviors. A meman Journal of Ohleirst drug-exposed infants and theirmothers. 1111 (1989) 92 June 1989Zero to Three (.1 The Developmentof Young Children of Substance-AbusingParents: Insights from SevenYears of Intervention andResearch by Judy 'Inward, M.D., LeilaBra:with, Ph.D. Co-Pr intipal investigators Carol Rodning, Ph.D., Research 't arid Vick, Kropenske, M.P.11., ProjectManager 1 Department of Pediatrics UniversityofCalifornia,Los Angeles affects the personal lives Addiction is a tragedy that I- of substance abusers, theirability to be parents, and then children's development.Drugs and alcohol affect the developing fetus; prenataldrug exposure and parental impairment fromchronic drug abuse both affect the developing child.Our research on the developmental sequclac of prenataldrug exposure and the effects of being reared in asubstance-abusing family is informed by the patterns,questions and methods of normal child development. But ourefforts to reach, as'ict, and understandsubstance-abusing families and their young children over the past seven yearshave significant number of parents been anything but ordinary. father. (In fact, a experienced their first exposureto drugs and alcohol Unique issues in working withsubstance-abusing parents' encouragement.)Another through their own her families mother told us that whenshe was upset as a child The foundation of informed andilluminating research a drink and say,"Drink this; effects of both prenatal mother would mixher about the developmental it will make youfeel better." A thirdmother stated e..p:).-ore to illicitdrugs and postnatal impact ofliving "shot me up with heroinwhen abuses substances is the provisionof that her own father in a family that I threatened to callthe cops on him." clinical services that addressthe prevalent survival and their children. needs of :41bstance-ahusing women address the survival needsof C finical services are necessarynot only on ethical Clinical services that ..rounds. but are the primary meansof maintaining substance-abusing women andtheir children must form subjects in a research study.Substance-abusing parents the foundation for researchabout the dcyclopitrental effects frequently, lack telephones, fail to are unstable. move of prenatal drug exposureand the impart of living in keep appointments, and drop outof sight when abusing that abuses substances. it drugs. Friendsand often family collude withthe a family flight from representatives substaot e-abising person's Parents who are addicted todrugs have a primary of authority structures such asuniversities, medical and children found, therefore, that it is very commitment to chemicals,not to their legalsystems. We have Disruption and chaos in thehousehold often result in important not only toprovide clinical services but to of the child's needs. For provide them through anintervenor who is able to the neglect or disregard nurturing, and non- example, a three-month-oldbaby in one of our research establish an ongoing, stable, underneath a bed by a neighbor. the subject. projects was found threatening relationship with and friendswerehigh and Substance abuse underminesnormal patternsof The baby's parents consequently not merely inattentiveto thehebaby's needs interaction and altersconventional priorities (Howard, have worked with, who are but completely unaware ofthe baby's presence. Another inpress). Thefamilies we inability to keep medical chronic polysubstanceabusers, have mother explained her poor and are appointments for her childbecause she was out "chasing multiple legal, social, andmedical problems. They often abuse, and the bag"that is, lookingfor drugs. Yet another mother ome from ahistory of impoverishment, that "I need this dependence. One mother, explained her pregnancy by stating intergenerational chemical keep me offthe streets". for example, told us howher mother taught her to baby to help slow me down, to Chronic drug use can impairand distort a parent's shoplift and then to sell thestolen goods on the street. and perceptions. Chronic useof mind-altering This motherwas introduced toheroin by her own thoughts hole I 0541Zero to Three BEST COPY AVAILABLE 93/"" and infant develop- with Substance Abusing and extended family about fetal History of Our Work ment and the special needsof drug exposed infants, Families as well as basicinformation about child nutrition and of The UCLA Department ofPediatric's introduction safety, 4) counseling for crises and management foster to substance abusingfamilies grew out of the UCLA daily problems for the biological parents, Suspected Child Abuse and Neglect(SCAN) Team. parents, and extendedfamily, and 5) coordination Newborns exhibiting withdrawal symptomsfrom and collaboration among all agenciesinvolved with prenatal exposure to drugs wererequired by the identified family. California law to be reported tothe Child Protective The multiple needs of thesubstance-abusing Agency as possible childabuse cases. The SCAN families necessitated bothinterdisciplinary an child development to interagency cooperation. Inorder to facilitate the Team enlisted our expertise in professionals were identify atypical behaviors thatmight be indicative goals of intervention, three withdrawal, and to assess the assigned to each family: a social worker,pediatrician, of drug exposure and month period impact of the parentaladdiction on family function- and public health nurse. During a 12 developed to identify severity these professionals worked with an averageof 5 ing. A protocol was families an average of dysfunction in both the infantand the family in agencies per family and contacted be made to the of 52 times. This need forinterdisciplinary and order that recommendations could the need for medical, ecnironmental, and interagency collaboration alerted us to courts about the specific training, for a wide range ofprofessionals, developmental needs of these children. abuse SCAN, beginning focused on the issues related to substance From this initial participation in A project for interdisciplinary trainingin the area in 1981 we developedclinical service projects, an abuse, was interagency of child abuse, including substance interdisciplinary training project, implemented for students at UCLA in thegraduate training projects, and aresearch study of the and illicit departments of psychology and education, developmental effects of prenatal exposure to professional schools of medicine, dentistry,public drugs. These projects had adifferent focus from health, law, social work, and nursing inorder to traditional programs that targetsubstance abuse. professionals to respond to these of development prepare these new Our emphasis was on the processes issues as they enter their chosenfields (Child Abuse in the children, the effectof the family environment and Neglect InterdisciplinaryTraining Grant, on the children,and the effect of wider social systems Department of Health and Human Services90-CA- on the children'sdevelopment rather than a medical 1343). At the same time, trainingfor interagency model focused on the addiction itself. cooperation between case workers inthe Department The clinical services projects included athree year of Children's Services and nurses inthe Los Angeles early intervention program, PROTECT,funded by County Health Department (Training,Education, the Department of Education,Handicapped Child- and Management Skills: Meeting theNeeds of Infants ren's Early Education Program(HCEEP Grant Prenatally Exposed to Drugs, TEAMS) wasmade 024AH50027) that subsequentlyspawned a state- possible through funding from theDepartment of wide interdisciplinary and interagencyOutreach Health and Human Services (90-CA-1194) Training Grant (HCEEP GrantH024E80008). Since The research findings from the earlyintervention by this time we were familiarwith the nature of project provided the preliminarydata for a research substance abuse we made the goals ofthe interven- grant from the NationalInstitute on Drug Abuse tion purposefully basic andrealistic:1) ongoing health (NIDA Grant RO1DA4139) to studydevelopmental care for identifiedinfants and siblings, 2) develop- patterns in children prenatallyexposed to phency- mental assessments and appropriatecommunity clidine (PCP) as a primary drug of abusein the referrals for the identified infantand siblings, 3) mother's substance-abusing history. education to the biological parents,foster parents, understand that the substance-abusing parentis often drugs can interfere with memory,attention, and unable to assume this primary protectiverole. The first perception. Mothers in ourstudies have had difficulty goal of professionals, therefore, is tokeep the child remembering their own children'sbirthdates. visible in the community m order to monitorthe child's Safety is an issue for familymembers, for professional safety in a dangerous drug culture staff who make home visits,and most of all for the families. Drive-by Unique qualities in the clinicaland research staff children of substance-abusing Bet Just. turnover in staffinginterferes with the shootings and violence wheredrugs are used and sold Further, formation of nurtm mg, non threateningrelationships are daily occurrencesin their neighborhoods. with substante-abusing families, continuityin the children are often in dangerbecause their addicted essential to success. protectors and advocates. clinical and research staff becomes parents do not function as just as several characteristicsof the drug culture and Infancy professionals whohave been trained to the demanding have a primary substance-abusing families are unique, acknowledge and respect that parents nature of the needsand problems in families requires leadership role in their children'slives must learn to

