Prenatal Substance Exposure

Putting it into Perspective and Responding Appropriately

Steven J. Ondersma, PhD

Departments of Psychiatry & Behavioral Neurosciences

and Obstetrics & Gynecology

Overview

Closer look at the controversy Factors behind controversy Review of studies Surveys of actual practice

Reasons to reconsider the strongest responses Applications to child welfare and

permanency planning

A Closer Look, Part 1: Made to Order

Models of Addiction

Moral

Model

Compensatory Model

Spiritual Model

Disease Model

PERSON RESPONSIBLE FOR ADDICTION?

Yes No

PERSON RESPONSIBLE FOR CHANGE?

Yes

No

Prenatal Substance Use: Is It…

A CRIME: Voluntary Illegal &

destructive, like arson or robbery

A DISEASE: Involuntary More like

depression than like arson

Why So Difficult? Multiple Viewpoints

Social Services

Child Protection

Social Work

Nursing

Substance Abuse

Law Enforcement

Justice

Psychology

Early Childhood

Medicine

When and Who to Test?

Many hospitals don’t test at all

Most hospitals use targeted testing, with rates varying wildly

Testing usually catches only very recent use

Universal Testing?

Issues of civil liberties and consent arise

Universal testing would result in huge numbers of identified infants (at least 5.5% of all births)

Avoidance of hospitals and health care providers could result

Unclear whether cost is justified

So You’re Involved…Now What?

To use the court or not? If so, when & how?

To remove or not to remove?

To be short or long?

Use of Court System

Pros: Addresses reality of

resistance to treatment Sends a strong message May be the best way to

protect individual children

Cons: May lead to avoidance

of health care/other services

Is primarily reactive Only possible with a

minority of all cases Based upon assumption

of unique damage

To Remove Or Not To Remove?

Pros: Improves safety for a

vulnerable infant Provides incentive for

treatment

Cons: May lead to health care

avoidance Disrupts the

relationship we seek to enhance

Increases stress in high-risk parent

Very expensive

How Much Time To Change? Two Clocks:

Clock of child development--all children need stable and secure caregivers immediately.

Clock of addiction—most persons who do achieve long-term sobriety do so after a long period of cycling relapses

A Closer Look, Part 2: Literature Review

The Birth of a Social Problem

The Prehistorical Period

Concern regarding alcohol exposure first noted in 1973, with limited public reaction

Prior to the mid 1980’s, drug exposure received little attention among the scientific and lay communities

The Early Period

Mid 1980’s (Reagan years): growing concern regarding illicit drug use in America, particularly crack cocaine

Research suggesting significant deleterious effects of crack cocaine exposure emerges

Early Period: The Media Responds

Public fear and outrage regarding illicit drugs galvanizes around the “crack baby” image

This media portrayal burns lasting images into the minds of the public

Middle Period: The Backlash

1993: Growing skepticism among scientific community culminates in a 1993 special section in Neurotoxicology & Teratology

Most researchers assert that the effects of prenatal exposure to drugs have been greatly misunderstood

Why Are Effects Not Clear?

Ideal methods for proving effects cannot be used

Correlation does not imply causation

Without random assignment, it’s impossible to rule out other possible causes of infant problems

What Kinds of Factors Complicate Interpretation?

Polysubstance use Pharmacological characteristics of drugs used Maternal health--nutrition, prenatal care,

environmental risks Genetic influences on behavior Postnatal vs. prenatal environment Sampling issues Blinding

Meanwhile, Society Forges Ahead…

Criminal prosecution for cocaine use during pregnancy is the first reaction in many states (Ondersma & Tatum, 2001)

A hospital in South Carolina begins testing women, without their consent, and sending results to the police; 29 of 30 were African-American (leads to Ferguson v. City of Charleston)

Women are charged with murder if their stillborn children test positive for cocaine (McNight case)

Contemporary Period: Recent Research

Ostrea, Ostrea, & Simpson, Pediatrics, 1997

Meconium screening of 2,964 infants at Hutzel Hospital in Detroit, MI

Data cross-checked with death registry at age 2

No association between drug exposure status and mortality

Lester et al., Science, 1998

Meta-analysis suggests that prenatal cocaine exposure is associated with an IQ deficit of approximately 3.26 points

This very small decrease, due to the increased number of children falling below 70, is estimated to lead to approximately $350 million annually in additional costs.

