Prenatal Substance Exposure

1. Prenatal Substance Exposure Putting it into Perspective and Responding Appropriately Steven J. Ondersma, PhD Departments of Psychiatry & Behavioral Neurosciences and Obstetrics & Gynecology

2. 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

3. A Closer Look, Part 1: Made to Order

4. Models of Addiction PERSON RESPONSIBLE FOR ADDICTION? Yes No Yes PERSON RESPONSIBLE FOR CHANGE? No

5. A CRIME: Voluntary Illegal & destructive, like arson or robbery A DISEASE: Involuntary More like depression than like arson Prenatal Substance Use: Is It…

6. Social Services Child Protection Social Work Nursing Substance Abuse Law Enforcement Justice Psychology Early Childhood Medicine Why So Difficult? Multiple Viewpoints

7. 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

8. 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

9. 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?

10. 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 Use of Court System

11. 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 To Remove Or Not To Remove?

12. 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

13. A Closer Look, Part 2: Literature Review

14. The Birth of a Social Problem

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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)

22. Contemporary Period: Recent Research

23. 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

24. 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.

25. 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

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

27. 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

28. 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

29. 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

30. Singer et al., JAMA 2002

31. 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.

32. Frank et al., Pediatrics, 2002

33. The Importance of Dosage THE DOSE IS THE POISON

34. 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

35. 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

36. 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

37. 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.”

38. 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.”

39. A Closer Look, Part 3: How Society Is Responding

40. 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 Ondersma et al., CAN, 2001 Child Welfare Intake supervisors from:

41. Percent of Counties Receiving Referrals 90%

42. % Cases Juvenile Charges Filed (Among Counties Receiving Referrals) >75% of cases None 25% 21% <10% of cases 14% 22% 19% 41-75% of cases 11-40% of cases

43. % Infants Removed--Cocaine (Among Counties Receiving Referrals) >75% of cases None 13% <10% of cases 29% 15% 17% 26% 41-75% of cases 11-40% of cases

44. Opinion of County Practice Too strong Inadequate to protect child 26% Appropriate in most cases 69%

45. 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)

46. Handle Cases of Prenatal Drug Exposure? 42% 58%

47. How Big A Factor Is Exposure In Decision to File Charges? 12% 44% 38%

48. 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

49. 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

50. What % Of Perinatal Drug Users Should Be Prosecuted Criminally? Response: Ideal Percent