Zero to Three bum 1089 94 abusers not be surprised orinterrupted by people clinical and researchprofessionals who a staff of outside of the drug culture. themselves possess specificand unique qualities. both home and laboratory focused professionals who have The accomplishment of Dedicated, stable, and assessments is governedby a knowledge of families' personal maturity and innerstrength, who can be daily lives. Our subjects are bothdrug-abusing and poor. realistic and creative in theface of overwhelming social the first or fifteenth personal humility that Assessments cannot be done on tragedy, and who have a welfare checks are motivates them to organizetheir relationships to of the month when AFDC or received. Cashing and protecting thecheck from theft subjects and colleagues from a stanceof respect, help families and the (and often from other family members)and spending reduce attrition in both the subject days. Assessments professional team. Some membersof our staff have the money are the priority on these impact of the drug culture upon are also not scheduled onFridays and Mondays because seen the destructive and recovery family members or friends; othershave gone to great of the anticipation of, preparation for, from weekend activities. The windowof time for home lengths to become fluent in thelanguage of street, gang, It is and drug culture in order to betterunderstand families' observations is late morning to early afternoon. The staff are united too dangerous for theresearch staff in the late descriptions of their life experience. darkness and in common goals and takeproblem solving in stride. afternoon and evening because of increased gang activity after school dismissal. As one community staffmember asked, "How would we know we werealive if there were noproblems?" In our projects, staff turnoverhas been negligible When home observations are made forresearch and our research subject attrition rateminimal. In their is critical to the safety the subjects purposes, advance preparation relationship with stable intervenors, and abusers experience the rudiments of trustsufficiently to of staff. It is essential that drug dealers by people outside of the sometimes maintain contactwith their intervenors not be surprised or interrupted when they are in difficulty.When the intervenor- drug culture. subject relationship does notresult in maintained contact, the intervenor's ownknowledge of the Members of the clinical and researchstaff do not community and the community's trustof the intervenor take unnecessary risks in the communityby carrying 6nables her to locate the subjectswho have gone into purses, wearing jewelrythat looks valuable, dressing construed as sexually hiding. in a manner that would be provocative, stopping at service stations, orusing public children of substance- Unique problems in research on telephones. At the same time they arecareful to greet abusing families each person encountered in order todiffuse antagonism Locating subjects is only thefirst step in collecting be outsiders because they do It is often necessary to those considered to data at reasonably consistent times. not reside in that immediateneighborhood. Even with provide transportation, for the intervenor not only to these precautions, some neighborhoods arestill too but also methodically to structurethe addict's activities dangerous for any outside person to enter.In our in order to get thesubject to the laboratory for have had to drop six families study not only current research project we assessment. The intervenors in our who wanted to remain in the studybecause incidents and transport the subjects to the arrange to accompany associated with drug activity, including guns,shootings, the subject's home laboratory, they often must arrive at mental disorders, and known gangmembership put our up to 90 minutesbefore departure in order to wake difficulties notwith- preparations and their staff in personal danger. These mothers, and organize their own standing, the knowledge gainedfrom home observa- child's di esing and feeding.In their cars, our culture, conditions of inner formula, children's clothing, tions, exposure to the drug intervenor, keep diapers, city living, and an awarenessof the character of daily women's ( lot hing, combs, shoes,and personal toiletries children and their families arrival at the lab at the life events experienced by the to use as needed to ensure is essential to generatingmeaningful research hypo- appointment time. theses about developmental process inthis population, These extraordinary efforts arc notlimited however, of the complex Observations in the home are and to understandable interpretation to laboratory visits. findings. equally vulnerable to failure.Subjects who are addicted the quality of and leave. If they have Even when appointments are kept, forget, aren't awake and ready, disorganization found in the subjects'daily lives is also of other drug abusers and failed to tell their network evident in the laboratory. Research assistantsgenerally sellers about the appointment,they are preoccupied mother as much as addiction, and observation is need to focus on organizing the with activities of the or more than organizingthe child. It is not uncommon impossible. When homeobservations are made for must also act to for substance-abusing mothers tohave difficulty research purposes, the intervenors remembering simple instructions or toexhibit difficul- ensure thesubject's readiness. Insubstance-abusing For example, in a is necessary for the ties with attention and perception. families advance preparation that required the critical to the safety of the structured laboratory teaching task collection of data and is parent to teach her childhow to do a puzzle designed research staff. Itis essential that drugdealers and Zero to Three 95 (' 7- lune 10so 10 * k previous studies have for three-year-olds, the parentstruggled without as a comparison group since triangle so that it would fit into implicated poor prenatal care and difficult perinatal success to orient a events as the source of negativedevelopmental its appropriate spot.The mother then turned to the children experimenter and said, "Youneed to get a file to fix outcomes from prenatally drug-exposed this piece so it will go in." Parentsoften seek the (Chasnoff, Schnoll, Burns, & Burns, 1984; Lifschitz, attend, Wilson, Smith, & Desmond, 1985). researchers' attention for themselves or fail to The drug-exposed toddlers had significantly lower soothe or help their children feel comfortable inthe mothers who have developmental scores, but were still within the low assessment situations. Some average range. Because standardizeddevelopmental recently taken drugs fall asleep during the laboratory assessments imposed an external structure in which assessments. an examiner directed the tasks for thechild, the children Current findings from our ongoing research appeared more competent than we clinically judged Our current research is designed to extend our them to be. Our clinical observations led us to include understanding of the developmental sequelaeof within the research assessments an unstructured free prenatal drug exposure and the effects of being reared play situation that required self organization, self in a substance-abusing family. We wanted todiscover initiation, and follow-through without the assistance where normal processes of development hadbeen of the examiner to guide the task. In that context, the altered and which developmental processes seemed drug-exposed children showed striking deficits. The resilient to the impact of a dysfunctional prenataland drug-exposed children had significantly less represen- postnatal enviroment. In determining issuesfor tational play than the high risk preterm children. Play assessment we were guided by two principles. for the majority of drug-exposed children was First, the effects of prenatal drug exposure would characterized by scattering, batting, and picking up and be found in a continuum that ranges from mortality, putting down the toys rather than sustained combining to anatomical dysmorphology, to moresubtle behavioral of toys, fantasy play, or curious exploration. Repres- effects; severity of effect and rate of occurrence inthe entational play events, such as combing hair, stirring population would be inversely correlated (1988, a pot, and sitting a doll at atable, were significantly September, Prenatal abuse of licit and illicit drugs. less frequent and less varied in the drug exposed group than the comparison group. Proceedings from the conference of the New York When we looked at the Strange Situation paradigm Academy of Sciences). Our observations and knowledge (Ainsworth, Blehar, Waters, & Wall, 1978), we found a similar pattern of average scores yet verydeviant Drug-exposed toddlers score within the low average behaviors. The drug-exposed children did not have a range on structureddevelopmental tests, but they show significantly higher percentage of insecure attachments striking deficits in free play situations that require self than either the preterm sample or that expected in a poverty group. However, the drug-exposed childrendid organization, self initiation and follow-through. not show the strong feelings of pleasure, anger,and distress in relation to novel toys and the caregiver's of normal child development taught us that develop- departure and return that the attachment assessment mental and intelligence tests alone would be inadequate was designed to elicit. Moreover,the majority of drug- in demonstrating the subtle deficits thatwould be most exposed children had insecure attachments character- common in these children. ized by disorganization rather than organized patterns Secondly, we recognized that the alternative of avoidance or ambivalence. The antecedents of the postnatal rearing environments in which prenatally disorganized classification need to be carefully under- drug exposed children are placed would mitigate or stood both in the parent-infant interaction and in exacerbate the adverse effects of in utero durg possible biological factors within the infant. exposure. We understoodthat haphazard placements In comparing securely and insecurely attached by the courts, which resulted in somechildren being children within the drug-exposed group, we found that reared in foster homes, some with extendedfamily, and the insecurely attached children had significantly fewer other with their biological mothers, presented anatural play events and poorer quality of play than the securely experiment for disentangling the effectsof prenatal and attached children. Even though the securely attached postnatal environment (Rodning, Beckwith, &Howard, drug-exposed children had more play events than the in press). insecurely attached, both groups were still more sparse In our first empirical study we compared 18prenatally and disorganized than the preterm children. Since a drug exposed 18-month-old toddlers to asample of high link between representational play and language risk preterm toddlers (Beckwith, 1988)who were of acquisition has been demonstrated in other studies earlier age and lighter weight thanthe drug exposed (Bretherton, i98i, Largo and Howard, 1970), we also the children, of similar low socio-economic status,ethnicity, anticipate problems in language development for and single parent households. Welooked at the drug-exposed children at late.; ages. children's intellectual functioning, qualityof play, and The data from that initial study, and the preliminary security of attachment to the parent orparent figure. findings from our present research project showed that prenatal drug exposure increased the initial risk evident High risk preterm children werespecifically selected

Zero to Threelune tam)

BEST COPY VAR iSkr" at birth byextending the organic, physiological effects. 1) into emotionaldevelopment in affect regulation; 2) into socialdevelopment in the organization of relationships; 3) and into cognitivedevelopment in the representational and symbolic aspects ofchildren's play. The rearing environment,through fostering secure attachment, mitigated the impact ofprenatal drug exposure ondevelopment to some degree, but did not eliminate the effects entirely. Clinical and research implications Children of substance-abusing parents are living in unstable, often dangerous environments, cared for inconsistently by parents impaired by chronic drug abuse. Postnatal environmental factors andthe possibility of biological impairments pose grave risks to their healthy development. Whileresiliency and change are always possible for the child and for the adult, resiliency cannot be taken for granted. Developmental effects of the multiple adversities that children prenatally exposed to drugs and growing up in substance-abusing families experience daily will have an increasing impact on the educational, medical,social welfare, and justice systems in our society. This burden will only increase as the numbers of children in these circumstances increases. Clinicians and researchers now face the challenge of identifying the services that will prevent and remcdiate this social tragedy. Communities that are only now organizing their systems of law enforcement and drug treatment to deal with addiction in adults must turn their concentrated attention and expertise to these vulnerable children as well.

References Ainsworth, M, filehar, M., Waters, E., & Wall, S. (1978). Patterns of attachment. New Jersey: Lawrence Erlbaum. Beckwith, L. ( / 088). Intervention with disadvantaged parents of sick preterm infants Pirthiany. 51, 242-247. Bretherton, 1 , Bates, E., MeNe;.1, S., Shore, C., Williamson, C., & Smith, M. (1081). Comprehension and production of symbols in infancy: An es.perimental study. Dmelopmental Pshehology. 17, 728 - 736. chanoll, I., Schnoll, S., Burns, W.I, & Burns, K. (1984). Maternal mutilation: substance abuse during pregnancy. Effects on infant development. Neurobehavioral 7 ontology and Triatelogy. o, 277-280. I itiwArd, J. (In press). A prevention/intervention model for chemically dependent parents and their offspring. In S. Goldstun, C.M. lieuticke, R.S. & ). Yager, Preventing menial health disturbanies Jr childhood. Washington, D.C.: AmericanPsychiatric Press. Kaltenback, K., & Finnegan, I.. (1484). Developmental outcome of children burn to methadone maintained women: A review of longitudinal studies Neurobehavioral Toxicology and Teratology. 6, 27I- 275. Largo, R., & Howard, J. (1979). Developmental progression in play behavior of children between nine and thirty months: II: Spontaneous play and language development. Developmental Medicine and Child Neurology. 21, 402-503. Lifschstz, M., Wilson. C., Smith, F.., & Desmond, M. (1485). Factors af (Tung head growth and intellectual function on children of drug addicts. rediatrus. 75, 20-274. Rosdning, C., Beckwith, L.. & Howard. J. (In press). Prenatal exposure to drugs: Behavioral distortions reflecting CNS impairment?In I Cranmer and R. Wigginis (Eds.), Drag Abuse ani Pram Dreelement. Ai kansas. limit Press.