Frank et al., JAMA, 2001

Performed a systematic review of all studies of prenatal cocaine exposure meeting criteria for rigor

Excluded studies in which a substantial portion of children were also exposed to opiates, amphetamines, or PCP

Frank et al., JAMA, 2001Of studies Controlling for Tobacco:

Outcome Type Effect No effect

Growth 0 2

Cognitive ability 1 7

Language 0 1

Motor skills 2 2

Behavior 8 7

Maternal Lifestyles Study

Large, multisite, prospective, masked study of prenatal cocaine exposure funded by NICHD, NIDA, ACYF, and CSAT

Designed around the reality that cocaine is a marker for other drugs of abuse and compromised caregiving

Lester et al., Pediatrics, 2002

Total of 1,388 infants (658 exposed infants and 730 comparison) evaluated at one month of age

Exposed vs. unexposed: significant differences on 2 of 12 neurobehavior scales (arousal, regulation), no cry variables

None versus some versus heavy exposure: differences on 4 of 12 neurobehavior scales, 1 of 14 cry variables

Singer et al., JAMA 2002

Longitudinal, prospective, masked study of 218 cocaine-exposed and 197 unexposed infants at age 2

All infants identified via hospital screening measures

Significant cognitive delay twice as likely in cocaine-exposed children; no motor delay

Singer et al., JAMA 2002

FACTOR

Correlation with 24-month

mental development score

Prenatal cocaine -.20

Prenatal cigarettes -.12

Prenatal heroin -.13

Prenatal alcohol -.15

Maternal education .14

Current cocaine -.16

Current HOME score .37

Infant sex -.20

Frank et al., Pediatrics, 2002

Prospective, longitudinal, masked study of prenatal cocaine exposure in 203 infants: unexposed, exposed, and heavy exposure.

No differences were found for cocaine-exposed children at any level of exposure, in either cognitive or motor skills.

Frank et al., Pediatrics, 2002

Cognitive score, no intervention

Cognitive score, intervention

No cocaine 103.1 99.0

Light exposure 104.8 103.2

Heavy exposure 106.5 116.5

The Importance of Dosage

THE DOSE IS THE POISON

Soup: Short-Term Effects

Short-term effects are more consistently reported, although not in all studies: Low birthweight/reduced head circumference Poor tone, tremulousness Poor state regulation, sensitivity to stimulation,

inconsolability, irritability

The above may be restricted to infants with the highest levels of exposure

Soup: Long-Term Effects

Long-term effects are less clear

Consequences inconsistently found include: Attention deficits and behavioral dysfunction

Difficulty with self-regulation under stress or with minimal structure

Mild cognitive/learning deficits

Delayed growth and development

Summary of Drug Effects

Negative effects are clear when all drugs of abuse are considered together

Negative effects of single drugs occur in some of the most heavily exposed infants

These negative effects are comparable in magnitude to those of tobacco and are less than those of alcohol

Frank et al., 2001, JAMA

Among studies meeting meeting criteria for quality of methods and controlling for tobacco and/or alcohol, most showed no effect of prenatal cocaine exposure

“There is no convincing evidence that prenatal exposure to cocaine is associated with developmental toxic effects that are different in severity, scope, or kind from the sequelae of multiple other risk factors.”

Lester et al., Pediatrics, 2002

“It is now well-documented that early scientific reports in the 1980’s that portrayed children who were exposed to cocaine in utero as irreparably damaged were inaccurate.”

“Current research suggests that, although there are effects of cocaine on child development, these effects are inconsistent and subtle and need to be understood in the context of polydrug use and the caregiving environment.”

