prenatal substance exposure putting it into perspective and responding appropriately steven j....
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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