BEST COPY AVLLikE Psychological andBehavioral Effects inChildren Prenatally Exposed to Alcohol

Ann Pytkowicz Streissguth, Ph.D. Robin A. Lahti!, Ph.D.

children with I;AS. A recent 10.year Samsun 19140), aril WM11441131 414.`Velip- Alcohol is nom recogniled as a terato- Mellt 01 the mulatto; pathway in the genic doo. meaning that prenatal expo- followup study of the first children gisen this diagnosis (sec article beg lll ing tin (minimum (Pettigrew and it sine can cause adverse effects tothe tuf- intellectual del- I9H-11- The findings ol kir and col- soling. teratogenic drugs were page 131 indkates that the wits and the academic and behavioral leagues (19X.1) suggest that !emit:mon III thought of in terms of their ability to in- 110141110114: systems may also be li) duc physical malformations to offspring. 4411111111e 11110 adolescence. l -etal the pienatal alcohol exposure and that sow but now itis recognised that teratogenic alcohol syndtome has been tel most frequent teratogenic cause ofnvmal of the aberrant behaviinal ellects assoti 'hugs man cause death. malloonalions. ated with alcohol may he hormonally gissIli deficiency. and functional deficits tetholation in the Western World 'Wien aril Smith 197f11. niediated. 1971). 1)111m:ices in the dose. Genet:it conclusion% limn the annum It liming and conditions of exposure. aswell The present paper will hist %us lllll Wife the animal liter:time on alcohol a-, a search on menatal alcohol Meets include as ditlec.ms es in individualsensitivity.. ac- the lidlowing: 111 Thew es a dose- neurobehavioral tel fa pienatal In- count 1414 41111e0111431 OU1COMCS.111111411Cds the inarni. ducer ol detects) and then will discuss the respinew telationship houeen 01 sindies using laboratoryanimals under empsocal and clinical Inklings with re lode ol the dose and the sevetity of the el ,ontrollcd coniliiiiins have confirmed the beet (Horgan and Rainfall (ingo;t.!) lemiogemcity of alcohol even though sped to the psychologual andhehavitnal Meets in addict' prenatally exposed to hehaiotal effects ate olisersed at lesels of Mier conditions such as maltualrif exposure too low to poiducemalloona real mg conditions. and useof other drugs alcohol. awl Neurobehavallal effects of teratogenic lions and growth deficiency Iltliggaii often twary with alcoholism in human 19X tf. (tt the (malformation inducing) dings are dill, - Randall 14)K1), Abel et al beings. timing ol the exposure is an 1114)4111am 1 as cult to establish in humans becausebehav- Some ieratogenic thugs are also recog- 19)(.11. ior has so many determinants and often for in the ellects produced tSulik wed as oeurbehavioral teratogens in that and 14) large individual ifilletemes exist pienatal erposure can produce lunctional dillicult to measme. However. carefully controlled studies on laboratory animals in vulnerability to damage trim, a gOcti impairment and almminal behavior in off- &vie of alcohol ft'heinoll 1977: Su:11111(p spring (Vortices and Butcher19112). I'm have shown that prenatal alcohol exposure can produce a vatiety ofneurobehavimal and Crumpacker 19771 drugs that poiduce neurobehavioral el- 'the tem:tinder ol this paper still discuss Ws. the functional deficits arc usually effects including hypciactivity. decreased learning ability. poor lcomotion. thine types ol alcohol-telated efteets tin ponlaced au lower of exposure than tlw behavior and peilltaniati col picim those required III produce physical malfor- them:dm:aim. developmental delays. sucking and teething dilticulties. antite- tally exposed children. mations Akethol has been calledthe most I itehaviood poilitems of v1111111'1 nab spoose 41111111010U (Abel et atPM t; I 1onitivinly used neurobehavioral tetatogen Streissgmh and Martin 19X 1: Stieissguth file 14131 314:01401 s),041,040v. {hitching% 19111.)). Mil. Animal studies are important ha II Behavioral problems of cluldien of al The chikhea most severely atlectedby coholw inottwis, itiespecioe of the diar prenatal exposure to alcohol arethose understanding the behavioral and psycho. logical consequences of pienatal alcohol sus- % IAS: and with a diagnosis of lend alcohol syndrome Behavimal desianons iii thildien 01 exposute in I ass and for tdentilying (1;ASI thew children ale growth deli- modeiate to heavy drinking millers cient. have a cluster of physical*suitor- the mak:flying central 11111401.1s system defects. Alcohol effect% on the bothhave mations including a characteristic laceand been shown in studies of hippocampal Behavioral and Developmental they have a high risk of being intellectu- Problems of Children obit Fetal ally handicapped. Chrome alcoholic changes (West el al. I9)-1). decreased cer- ebellar weight !Borges and I .ewis 1910.). Alcohol Syndrome mothers who continue to drink during &creased total brain weight (Ma/ and Chilthn recel%ing a diagnivos ot tend pregnancy are at increased riskfor having

6Alcohol Health and Research World

98 udancy, hypotoma fa condition of dunin 1111111111111111111111111111V islwo muscle tone) and delayed devehy children having the fetal alcohol Figure 1. Common facial characteristics seen in non' arc often noted. Its the pit:school !hose most frequently seen in syndrome. The characteristics on the left side are years children with 1AS oltos ate side are less specific. Source: the fetal alcohol syndrome. Those on the right hypoactive. nementive, impulsive, fear the Fetal Alcohol Little and Streissguth 1982. *Alcohol, Pregnancy and less, and demowarate p4101 1111111)r I MCI itm Syndrome" Unit in Alcohol Use and Its MedicalConsequences: A Education. Project Cork of ISM:MI:nth et al. 19781,). Neural mile de- Comprehensive Teaching Program for Biomedical fects (implying mimy to the eintnyis dur- is available from Dartmouth Medical School. This slide/teaching library unit ing early ('NS formation) have been suited MD 21093). Milner Fenwick. Inc., 2125 Greenspring Drive. Timonium, in several cases (('larren 1981:iedman 1982). In cases that have etc to autopsy Clones and Smith 1973; Malewski 1981; Clarren et al. 1978: reillo et at.19791, microcephaly epicanthal folds diminished brain growth has been noted, as well as abnormalities ofbrain low short palpebral development. nasal bridge Mental handicaps arc probably the most fissures debilitating aspect of !oat alt (wl expo- minor sure. Although slow desehipment and flat midface ear anomolies mental retardation hive trequently been descisbed as characteristics ma:M- snort nose ardi/ea IQ tests have not always been indistinct philirum carried out to t hmeal studiesIn an early report on 20 clulthen with IAS diagnoses (il varying degrees of sevetity tStsossgudi thin upper lip micrognathia et al. 1978b1. the average IQ was65: Courtesy of Strerssfietti et at however, wide differences of intellectual function were manliest, will. ID's ianeing Irons 15 to 105 (we lime II. Thus, tt alctihol syndrome have a trilogy of symp- or pi nimbi y total alcohtil syndrome." or would not be advisable to make a firm and "petal alciamt Oleos" depending on the predictum 01 nwntal etaidatum lust be- tom% including: (I I giowth deficiency of FAS. In microcephally, 12) dysmorphic diameter- prethleditin of the examine:. cause an infant had a diagnosis the afiirementioned study, severity of ;sties honor physwal anomalies):and f3) Most studies show that there are ap proximately twist. as many children called growth deficiency and dysmoiphology central nervous system (('NS) dystunc- IQ. wall the non Their mothers ate usuallychronic af- "mildly Metier as "severely affected." woe significantly ichned to t:0)01W, who were abusing alcohol duringChildren with :attain! syndrome are lust severely :heeled patients generally the average the pregnancy Whalen and Smith 197K: the most severely allected: they arc the having the lowe.a scores IQ of vatious samples of persons with (larren 1981, 1)eh:tette 1977: Maley:ski must growth th:lictent, and most dystnoiphic. and the most likely to be 1-AS will depend on the age at testing, the 19781. Figure1 depicts the must frequent Lida! characteristics. Figure 2 shows mentally telakleti (StICIsintill et al. kinds th tests administered. :.nil the man obtained mime children with fetal alcoludsyndrome 197861. Chdthen with only sonic ul the no in which the sample was 11AS) Heart defects occur in 30-40 per- characteristics of the Icial alcohol syn- While retarded mental development is well iciognind as an tmontant leanue of cent of the patients with FAS.The fie- drome may have intellectual Itmcnon FAS. teeella Uorl. limn Beam (plenty of other congenitalmalltirmations within the nut nal core However. they lie 1412o. I9S2111 has te is elevated as well (('lairoland Smith can. manifest a variety 01 maladaptive (titemliatisen CI al hasiots and tattle milifIC (NS ellech. tit waled a wideiNittlitt ul tkunfits 191S) t tutting Icationg disabilities,speech and signititanth difteteunaied thluhten with henatal alcohol exposure pittances a a omits): pony of :knout did specutun of ollspring Meets, humcause language poilslems, hypo activity. and FAS I then. minding head and both nwking. that ate clumally observable in theintli attemumal pioblems Although I.AS strentYped helm% ohs. sps-ech and healing vulual child (such as FAS) to those it:gno- well detmed, considerable contusion presently exists tee:tiding these "partial" el impairment. clumsiness, difficulty with me statistical studies OH groups411 peers. and management moblems. This &CO in

Fa111985 7

9 1(L) BEST COPY 17,71 71. Prenatally Exposed to Alcohol Psychological and BehavioralEffects in Chikken

show several of the commonfeatures fetal alcohol syndrome. Allthree of these children bridge. Note Figure 2. Children with the short palprebral fissures.epicanthal folds, and low nasal including the indistinct philtrum, 1973. associated with FAS they relate to racialbackground. Source: Jones et at. the differences invarious of these features as .^..,