A Closer Look, Part 3: How Society Is Responding

Ondersma et al., CAN, 2001

Urban Counties: Two of three largest

counties in each state

Exceptions replaced by Census region

Total N = 100

Rural Counties: Random selection

of two counties with population between 10,000 and 100,000

Exceptions: CT, HI, MA, RI

Total N = 100

Child Welfare Intake supervisors from:

Percent of Counties Receiving Referrals

Receive referrals

Don't receivereferrals

90%

% Cases Juvenile Charges Filed (Among Counties Receiving Referrals)

>75% of cases

<10% of cases

11-40% of cases

41-75% of cases

None

25% 21%

14%

19%22%

% Infants Removed--Cocaine (Among Counties Receiving Referrals)

>75% of cases

<10% of cases

11-40% of cases

41-75% of cases

None

29%

13%

17%26%

15%

Opinion of County PracticeToo strong

Appropriate in most cases

Inadequate to protect child

69%

26%

Nationwide Survey of DA’s

Participants: Criminal District Attorneys randomly selected from urban, urban fringe, and rural counties, 4 per state

The DA most familiar with prenatal drug exposure policy or practice identified

Current N = 100 (goal is 200)

Handle Cases of Prenatal Drug Exposure?

YesNo

58%42%

How Big A Factor Is Exposure In Decision to File Charges?

Only factorPrimary factorSignificant factorMinor factorDon't know

12%

38%44%

Frequency of Past Year Referral Among 18% Filing Charges

Range was from 0-150, with a mean of 18.7 and median of 4

56% of these respondents said this number was increasing from past years

11% said it was decreasing

Opinion: How Damaging Are Various Exposures? (1-7)

Prenatal exposure to illicit drugs: 6.14

Postnatal exposure to drugs: 6.02

Prenatal exposure to alcohol: 5.89

Prenatal exposure to tobacco: 4.48

What % Of Perinatal Drug Users Should Be Prosecuted Criminally?

0

5

10

15

20

25

30

35

0-10% 11-40% 41-99% 100% Don'tknow

Response: Ideal Percent

Reasons to Reconsider Strong Interpretations/Responses

Prenatal Alcohol Exposure

Alcohol presents more risk to the fetus than any other drug of abuse

Risks associated with prenatal alcohol exposure include: Intrauterine growth deficiency Facial dysmorphology CNS damage, including developmental delay

(severe to undetectable), hyperactivity, and attention deficits

Alcohol: Baer et al., Arch Gen Psychiatry, 2003

Study of 21-year old children of pregnant women evaluated between 1974 and 1975, N = 433

Prenatal exposure to alcohol associated with increases in alcohol problems (14.1% versus 4.5%) and heavy drinking (11.7% versus 6.9%)

Prenatal Tobacco Exposure

Tobacco’s effects are simpler to detect More common, with less stigma Many women use only cigarettes

Dose-dependent effects on: Birthweight and mortality IQ, especially verbal ability Behavior, especially conduct disorder in boys Lung function, especially in children with asthma

Relative Harm

Tobacco and especially alcohol are more likely to cause harm than illicit drugs

Tobacco and alcohol use during pregnancy is far more common: 5.5% used any illicit drug 18.8% used alcohol 20.4 % smoked cigarettes

Lead

Prenatal and postnatal exposure to lead is clearly associated with cognitive and other impairments

Recent research (Canfield et al., NEJM, 2003) reports IQ decrements of 7.4 points before blood lead levels reached the official cutoff

Other Prenatal Factors

Nutrition Prenatal Care Folic Acid Medications Violence: physical violence associated 3 times the

risk of hemorrhage or growth restriction, and 8 times the risk of death (Janssen et al., Am J Obstet Gynecol, 2003)

Prosecution Based on Risk

Is prenatal drug exposure equivalent to maltreatment?

The answer to this question is key: Actual maltreatment does not require harm to

merit a potentially coercive response Risk factors alone do not merit a potentially

coercive response

Screening Issues: Prevalence

Many rates based on non-representative samples misquoted

National Pregnancy and Health Survey (1992; published 1996) 5.5%, or 221,000 used any illicit drug (marijuana

used at more than twice the rate of cocaine) 18.8%, or 757,000, used alcohol 20.4 %, or 820,000, smoked cigarettes

Illicit Drug Use

in Pregnant and Non-Pregnant Women

NHSDA Report, SAMHSA, 2001

Screening Issues: Chasnoff et al., NEJM, 1990

Rates of illicit drug use similar in African-American vs. white, public vs. private

African-American and poor women reported to authorities at ten times the rate of white women