40101118.41",... 't boo.. 7

(1 hey welt: nut matched Icemanikliig. al. had 1Q's in the mildly reiaided range in At 12 months ol (Streissguth et al. 197Ra. Darby et late adolescence. wink the youngest 1r:- 1110111C1. s age. or pinny 19t(I). lit flee former study. webuild that age, the infants ofalohrti.abusing wanted moderately retarded.lostib's find- these patients as a group,did mil show mothers were sigmlicantly delayed in ing is in keeping with our clinical nitrites- in It) over time. plivswal posedh and in mentaland inter any remarkable chimge stun that successise IASchildren ol a llowever. four irxhviduals showedconsid- deselopment m comp) oson withcommis given mother. will beincreasingly al- erable change in one direction oranother to Recently. we completed a limp icon (coed as lung as the mother cimonues story begin (see Figure 4). Thesmall sample sue colleagues 10 -year follow-up study (see rxmuit systematic e-sioni abuse alcohol. ikhaene and diddle', to = 19) did not (1M), in France. have made the same ning on page 13) ol the first 11 nation of environmental factorsassociated given a diagnosis ol f-AS bad, in1971 although observatirm. IStieissgoth et al. 1985o. Jones etof with large changes in IQ sews, lit another recent cep oll 110111 ourlab increasing 1973). Two ol the cluldien weredead and decreased hyperactivity with (Dai by et al. 1981), we focused onthe age may have permitted amore valid test tight prognoses for childrenValli a diagnosis of one was not bicated 'lbw of intelligence in some children.Social (art whom six were teenagers)(cumuli%) Wine- FAS at both or within the hist few tot head and emotional Illiprovemeni were 01 eight growth deficient 1411 bright and absence of months ol life. Out ol a sample tall of Hines apparent esen in the such mlants followed lot 1.5 to6.5 yems, cuctingelent e Ilowesei. the guts clear U) change.. particularly whenthe liv- tIme apirt only one child (the one with theleast se whims had leached menaiche ai ing situation hadempower!. Our clinical art lst had pirate age) wile no longergiossih . who had verc physical chinacteitsnes 1111, sample included Iwo young men limits at lisllownp deficient with tespect to weight retarded (un- an IQ within mitmal been diagnosed as mentally with the study suggests that the fthySICA 2 years ol Thus, eltildtez% who ale diagnosed known etiology) as early as hill syndmme at built appear tobe a minus m the pubescent pesos may and 21 yews, when the growth detwiency age. Later, at 20 group most al risk Inr poordeveloppient. not necessarily include diagnosis of FAS was made, theyhad 1(r for weight. The adolescentgut. in this sociall: Another shortterm notcome study which ol 57 and 67. Although they are 12 children study were shoat and ovetweighl, (Golden et al. 19821 examined good engaging. they have masteredonly de- diag- changes their ovetall appeagance a skills. We an- with possible Mal :denim! Oleos litho mental reading and writing asteitamed deal hom the thin, almost emaciated. continue to need nosed at birth Cases weir We belse ticipate that both will from medical records notingmaternal at they Mien had when young. this change in adipose tissuethat sheik:led etivitonments. ening abuse and firms physical examuct Insub et al. (19)(1) basealso reported chat adenies 111111 alfoleseent galswith 01 the neonate (*ontiols wene lollowup three: sib- I FAS may he one faun that at t 4111111511)1 on the long-term matched on gestational age, sex.and race. ling, with FAS The twocider siblings

8Alcohol I lealth and ResearchWorld 1 100

BEST CC''V r"r"h,111;o14r E has been the acgree to which the mental impairment derives from prenatal ethanol 20). Figure 3. 10 in 20 children with fetal alcohol syndrome: Aclinical sample (n exposure rather than to the unfavorable The figure shows the relationship between 10 scores andthe severity of environment erten powiited by the alco- and the more diagnosis. The more severe the diagnosis, the lower the 10 score holic mother who continues to drink. cognitive deficits are noted. Source: Streissguth et al. 1978b. While this issue cannot he resolved in all cases, some children with FAS have been XIO Range of JO Severity of Diagnosis (N) raised entirely in excellent foster and adoptive homes and yet have continued to (4) 82 60 to 105 Mild 3 Very Mild he retarded (Strcissguth et al. 1978b; 59 to 81 Moderate (6) 68 Olegard et al. 1979). Furthermore, the de- (5) sa 15 to 89 gree of mental retardion in older chil- Moderately Severe dren with FAS seems to be more directly 41 to 69 Severe (5) 55 a reflection of the chronicity of the mother's alcoholism during pregnancy 65 15 to 105 than of the caretaking environment. Summary (20) (Strcissguth et al. 198: Steinhausen SitemsoNa Norman 6 Sm.", 1978 1982a, 19826; Aronson et al. 1981). Thus, when a diagnosis of fetal alcohol syndrome is made at birth, the prognosis will remain guarded, at least through the the 'el:lovely small number of adolescents learned the mechanics of reading and early schoc years, panieularly in those who have been identified to date. spelling and were fairly independent in Dour of these original children with daily life, although at least two appear to children who are the most dysmorphic and the most growth flefLient. Close surveil- 1. AS were clealIN mentally handicapped he at risk for social and emotional functioning intellectually in problems. lance of the needs id both mother and on child should assure that the child has a be- the booleiline to severely-regarded range A continuing question in assessing re- ot intelligence (IQ seines of 20 to 57). tarded functioning in children with FAS nign environment in which to develop to These children all were living in protected env it iminents and attending specialclasses lot the !moted. They will always need Figure 4.10 of children with the fetal alcohol syndrome tested ontwo occasions, hehereJ envioninients. They manifested 1 to 3 years apart. 10 scores from test #1 arerepresented on the abscissa, those poor judgment, were indiscriminately from test #2 are along the ordinate. Circled points representchanges of one wildly. and had not changed much in IQ standatd deviation or more for the tests given. Source:Streissguth et at. 1978a. ores across Mlle. Figure 5 shows oneof children photographed at four Miler- erit agesAll of these severely affected ctillthen h,ul been in excellent, stable !Os- lo in Inane\ tot at least S years. 1 wo had never lived with their natural inothers: the other two had a history of 11- neglect andmi child abuse while living with then alcoholic mothers. 'Ile degree 1,, which early adverse conditions contrib- 11- uted to their Imo intellectual handicaps tutu be docinunedI lowever, ens iron- oictital umniivements were associated 1 V. libMI11410.11 de 11111114)Veiiklit in their .16 11 it 1.11.111t1 emotional behavior though not 4Mi ,s men intellectual functeiming. 111 "1 he ientaming tour original children with teial alcohol syndrome were funtioning intellectually in the borderline- SI- to dull normal range of intelligence (IQ fit Wit art the It) year tollowup. They at- tended regular classes but received special tesneilial help and tutoring during the pri- 11- mary school years and had oftenbeen kept hack a year in school. Schoolwork was increasingly difficult by the time they 11 11 N IN teat bed middle school, and schoolattend- 1$ i1 N IS ane was becoming a problemour the two II es Hilt living in the least supportive environments All of these four childrenhad

Fall 19859

101 II , C'S;rcif-- 12 4.Q? fr; Psychological and Behavioral Effects inChildren Prenatally Exposed to Alcohol

mothers arc at risk when FAS is diag and 8 nosed in a umlauts. On the other hand. syndrome at day 1. 8 months, 4.5 years, the caretaking environments of even the Figure S. Child with fetal alcohol 1973) and has diagnosed at birth (Jones and Smith mildly affected children should he caw years of age. This child was very good. home where the quality of care has been fully monitored, as these may he the chit spent all his life in one foster and He has received various types ofremedial help, including corrective lenses dren for who the prognosis is best if ap- 10 has remainstable ear tubes, and was placedin special education programs. His propriate interventions are available. at 40-45 and he has beenhyperactive and hyperdistractable throughout !Mains with FAS and 1AI'. arc at risk childhood. Source: Streissguth et al.1984c. for failure to drive and for sullying neg lect or abuse when they live in alcoholic environments Furtheimme, then pool .474:er* S'esimiler sucking ability, medical pioblems, and hyperactivity all may snake them difficult 4.; to manage. As they get Wei. the condu. station of these011111101'Salert. lesponsive manner with then deficits in pulmentand earning makes it paniculaily dillrcrdl fur :. caretakers to set realistic eXpeClalIOns Strong support systems are milkmant for vgi-Nrm. such families. We usually !nod peat imi4IVelliill tit emotional development and social lune- tinning when shildtcn with hodi Intl and partial FAS have stable and supp,irive , living arrangements (Stieissguth et al 19711b; Aronson et al. 19K I )loquovcil behavior, winch alien occurs even in the absence of changes in IQ. should tug be ipotesi simply because n Is 11101e thilicalt to measure and quantify. The needs of the individual family may rangy I salmis"' and alcoholism treatment far the mutual mother to felIOV;11 01 the child Isom a neglecting or abusing environment. Sup- port in behavioral management and academic Owning lor the caretakers is al most always needed, whether they bethe natural parents. natmal relatives. luster parents. adoptive parents. in a single pai cnt raising the child aloneIn managing the individual child with VAS, we rcom mend giving every oppommily ins lull tie velopment of the child's potential