National Pregnancy & Health Survey, DHHS,1996

Relative Focus on Cocaine: Pubmed Results, June 2003

Prenatal & Alcohol 2661

Prenatal & Cocaine 1016

Prenatal & Tobacco 516

Prenatal & Opiates 491

Prenatal & Marijuana 235

Prenatal & Amphetamines 186

Applications to Child Welfare and Permanency Planning

Four Ideas That Can Help

#1: Focus Your Attention on the Postnatal Environment

The risk that postnatal substance abuse presents is much more clear

Thinking in this way is more consistent with how we work with other risks

Risks Associated with Postnatal Substance Abuse

Impaired parent-child interactions Financial problems Domestic violence Decreased parental availability Parental illness--mental and physical Legal problems/criminality

Bays, J. (1990), Pediatric Clinics of North America, 37

Substance Abuse & Maltreatment

At least 40% of confirmed cases of maltreatment involve substance use

Alcohol use was the single strongest predictor of maltreatment in a 4-year prospective study (Kotch et al., 1999)

Substance Abuse & Maltreatment

Substance abuse increases the risk of abuse or neglect threefold (Chaffin et al., 1996)

Increased physical abuse potential in parents with histories of substance abuse (Ammerman, Kolko, et al., 1999)

Substance Abuse & Neglect

Of four major risk factors, substance abuse was the strongest discriminator between families with and without neglect (Ondersma, 2002)

Parental substance abuse and/or criminality was a top predictor of neglect in a 17-year prospective study (Brown et al., 1998)

Substance Abuse & Recurrence

Substance abuse was one of 7 key reentry correlates identified in a recent study of over 1,500 reunited children (Terling, 1999)

Child maltreatment re-reports are approximately twice as likely in families with substance abuse problems (Wolock & Magura, 1996)

Other Risks Associated with Postnatal Substance Abuse

Heroin-exposed infants raised at home versus those adopted (Ornoy et al., 1996) 74% vs. 20% “hyperactive” 96 vs. 110 IQ

Infants of drug-using versus matched non-drug using parents (Rodning et al., 1991) 18% vs. 64% secure attachments Worse parent-child interactions in drug-using group

Advantages Of This Approach

You’re more likely to get—and keep—support for your approach

You’re more likely to achieve consensus

You’re less likely to cause a child to be labeled or seen as damaged

#2: See It In Context

Prenatal exposure to illicit drugs is only one of many prenatal risk factors Inadequate nutrition (caloric intake, folic acid,

etc.) Lack of prenatal care Alcohol and tobacco Environmental toxins Natural genetic variability

See It In Context (Cont.)

Prenatal drug exposure is also only one of many postnatal risk factors Poverty, homelessness Mental illness, social support, IQ Exposure to violence Poor physical health, disabilities

Substance abuse may be #2 in importance

Advantages Of Seeing It In Context

Allows you to use limited resources most effectively

Maximizes positive outcomes for children

Increases fairness, and thus stability as well as respect

#3: Emphasize Prevention

7.5 million children have a parent who abuses drugs and/or alcohol

At least 5.5% of births are drug-exposed

We “catch” only a fraction of all cases of prenatal drug exposure

Advantages of Prevention

Prevention is more cost-effective than treatment

You can prevent much more than just illicit drug exposure

It avoids the dilemmas inherent in court involved responses; no one disagrees!

Prevention Math--Smoking

Effect size of .30 (which is very good in our business) multiplied by 5% (fraction of all smokers you can get to come in) = .015.

Effect size of .05 (typical for very broad prevention) times 90% = .045.

Prevention Programs That Work

Strengthening Families Program—Karol Kumpfer, PhD

Life Skills Training Program—Gilbert Botvin, PhD

Adolescent Transitions Program—Thomas Dishion, PhD

#4: Deal With What You Have…

At worst, prenatal cocaine exposure raises the risk of severe developmental delay by a factor of 2.

These effects are not strong enough to assume deficits

Each child must be considered individually

…Using What You Know

There is NO evidence that specialized services are needed

As far as anyone knows at present, it doesn’t matter how or why a certain need is present

Practical Suggestions: Baby Skills

Avoid Labeling/Focus on Drugs

Can lead to negative expectations

Pygmalion Effect: Children perform up (or down) to others’ expectations

Try “premature” or “feisty”

Soothing Techniques

Vertical rocking

Reducing stimulation

Swaddling

Midline position

Got A Minute? Prevent Shaking!

The one bit of prevention anyone can do, and everyone should do

Give options for when frustrated: Get a support person Take a break Use soothing techniques

Practical Suggestions: Early Childhood Options

One Effective Approach:Behavioral Parent Training

Training is individual rather than group Skills are directly coached Skill mastery is required in order to move

from one phase to another Interaction and play skills come first Appropriate discipline comes second

Behavioral Parent Training: Evidence of Efficacy

All are effective for undercontrolled behavior of children ages 2-10

One (PCIT) has recently been validated with physically abusive parents

All have been used successfully with diverse groups of caregivers

Exposure-based Therapy

Exposure-based therapy involves gradual exposure to reminders of a traumatic event

It often includes relaxation or cognitive components

It is very effective for anxiety problems, such as PTSD

Cognitive-Behavioral Therapy

Involves teaching children to recognize and replace thoughts that cause problems

Is especially effective for depression, but also good for anxiety

May be the single most studied child therapy

Pharmacotherapy

Psychiatric medication for children and adolescents needs much more research

It is clearly effective in ADHD Adolescents may benefit from

antidepressants; children do not Its use in psychotic disorders is generally

considered necessary

Practical Suggestions: Prospective Adoptive Parents

Tip #1: A Reasonable Summary

Prenatal exposure to any drug, whether legal or illegal, may have a negative effect on a child’s cognitive ability, growth, motor skills, and/or behavior (particularly attention). With the exception of some cases of alcohol exposure, these effects—if any—are small.

Tip #2: Put It In Perspective

Emphasize that the effects of illegal drugs are not different than those of, say, tobacco or of not engaging in healthy behaviors

Also emphasize that there is a nearly infinite array of factors that determine a child’s level of functioning: Postnatal environment is a very big factor Prenatal drug exposure is a very small factor

Tip #3: Tell the Truth

Note that this is a controversial area in which even some scientists disagree strongly

Offer references to key articles Frank et al., JAMA. 2001; 285(12): 1613-1625 Singer et al., JAMA. 2002; 287(15): 1952-1960

Web Resources

National Clearinghouse on Alcohol and Drug Information (NCADI): www.health.org

Children’s Bureau--Blending Perspectives and Building Common Ground (http://www.acf.dhhs.gov/programs/cb/)

Motivational Interviewing home page (www.motivationalinterview.org)

Web Resources--continued

Substance Abuse and Mental Health Services Administration (www.samhsa.gov)

National Institute on Drug Abuse (www.nida.nih.gov)

PBS—Bill Moyers’ 1998 special, “Close to Home” (www.pbs.org)

Resources Only In Print

Substance Abuse, Family Violence, and Child Welfare: Bridging Perspectives. Hampton, R.L., Senatore, V., & Gullotta, T.P. (Eds.). (1998). Thousand Oaks, CA: Sage.

Responding to Alcohol and Other Drug Problems in Child Welfare: Weaving Together Practice and Policy. Young, N.K., Gardner, S.L., & Dennis, K. (1998). Washington, D.C.: Child Welfare League of America Press.

Distinguish Between Harmfulness & Wrongfulness

Research can address the issue of harmfulness, but not wrongfulness

Sexual abuse

Drug exposure in a toddler

Research can evaluate the effectiveness of responses, but not justice

Be Flexible

Nothing is more clear than that this area is complex and controversial

Never stop assimilating new information

Never stop learning

Educate Your Colleagues

Help others understand the real risks of prenatal exposure to drugs

Help others see it in context

Help others see the problems of over-reliance on court-based responses

Don’t Give Up

Children in substance-abusing homes need you.

There is a desperate need for more collaborative groups like this one.

Methamphetamines

Epidemiology of Meth in Seattle

Frequency went up quickly before 1997; 220% increase in Emergency Department mentions for women between 1990 and 1997

Such mentions decreased 44% between 1997 and 1998

Indicators currently mixed 0

50

100

150

200

250

300

1984 1989 1995

Labs

ED Mentions Per 100,000 (1999)

0

2

4

6

8

10

12

14

SanFrancisco

San Diego Phoenix Seattle LA

5-Year Trends in Meth ED Mentions Per 100,000: Seattle and Other Cities

Methamphetamines (Cont.)

May be relatively strongly associated with permanent brain damage

Lead may be used as a reagent Very preliminary research looks similar to

that of cocaine and other drugs Consider moderation