Behavior:1 and Developmental Problems in Children of Alcoholic Mothers Not all children of alcoladre mothers have FAS and not all have licV1:1011111C111.11 01 behavioral problems.Veis lea studies have tuklresse.1 the question of what pro plution dal aletilsolic motheis 11.ive cluliben with FAS. 'llus WI:MIMI Is rumples be cause the answer will ik.pend onboss se vesety aleoin.lic the mothis ate and on ft0141":. characteristics that seem to pot some mothers at higher risk than tuners tut has log an allected childIt is also clear that canine chiklren of alcoholic niotheihaw the hest of his or her abilities. the children entered school The Ince children horn to these mothers were developmental and helms total inobleins In our 10. year followup of the eight th amimg the lour no-.l severely apart lonr the itaapholiigical and gum osiginal children with an FAS diagnosis. changes aMIL sated with 1.ASIn we lounit that three of Ibis, eightmothers capped children in Ow %Only Tints. one and then two studies of luldien ell altollit had died of alcohol-related causes before Can see that loth the chattiest

10Ak.-01101 health and Research Wirld

102

rirqTerrt"41111 "1r-1PLE that tIK: proportion of children with FAS mottles.. wen: tnoned.. one from Russia leagues (1981) of au earlier study retro- may be lower than this 10 SOUK: groupsol hotygm 1974) and one from Seattle tOlegard 197')) presents data from a spective study of 99 children horn to30 alcoholic mothers. In our Seattle sa mple. thines el al174). Shinygin reported on alcoholic mothers. Compared to expected the women were not only recovered alco- 42 chthlten boot to IX alcoholic mothers holics but were mostly well educated and ottsprine horn poor to norms, they found a 5-toldincrease in low Rte,sta. 'me Iron middle-class backgrounds. 'the the motheis' alcoholism displayed dinar birth weights, a 10 told increase in infants itchy- samples described by Jones, Majewski. that were primarily "vegetative. emir- called "small" fOr gestational age at de- and Deform: were mostly unemployed, Inmal, and behasnnal." with symptom on- ety, and twice the number of preterit 35 poorly educated, and at high risk on many set al 9 to 01 years of age and symptom liveries. In icons of ('NS dysfunction. percent had borderline menialretardation other vart...bles. Factors associrted with remission %cull improved social circum- individual vulnerability to alcohol have the (lQs of 70 to 85); 13 percent hadmild to stanes On the other hand. many of not been thoroughly studied. 23 children who were born alter the severe mental retardation(IQ below 70); 50 percent had symptoms of braindam- Thus, it may well be that the prevalence mothers became alcoholic bad "prolOund depends age; and 50 percent had psychosocial of FAS among alcoholic women impairments of the CNS that weremani- factors that are problems. Early placement and continued on a variety of other risk lest catty in infancy." Fourteen of these variables residence in single lOster homes did not only now being identified. Such 23 were mentally retarded with concomi- genetic factors. significantly affect intelligence or symp- may include racial and tant mallormattons and charactistiesof Certainly, it is clear that the vulnerability toms of brain damage hot didresult in FAS. of the fetus is one important factor.Cases The study by Jones and colleagues of reducing the frequency of psychosocial symptoms. A subset of these childrenof ul fratental twins (Chnstorfel and obrittrip of ah.irliithe mothers 'Milted Salatsky 1975; and unpublished (MC% data gathered tor the Perinatal Collabra- alcohohes compared with a well-matched IQ from our own clinical observations)have tive Study of the tinnier NationalInstitute control group had significantly lower impatred motor shown that twins can be differentially in Neurological Diseases and Blindness. scores and perceptual age, affected. A.1-oholic and C0111101 1110111ers were care - function. and persistent !nowt!) defi- front this Some studies have suggested thatthe hdly on a variety or factors that ciency Two recent publications arife (lieu findings on a prevaloice of fAS is relatively higher could be expcded to influence outcome. groups alcoholic women 11)3 offspring of these 30 alco- alining certain groups of Mew ete sic Welt/00110C status, race, sample t,1 The ex- holic mothers. Ammon and colleagues such as the poor and nonwhites. maternal age, parity. marital tern to which this apparentrelationship is slams. and hospital of birth. However,the (1985) discuss the perceptual and such as behavioral outcomes; Kyllerman and col- influenced by other related factors ih oholic mothers were severely chronic other drugs, or to leagues (1985) discuss their growth and poor nutrition. use of oholics. and both groups of mothers differences in actual drinking patternslu.s %%etc 11t011 low SticiteC0100110:levels and motor performance. studies of more Le.anung disabilities in children with not been clarified. Larger were pool iv educated Data weregathered diverse groups of alcoholic motherswill prospei lively in a "blind" researchdesign normal IQ have been reported in one clini- In cal study of children of alcoholic mothers be needed to answer these questions. Ii t'., eXatIlltierS and authorshad no addition to the risk of FAS and fetalalco- knowledge of maternal history at the time (Shaywitt et al. 1980). Iklays in onset of in mind that speech have also been reported clinically hol effects, it should be kept the were gathered I Comparedwith the alcoholic family environment may coffin)! mothers. offspring (Shaywitt et al. 1981). In general, the ott Tong of children of jets iardize optimal offspringdevelopment in 2 I alcoholic mothers had ahigher rate area of language problems in (ei- alcoholic mothers has not been well stud- in other ways. Several reviews in infant mortality t17 percent vs.2 per- Guebaly and Orford 1979; McKennaand t-inn. a lughei incidence ul growthdefi- ied. It is ma clear at this point whether the observed delays arc simply related to the Pickens 1981) of behavioral problems in ctency, , and a Inghei proportionof retro- in gen- children' developmental delay and intel- children of alcoholics conclude, spctively classified FAS (32 percent for eral, that such chilthen arethemselves at this sample vs .4) percent). Intelligence lectual handicap or to specific language deaths, and disabilities. Further fewarrh is needed in risk for alcoholism, accidental testing at age 7 indicated thatoffspring of poor school and jobperformance. Inevita- the t iti..tett al.obnhrs had significantly this area. Maiewski and colleagues (19710 in bly. each child's developmental outcome towel Itscow, than the contort children represents an interaction betweenIns or the Germany, it:porting on children born to a IS I vs 9s) foolwoinne, 44 percent of her genetic potential, prenatal exposure. (Witten of alcoholic mothers had Ill'she. large number of alcoholic mothers, found that the proportion of children with "fetal and postnatal experience. low 79 c pied with only II percent of the controls As Itscotes are also Whs cmhyrnpathy" (the descriptive term preferred by Maiewski) was related to the Behavioral and Developmental cocct by genetic 1IC10tS, these childIQ to chronicity of the mothers' alcoholism. Problems in Children of Moderate- scores should not be generalind toall Ileavy-Drinking Mothers children of alcoholic mothers, as this wasThus, in mothers with the most advanced and chronic alcoholism. 43 percentof the Women who consume motkrate to it select group. flowerer, thisstudy points heavy levels of alcohol during pregnancy offspring had fetal cmhryopathy. For up the added impact ofprenatal alcohol have an increased risk of adverse preg- W011100 whose alcoholism was inthe "crit- exposure upon children who arealready at dose and ical" phase. (according to the Jcllinckcri- nancy out..omcs, depending on tisk. Academic functioning (reading, teria for diagnosis), the rate of fetal tinting of exposure and on individual sen- spelling, and arithmetic scores) werealso einbryopathy was 20 percent. An unpub- sitivity factors. The related studies arc significantly lower than normal for the studion lished study from our clinic, on 50chil- usually large-scale epidemiologic children ii1 alcoholic mothers inthis in which some of the confounding vans- dren of recovered alcoholic womenwho study. suggests files can be statistically adjusted to assess A recent update by Aronsonand col- were drinking during pregnancy, Fall 1985 11

lt 103 an COPY AVAILABLE Psychological and Behavioral Effects inChildren Prenatally Exposed to Alcohol

children lies in their presumed assciation .Owycr ct al. 1978). subtle effects. Most such studies have ex- signifi- with later ('NS function and in terms of attuned (anemic variables that ate easily Neonatal operant learning was whose the implications for later learning and obtainable frum hospital records such as cantly decreased in offspring and attentional deficits in school. From a later birth weight, birth length, head circumfer- mothers wcrc both heavy drinkers heavy smokers (Martin et al. 1977).liven followup evaluation of the same children en ce. gestational age. morbidity,and mor alcohol 'elated effects on attention and re- at 8 months of age, childrenof heavier tality. Several studies indicate that moder- signifi- action time are still observable at 7 years ate to heavy drinking during pregnancy drinkers had small but statistically cant decrements in mental and motorto of age (Streissguth et al. 1985 /11 increases the risk of decreased birth-size 'they In evaluations the effects 01 prenatalal parameters and increases the risk of spon- velopment (Streissguth et al. 19811). height. cohol exposure. one should keep in mind taneous abortions and stillbirths, although also had continued decrements in humans weight, and head circumference at that the assessment 01 expostne in not all studies show significant effects on is imprecise and derived by averaging all variables. Reviews of these studies arc It-months (even alter adjusting for many other pertinent variables) 'together. these self-reprts of women whose individual available elsewhere (Little et al. 1982; onsulmably behavioral studies suggest that maternal patterns of consumpinm vary Streissguth and Little 1985). woman 110 woman and limnweekt alcohol consumption darling pregnancy f Behavioral outcome studies of moderate week .1 bus, any reference to -ounces pi prenatal alcohol exposure have been less related to higher risk of subtle ('NS dys- tough function in exposed offspring. The pre,s day" should be con...Dued as tudy a frequently carried out because it is diffi- estimate. In reviewing the helms final et once of some measurableadverse ellects cult to use behavioral outcomes with frets of modetate to heavy picrimal even prior to hospitaldischarge suggests larger groups of infants and children. hod exposure. we have concluded else llov.-ever, several investigators have stud- that these CNS effects arc of prenatal on- gin. Furthermore, most of these studies where (Streissguth et al. 1984( ) that the ied newborn infants in rogation to prenatal .1 he have adjusted statistically for imponant effects are generally dose-iclated alcohol exposure. Ouellette and Rosen magnitude of the Meet and the shape and covariates such as maternal smoking, par- tom) significantly increased maltOntlia magnitude ol the tlose response distobo nuns, jitteriness. weak sucking. and ab- ity. and eduvat . ol the our Even fewer studies of the long-term non appear to be a filltdiou normal sleep patterns (Ouellette et al. COW IOCaStIled aril the ageof the ay.e.o. 1977; Rosen ct al. 1979). Alcohol-related behavioral sequelac of MOdelate prenatal exposure are available A report burn anent. Increased risk of clinical disttubance in sleepwake patterns over abnormality in the individual child at 4 the first few months ol lite have recently Germany (Mau 1980) has documented no mound 2 or alcoholrelated decrement. in develop- years of age seems to occur at been reported in a new sample of children day timing mental landmarks, neurological develop- or more of absolute alcohol per (1-andesman-Dwyer et al. 1983). pregnancy (Streissguth et al1984( I. The Seattle longitudinal study has re- ment, or malformations. Alcohol use was primarily defined as "dunks a little every However. for the more subtle behaviois ported a variety of neonatal effects signifi- such as anentional deficits arc) MOW ICJi- day"; no standardized neurological or psy- cantly related to increased alcohol use tion time. where group ellects are oh choloi!ical tests were used; developmental even when adjusting forother risk factors served, a monotonic slope is predicted. such as maternal smoking, caffeine use. data were derived from maternal diaries: statistical analysis was by chi-square. It suggesting that the greater the exposure, parity, maternal education, andnutrition seems unlikely that subtle long-termel the greater the elleet. II which have been summarizedelsewhere ( Strcissguth et al. 1981; Strcissguth etal. frets would be observed using such gin.. 1984c). 'the alcohol-related outcomes measures. Two separate longer-term followup studies ol 4-year old children have included (I) slow habituation to re- This research revs firs): lie published in dundant stimulation assessed with the whose mothers were primarily moderate drinkers (Landesman-l)wyer ct al. 1978; Spanish by the Vtilgrettule Uttutuit tttttt t Brazelton scale ( Strcissguth et al. 1983); Turn to page 7I for references. (2) weak sucking and longer latency to Streissguth et al. 1984b) have shown statistically significant alcohol rclated decre- first suck. melsured with a pressure Ann Pylkowiez Streissguth. IArt tranduseer (Martin et al. 1979);(3) lower ments in attention assessed in different PAidtain v types of empirical situations atter statistic- prOICAAs tr in the thartment Apgar scores. gtemer need lorventilatory and Beht11101.41/ SCICIIre1 14 the IIfifreLitt resuscitation and more heart rate ally adjusting for a variety ofrpotentially confounding variables One study of Wash:110mi in Seattle Robin A abnormalities (Streissguth et al. 1982); !Anise, Ph.D.. is !NW dcx totaar fellutt rot ( Strcissguth et al. 1984b) hasalso shown and (4) increases in tremors,hand-to- the Dtpunnent a/ Matt t and and significant alcohol-related dee:mons to mouth activity, head turns to kit, Be/ure 1 Sciences of the Owes site (I nonaterl wake state, as well asdecreases reaction time. 'the importance of these subtle attentional violations in 4-year-old Washington in Seattle nt vigorous bodilyactivity (Landestnan-

12 Alcohol Healthand Research World

104

Ur:7 BEST rkif Jane MO 978 The Journal //PEDIARICS

Behavior and learningdifficulties in children of normal intelligence born toalcoholic mothers

Harm; Hospital were evaluated fine (ltibben rerred to the tear g Disorders Unit of the Yale -New f57 children, 15 were f (to have sohlwat t c of prenatal cytosine to ell 1. In is total poopul ranged in age from a !moony of maternal heavydronLang during preg r. 'The 11 boys and four girls 181i teary. Birth weights ranged from 1.5101 to3.150 gm. Meehan Weight 2.213 .1t111 Alt groomh tenth percentile. meauironents were affected: headtiocumference W < tenth percentile. height WT. < of dc /lb features of weight 74% twenty-fifth percentile The children had o ton ttttttttttt of dr. phi( jimmies. All turd WI IMO se rch r slip Hated between age of presentation ttttt 1 ate [allure 10; had intelligence in tin' average range (1(? .5: toI13). tit esperienced perustent academic Ill midtown. all %hared problems of activity and rate rtguhrtom. Our results suggest a cmain ttttt preventable ura:agernr offerers of ethno! on theCNS. Alcohol eyeosnre in mem may he an important. determinant of attention deficit syndromes inchildhood.

Sally E. Shaywiii, M.D.,* Donald J.Cohen, M.D., and Bennett A. Shaywitt, M.D., NewHaven. Corm.

intelligence. and of the 126 that havereceived stanilaid- Iit orlCaitIrCS (7011StlititeS A t(I"kitAt 1t ills1it' C US I IQ 70. We are aUale of fetal alcohol syn- ized testing. 85% scored below the symptom complex termed the achieved a seine in (home." Core components of FAS center onindications only live children with FAS who have the normal range, and only twoof these received an IQ of (I) pie- and postnatal growthdeficiency. (2) dysmor- pluigencsis manifest primarily as shortpalpcbral fissures, above 96.' tuition, and mid- hypoplastic philtrum. thinned upper vet Ahbraniahl met{ facial hypoplasia. (3) central nervous systemdysfunction l'AS: fetal alcohol lidanme presenting as mental deficiency of varyingdegrees of ('NS: rental tunott% %%moil been considered severity. Of these, mental retardation has In a consistent scrod' of prenatal On the other hand. our own clinical expetience to be the most disabling and learning disorders unit. as well as other repolis. exposure to alcohol.' andFAS is now the third most human' and animal' '^ suggest that pet haps molesubtle ficquent disorder in which retardationis a component.' manifestations of CNS dysfunction in the formof behai- 'I bus, despite over 2(K) reports ofFAS in the literature. ioral and learning difficulties might besignilic.mt ire only rarely has a child been described ashaving normal frequently overlooked problems inchattiest esposed ethanol in uteri). To explore this possibility. weexamined limn the Department% of Pediatrics.Neurology. a group of childrenreferred for school dithcoltte, for Study Center. Vale Nit lonary. ant! The Vale Child indications of prenatal exposure toalcohol. In this report. thurersit School of Medicine morphogenie features. cognitive the National we describe the growth. Suppiated in part he Grants from in such a cohort of AA 03,699. the function, and school performance immures of Health NS 123114, intelligence born to .N',t,ttuu, Foundonon. Chnicid CenterGrant KR- learning-disabled children of normal that chil- UM; the National (mined on AlcoholismGrant heavy-drinking women. Our findings suggest and the Mental Health (linnet!Research ('enter No dren horn hi alcoholic mothers shouldhe followed carefully through the early ichool rearsfor the possibility of 04.1ols !coming hisoidris th-partment children experi- I 05110 learning difficulties. and conversely that I'. Sou t a I. Al can , New flown. (

0022-3476/40/06097K t 11CSISI.511/0 1980 thc C V ( '.1"6. NO 6. pp QMWil

105 BEST CUY AVAILABLE t, Nehavtai and learning di/ /realties inI.1.1 97 9 96 N ttttt her h

Table. Morphologic andpsychologic characteristics in 15 he evaluated for indications encing school failure should children with the expandedfetal alcohol syndrome of prenatal exposure toethanol. Number abort ied METHODS ;Ravin, deficiency referred to the Learn- Selection of sample. All children Prenalal (< 2,500 gm) In ing Disorders Unit of theYale New haven hospital Postnatal between September, 1977, andJune, 1978. were investi- Height* evidence of l'AS. We were -Fifth percentile 7 gated for 1mila-wit' and clinical 6 natal ik Till:nil In of 87 Twenty-filth percentile able to Wood v Is children from a Weight* history of alcoholism at youngsters whose mothers had a < Fifth percentile 4 the time of pregnancy." wo ofthe children were evaluated 5 Twentyfilth percentile 7 patients in our study. hecause they were siblings of other !lead circumference! 9 in age from WI to 181/2 Tenth percentile 'The 11 boss and from girls ranged S .'twenty-fifth pen conic vrats Deter nn nation ofMaternal alciihi 'km dining preg- I5 by parents or Mt data I aria! sugmatat nancy ss as based either on reports Short pa 1pebral fissures; 13 obtained from medical or social agencyrecords. The Associated fintlingsll 7 children were ben it to ten mothers, On.of whom had died Joint anomalies (4) i'or disorders related Ilearing loss (2) or were curt ently holm:di/a:A 1 Of the eight living mothers. five were Renal anomalies 0' their 1 home with Cardiac anomalies thVOleetil ive of the children were sharing a Intellectual ability their natural mothers, but twoof these were presently in IQ-80-85 1 mothers were undergo- 5 the care of surrogates while their IQ 86-95 9 ing hospitahiation tone tinsarices, one for detoxifica- IQ - 96.113 X -98.2 tion). All but our of the children were ubite and lived in ILISeli tin NCI1S (irowth ('barb. 1076 She was our only patient who Km ti on Ironer private suburban homes. prominent clysinorphre lectures -horiop-turned nme, hypopl.1% came from a welfarefamily and for whom the father's tn. plidtrnm, broad nasJI tool. thinned uppervermilam, relative piogiu whereabouts was unknown. Thereanameter of our rhrr rn adolescence, epitanthal 6441%. hypoplasticmodulo patients' fathers were all employed.Their occupations ;Based on Chnukc Mimed tin ("Lorca and Sirorth ranged from salesmen and self-employedbusinessmen to middle- and upper-level executives. extensive histo- Diagnostic evaluation. In each child an patient, the most perinatal factors. family history, birth, than one test was available for any ry concerning patients requiring additional initially obtained. An recent score was used. Those development. and behavior was Ilaven I hospital by one of csammation was performed by one Iif IiS ) testing were seen at Yak New us or associates in thedepartments of pediatrics and assessing growth, morphogenesis,and central nervous psychiatry. system function. and includedboth a general neurologic assessment. Cogreinve evaluation and neuromaturational ft Esuurs(TA/11.1-:) function was assessed bystandardized, age appropriate instance. the Stanford- Growth. individual intelligence tests. In one ranged r111111 1972 norms was adminis- Prenatal. birth weights of the children hmet Form I.-M scored with weight 2.213 gm and the Wechsler Pre-School I.580 to 3.150 grit. with a median tered; another chiki was given wide; 2.5(81 gin One 'mood. the Wechsler Intelli- Iwo thirds of die patients and Mammy Scale of Intelligence be 34 to 36 weeks' other hush weight 2.01-1 gun, was estimated to gence Scale fenChikben was administered to gestation; all other patients wereconsidered term accenel. children ages 6 to 16; children over16 received the records. Seale. Each chiltra school ing to parent report or hospital Wechsler Adult Intelligence of our popu- need for special ser- Portar(rl. Postnatal growth characteristics record, Including class placement. cohort had a substan- and results of any standard- lation arc shown on the Table; our vices, teacher's observations. and head cercumfer was obtained and tin) reduction in body weight, height, lied intellectual or achievement tesling. markedly affected. with undergone recent (within the rake." " Cranial growth was reviewed Most children had dime children (20%) below the thirdpeteentdc and 12 months) psychometric testing aspart o?' the past another sot between the third and tenthpercentiles thcie referral wove.+ Stir specialeducational services. If re

106 (), BEST COPY AVAILABLE Use 00000 not hStweeet 9N11 Shama:. (.0lien. and Nhanra: Jun.' 19101

Central nervous system. With the exception of mild hypotonia in six of the patients. classic net:tido& exami nation was untemarkable. Evaluation for the pi esenee signs nemomatmational Ott:gut:Miles ( "soli signs") revealed four patients with mixed eye-hand dominance and two with ambidexterity. In older patients (oyesII years) persistence of associated symmetric and asymmet- ric nuwecnts were seen. At all ages. the patients had indications of valying tierces of Elite mot,), dyshinclum involving lingo-thumb testing. Computed hum igtaphs a the brain was pet formed in five patients and the results were normal. Intellectual functi tttt ing. Intelligence testing indicated a mean full wale IQ of 98.2, with scoresranging between 82 to 113. Thus, the overall range of perlotma nee of our patients [elf:miff% the entire spectrum of a vet age intelligence." 1 bete was an equal division among the t hildiru who obtained superior %cotes in either the s bal or performance scales. Similarly. when significant disci epan. tap (15 points or more) occurredbetween vet and perfoo mance IQ. each .ablest gum!) was equally f 4.qt, seated at each cstteme. Of pa:Ocular interest was the 1ittnev. Patient with the expanded fetal alcohol syndrome. Note subtest profile with highest scores insist frequently tecoid- tissutes. nndfrtial Itspopl ilia, intleased the stunt italpebtal ed in siilatities, ctimpt ehension. object assembly, and distance limn the nasal tip to the vermillion hat tier. :Intl relative to a depressed prormithism. block design. which was in contrast pet formance on the coding. arithmetic.digit span. and was one child at, but none abuse. the Itlticth pelt Clink lot inlOration stibtests. A single child was gis en the Stan- fottIlinet and achieved an IQ of 8(1. .Igo'.Height was alb:tied: 7/15 )if (MI Significant telatonsinps invols ing age and I()Sprat- '1.1 belt /M: the lillh percentile lotare, and another 0', at in below the twents huh pcicentile. .1 %so man's rho z 0.47 /' (1.05). and an inverse lelautistship patients. both of v1.110111 Were among the lower -bittit (rho 0.58 I' -0.(125) between age and /um plfolffpc stigmata were noted. A possible tuterptetation tit this "eight tnlanls, "Tie n" aPPmaching the Illneth Percent- cohort ile As with head cireumletence. Mese were no children finding is simply that die older children in our presented themselves to us at a later age 11:3(me al")%e the tiltieth Percentile ("r age. Weight was 'cam the posinse alio:led. but the distribution was still skewed toward were less severely allevied. We did not note IQ (tho = 0 29 . lower weights. with 275,: of 'or patients bekny the filth cot relatitm between height and pet ceittile and an additional 47`g at orbelow the twenty- reported by Stteissguth et al.' School functioning. Common to all children %%asthe filth peicemile early experience of school lailme.I lyperacto.us was A :dies. 1 he patients had msolvement in all maim mewi known to he associated withFAS and bore an described in all but one of the patients' school lecsatls Sit umnistakable likeness II lgus c) to mhos' th,cibed in the had a history of tteatment with sit were currents teem mg Sinillani medication. Inability to function without noel,. Inetatute.I hey uniliuntly demonstrated at least two sive oneto-tme at small group instruction. shout attensuill pioniment dssmorphsc femme.. ofI AS: small Span and ditillactallilth were shared by the patient pupil. palpebt al fissures" were !Mind in 4)1" the alibi:en lation uniformly. Comments such as -behind ever since Assttated bnslnrgs included canton- of ditty-daciyis he entered school." "an itch," "cannot sitstill, easily (ses en patients) and a mild conductive heatinglilts (live patients). Single instaces Of renal andcardiac defects distracted." "never Concern raleS Unless threCilV supervised by a teacher.- "seems to have the skills yet is not learning.' were also noted. Although otherchildren in the coltot I of were noted in all of these children's teeords. 1Pte %eve' dr XI had souse Minor anomalies (Ingh-archedpalate. It tw- +r eats, single palmar crease) in no casedid they of school difficulties was reflected in the eat h releiral set special education services; 13 of our patients recessed deintuistr ate the constellation of stigmata chatactesisticof such tecommendations Iss the Inst grade and all were '.Whiten boot to alcoholic mothers

BEST COPY AVAILABLE 1°7 s Behavior and learning difficultiesin IS 98 I oluns NutotINT ti

cognitive processes to meetacademic services by the third grade. must lain higher recommended for special demands in a classroomsituation. Eleven of the children hadbeen retained for at least one closely associated with it failure and thus In our role as physicians year but werestill experiencing school particularly sensitive to assis- learning disorders unit, we arc Were subsequentlyreferred for special educational learning difficulties are ascribed require the frequency with which tance. Of the 13 childrenstill in school, seven fac- to environmentallydetermined emotional and social full-time special class placement,while four are in regular alcoholic women, witli little or no of learning disability tors in the offspring of classes with the additional support consideration given to thepossibility that poor school tutors. "%slit:hi Idren attendregular class one child who disability. Our find- is performance may reflect a learning has been referred forspecial education services and focusing solely on the another child who continues ings suggest that rather than awaiting class placement and intractable home situation ofchildren born to alcoholic difficulties in his regularclass- and to experience school women, considerationof a referral for evaluation room possible special educationplacement as a learning dis- DISCUSSION abled child he made. An increasing body ofevidence".suggests a relation- Although the deleterious effectsof maternal alcoholism abuse and the development antiquity. the concept of fetal ship between parental alcohol have been suspected since of disorders of activity andlearning in their offspiing a,. alcohol syndriime had its originsonly within the last ior example, in the symptomcomplex currently desig- decade. beginning with thessork of Lemoine et al' and this relationship is not this nated attention deficit disorder; 'piing to the attennonof must pediatricians in experience. Our data a meniand, and of Jonesand exclusively mediated by social colours with the wink indicate a constellation of milddysinorphic lea:Ines of ' Our report differs ft omprevious contributions assi fetal alcohol syndrome. tindinesof hyperactivity and hs emphasiting that subtleCOMA nervous system impair- difficulties in diddle.) with behavioral and learning deficits may persistent school learning in the filrin of heavy-drinking nirrinal intelligence horn toalcoholic normal intelligence horn to uncut In child ICH Or Alcohol exposure in utero mayhe an important. prevent 1110HICI1 able determinant of attentiondeficit syndromes m child- 14 the ,oust pait. severeCNS dyshinetion has been consult:led as one of the mostconsistent and disabling hood, components of this syndrome.Thus, ('barren and Smith' all persons affected areretarded, REFERENCES state. "Although not ttorterti JP. Cl al: I es enfant

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BEST COPY NUE lire Journal of Pediatrics 982 Shut wit:. Cohen, and Shaywit: June 19140

Cantwell 1): Psychiatric illness in the familiesof hyperactive development and operant performancefollowing maternal 16. 10:5. 1977. children, Arch (ku Psychiatry 27:414. 1972. ethanol administration. Dev Psychuhiol Morrison J. and Stewart M: A family study ofthe hyperac- National Center for health Statistics:NCI'S Growth 17. 11. tive child syndrome. Riot Psychiatry 3:189,1971. Charts. 1976. Monthly Vital Statistics Report.Vol 25. No. 3. 18:1/4 Morrison 3, and Stewart M: The psychiatric statusof the Stipp {LIRA) 76-1120. Health ResourcesAdministration. legal families of adopted hyperactive children.Atelt Gen Rockville. Maryland. June. 1976. development. in Forfar Psychiatry 2K:888, 1973 12. 'fanner JM: Physical growth and children- PT of pediatrics. Edin- 19. Cantwell I): Genetic studies of hyperactive JO, and Arncil GC. editors: 'textbook chiatric illness in biologic and adopting parents. Int ieve burgh, 1973, Churchill Livingstone. RR, Rosenthal D. and Brill II. editors: (knots research un Chouke KS: 1 he epicanthus or mongolianfold in caucasian 13. psychiatry. halt 1975. Johns Hopkinst husersny children. Am J l'hys Anthropol 13:255.1929. for Children - Press. 14 Wechsler 13: Wechsler intelligence Scale dtartiostic Cooftration. 20.Shaywitt BA. Cohen 1)3. and Shaywitt SF: New revised, New York, 1974. The Psychological logy for minimal brain dysfunction. 1Pt us silt Streissguth AP: Maternal thinking and the outcomeof to 15 95:734 1979. pregnancy: Implications forchild mental health, Am J Orthopsychiatry 47:422, 1977.

109 BEST CETYrtT,T17: APPENDIX B: LETTER FROM PRISON: A Cocaine-AddictedMother

The folking letter was written by a mother who wasincarcerated for a robbery she committed, while of Florida. to pregnant, to support her cocaine addiction.She wrote the letter as a testimony for Parent-to-Parent beused in hearings with Florida legislators. Today she hasthree children and has overcome her drug problem.

March 25, 1987

Dear B.T.,

How are you doing? I hope as your eyes fall upon these words you arein the best of health and happiness. I am doing fine. I am so sorry it took me solong to write to you. It might be too late for this letter,but I hope it's not and I hope this is what you wanted.

Well, it started when I realized that I was pregnant. By me smokingcocaine heavily, I didn't realize that I was three months. I thought I was two months.And when I did, the first thought was I didn't want to be pregnant. It was the last thing I wanted. I wanted to smoke and I knew Ihad no business smoking cocaine while I was pregnant, so I thought of the next thing and that wasof having an abortion, but the baby's father didn't wantthat. He wouldn't pay for it and got upset with me for eventhinking about it. I still didn't want to have a baby. I feltlike it was going to slow me down or stop me from smoking.I cedn't want to stop and so I didn't I kept right onsmoking.

At this time, I wouldn't tell anyone, only the father knew. I wouldn't go tothe doctor either. I had just made up in my mind that I was not having anybaby. One night I started having pains in my stomach andI thought I was having a miscarriage. I wouldn't say anything about the pains, I wastrying to wait until I saw blood until I went to the hospital. Then they couldn't stop me from losing it. But thepains got so I couldn't bear them and it was also making it hard for me to breath so I told the father to call the ambulancefor me. Anyway, I went to the hospital and at first they didn't know why I was havingpain and was so short of breath. After a little while I threw upand the pain went away and I could breathe again.

While I was waiting for them to tell me why I was having thesepains, I had given them a urine sample and they ran tests on it. Shortly after I threw up they came backand told Intl was pregnant and the pains were only gaspains that was all.I so when I threw up, it relievedthe pain. I had just eaten something that disagreed with my system, said to myself, Hell, I know I am pregnant and you meant totell me that lam not having a miscarriage. Youknow, it seems like I was so upset with them.

In the meantime, I was beginning to shot:, so I had to tell sooner orlater. &finally made up my mind to go to the doctor and by this time I thoughtI was about jive months. The doctor I went to haddelivered my last child and she knew me pretty well. By me smoking all thetime I didn't have money to pay the bill. The father hadinsurance how many months I on me from his job, so she tookthat. When she checked me she kept on asking if I was sure was. I told her yes, I was sure.So she decided to have one of those things (I don't knowhow to spell it) where it tells Just to make sure that I really you how many months you are,what you are carrying and how many you are carrying. was how many months I wassaying.

It turned °aft/tat! was more. I alsofmend out that I wascarrying twins. Justas she was about to take the guider off she spotted another head. I told her it was amistake, check again, it can't be true. I didn't want one baby,let alone two. What am I going to do withtwins when I am staying out and smoking cocaine. I justdidn't want any babies.

Now I go home and tell the father that I am carryingtwins and we decided to tell my mother. She got upset because she knew I was smoking heavy.

After a month or so I started liking the idea that I wasgoing to have twins. I would stop smoking for awhile and then start again after. My doctor aked meji I was using any kind of drugs and I told her that I was only smoking pot, but that was all. She told meI needed to stop smoking it and I lkd and said I would, but Ididn't stop smoking cocaine or pot. wanted more cocaine, but didn't One day when I went to pick up thefather's paycheck, I smoked it all up. I I was still pregnant. I was caught at have any money. So I robbed a store toget more money to smoke some more. They let me go because I was a high 3:00 that following morning andI stayed in jail until lunchtime on Tuesday. risk of going into early labor, that iswhy they let me go on my ownrecognizance. smoking cocaine and said My doctor had me come in and did afullcheck up on me and asked me why I was Well, one Friday morning I started that it could harm my babies. Butit just went in one ear and out the other. to the hospital. My smoking, but not that much. At about 6:00that Saturday morning I went into labor and went been smoking since I robbed doctor asked me ifl had been smoking andof course I lied again and told her no, I haven't babies were lying and whether or the store. Then she did an x-ray on me andtold me she wanted to see which way the because now I really did want the not they were in a downward position.They were. Then I got scared and happy too noise and the doctor goes babies. I had the first baby and heard it cryand all of a sudden it didn't make any more trying to push the other twin out. He won't to do all kind of things toit. I ask what is the matter with it and am also C-section and they are still trying to work with myfirst baby. I am waiting to have the C-section come so I have to have a don't know how to take it and the other baby's heart stops beating.Everything seems to be going wrong now. I just baby came and he had no heart beat when he came. or accept it.So finally I have the C-section and the other thinking When I finally came to, they told me that mybabies were having a lot of problems and I started is why my babies were about all the cocaine I had been smokingthroughout my whole pregnancy. To me, I knew that having problems and suffering like they were.

They were both rushed to Shands Hospital and put onbreathing machines. They couldn't breathe for smoking while I was themselves and the doctor didn't think they weregoing to make it. I just knew that if I hadn't been self mess up my babies lives. pregnant, they would have been alright. Ihated myselffor that because of my stupid, dumb they took him off the So one of my babies got to where he couldbreathe by himself. That was the first one T., and Shands and I did. machine. The second one, G., never did makeit off the machine. They called for me to come to he was in a deep They told me that G. was dead and that themachine was doing all his breathing for him and that I wanted to avoid the coma and was not coming outof it.They wanted to unplug his machine. I said no atfirst. would come out of it, and to issue, the thought of unplugging G'smachine. I told the doctor to wait and maybe he hard to hear that. So please give him some more dm:. He said that there was nouse, the baby was dead. It was so and watched my baby die. me and the father went backthe next day. I watched him unplug the machine enough to stop I felt like I pulled the plug. I killed my babysmoking cocaine. I was so angry, but not angry smoking cocaine. make is T. was doing fine. He had a set-back, but he wasdoing good. I tried so hard to make him at least as I lost G. I went homethat day and just said, Why, God, why? Whydidn't he just take me instead of him? and stayed a T. was getting better, so they transferredhim to Tallahassee at T.R.M. Hospital. I went make him sarvive. weekend there so I could learn how to take care ofhis special needs. I was trying ani I so determined to things they said he would There were certain things that the doctorssaid he wouldn't be able to do. And some of the happy when he did some of them. But I wasstill smoking and hadn't learned my not be doing he did them. I was so weight and The pediatrician that was seeing him was veryhappy with his progress. He was gaining lesson yet. had gained some more everything. I was so proud of myseff for doing sowell with him. I took T. to the doctor and he will always keep one because weight and he had a light cold. But it was notunusual that he have a light cold because he of his problems. Other than that he wasdoing just fore. other older son That was on Friday, March 21. OnSaturday morning, March 22, I was wakened up by my I thought. I couldn't at about 7:30 to feed him. I went tofix T's formula to feed him and he was still asleep, or so hospital and I waited and wake him up, so I tried to listen foraheartbeat and couldn't hear one. I rushed him to the They couldn't revive him. waited. After about 20 or 30 minutes the doctor cameout and told me my baby was dead. and said, No, not again! Not T, I was in shock. I fell like somebodyhad just slapped me in the face. I cried out God - You took one, wasn't he enough?!

1.12 did I. I just couldn'tunderstand what and he felt like it was myfault that he died and so hell happened I had to tell the father riday evening and this wasSaturday morning. What the just taken him to the doctor did the doctor. All went wrong. I had doing so good. At leastI thought so, and so please tell me. He was wantanybodyaround between then and now, wasdead and I just wanted tobe by myself. I didn't I knew was that thedoctor had told me that T. it would be over with, butit like it was a nightmareand when I woke up me or anything.Some how or another l felt wasn't. the State Attorney delayedit. They said they were sorry I. was due to go to courtthat following Monday, but get away from wanted them to take me to courtthen. I just wanted to go and they would waituntil after T's funeral. I everybody. home, get away fromhome and everything and funeral director asked t'wewanted put T .away. I went tothe graveyard and the The day came when I had to him as he was. But then,there was a part time. I didn't want to look,I just wanted to remember him with dirt, to see him one last I watched them put himin the ground and cover of me that did want to seehim. I didn't though. As Right then and there Isaid to myself being put in the groundand covered up with him. I felt like a part of me was the last straw. cocaine would never takeanything else from me and that was Right now I have acceptedthe loved and still do love him.I will never forget them. That was the bottom. I I will always feel responsible Put I have not accepted thefact of the way they died. fact that my babies are gone. stop smoking cocaine.Not jail or death. Because it took thedeath of my babies to make me in a way for my twine I am trying to bettermyself for my other death. l am now trying tohandle and deal with it. I thank prison, but my babies' but when I came to prison1 got a second chance. children and for me as well.Cocaine almost destroyed me the road about T. and G.. 1 have notquite recovered yet but I am on God for that. But I have gotto accept my feelings to recovery. I did me some good towrite this because I know B.T., I hope this is what youwanted and it helps you. It of with them and stop pushing myfeelings aside or in the back T.and G. and I need to deal be going still have problems about I wouldn't want to see anyone gothrough what I did. I must my head somewhere.I learned the hard way and now, but I hope tohear from you soon. TakeCare.

Love,

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