Hot Topic: Drug-Exposed Children

Substance abuse has been a risk factor for social service involvement with families for over 100 years, and drug use has been a key issue in child welfare for the past 25 years. Skyrocketing use of drugs and alcohol, leading to higher numbers of drug exposed children, has been targeted as a primary factor in the increase in children placed in out-of-home care in the late 1980s and 1990s (Barth, 1991).

The early research in the area of drug exposed children was overwhelmingly negative: parents who adopted these children reported that, after the long and sometimes frustrating process of terminating the rights of the birth parents of these children, raising these children was more difficult than even experts had predicted (Barth, 1991).

The late 1990s, however, has brought a new round of research to light, indicating that there is hope in this area: that the outcomes for prenatally drug exposed children need not always be dark, and that practice can improve the chances for these families.

Background

Studies estimating the incidence of prenatal alcohol and drug exposure do not agree upon a precise incidence level:

Alcohol: 2.6 million infants each year are prenatally exposed to alcohol (Gomby and Shiono, 1991).

• Fetal Alcohol Syndrome affects between 1.3 and 2.2 children per 1,000 live births in North America each year (Streissguth and Guiunta, 1988; US DHHS, 1990).
• Cases of Alcohol Related Birth Defects outnumber cases of FAS by a ratio of 2-3 to 1 (Abel and Dintcheff, 1984; Streissguth and Guiunta, 1988).

Illicit Drugs: Each year, 11% of all newborns, or 459,690, are exposed to illicit drugs (Chasnoff, 1989).

• More than 739,000 women each year use one or more illicit drugs during pregnancy (Gomby and Shiono, 1991).
• A substance exposed infant is born more frequently than every 90 seconds (Schipper, 1991).

Widespread media coverage of early negative findings for newborns prenatally exposed to cocaine created a mythic belief about the prevalence and outcomes of these children. Many of these perceptions have since been dispelled by research findings.

Popular belief holds that the drug epidemic created and continues to create "crack babies" and other disabled newborns, whose prenatal exposure will always result in lowered social and academic functioning. Research shows that drug exposure is only one of many factors which affect infant behavior and childhood development; others include

• the type of drug to which the child was exposed
• health and medical history
• maternal physical and mental health or problems
• mother's access to prenatal medical care
• child's biological vulnerability
• family and social environmental factors.
• family history of abuse or violence
• nurturing and stimulating environments
• inconsistent, inadequate, or inappropriate caregiving
• poverty
• disorganization and instability of home and work environments of family members

The research shows that effects of prenatal exposure cover the range from severe effects (neurological damage and growth retardation) to minor effects, resulting in normal outcomes. The interaction pattern between mother and child, and other social factors, have more effect on some outcomes for children than prenatal drug exposure (Myers et.al., 1992; Barth 1991).

For children entering foster care, research confirms that the number of moves experienced while in care is more significant to the child's outcome than prenatal drug exposure (Myers, et.al., 1992).

The effects of exposure to alcohol and other drugs in utero is not limited to North America; a review of medical records of children adopted from Russia found an incidence of FAS of 15 per 1,000 live births - eight times the world incidence. Over 12% of the children had a history of maternal alcohol abuse in their records (Aronson, 1997).

Implications for Policy

Suitable treatment resources for children with prenatal histories of substance abuse are often unavailable, and reunification of the children with their birth families occurs only half as frequently (Walker, 1994). This results in a likelihood of lifelong developmental and/or emotional complications due to multiple placements and inconsistent caregiving (Edelstein, 1995). As more children placed for adoption are prenatally exposed to alcohol and other drugs (Goldwater, 1997; Legg, 1997), increasingly the availability of services for these children with special needs will fall short of the need. Also, as the numbers of children adopted internationally by Americans increases, particularly from Russia and former Soviet republics, the need for services will further increase.

Lessons from Best Practice

Researchers, adoption professionals, and adoptive parents have learned from experience that parenting a child exposed prenatally to drugs and/or alcohol can be a rewarding experience, full of love and happiness for the parent and child. In order to successfully overcome the special challenges that these children face, however, parents need preparation, education, and supportive services before, during, and after the placement.

Obtain medical history of the birth parents

Practitioners should obtain as extensive history from and about both birth parents as early in the pregnancy as possible. If this is not possible, an extensive screening interview should be conducted by a medical professional at the time of the child's entry into foster care or an orphanage. Records that should be obtained include:

• photographs of the child over time
• growth data over time (height, weight, and head circumference)
• ages where developmental milestones were reached
• observation of behavior by caregivers
• status, known diagnoses, and current developmental status of siblings.

These assessments may be impeded by many factors:

• difficulty differentiating effects caused by specific drugs in cases of maternal polydrug use
• difficulty in determining time and frequency of use
• biological diversity of both the child and mother
• lack of correlation and relation between postnatal behavior and long-term medical and developmental effects.

Prepare adoptive parents or guardians

Adoptive parents and guardians of drug exposed children must have access to as much information about the child as possible in order to appropriately parent the child entering the family. It is critical that practitioners prepare these families by

• providing information about prenatal drug exposure and its effects
• examining the family's attitudes and belief about adoption
• examining the feelings about the birth family, including parents who abuse alcohol and drugs
• balancing optimism about the placement with awareness of the possible effects of prenatal drug exposure
• discussing open adoption options
• educating parents about available services and preparing them for those services.

Offer adequate and ongoing post-adoption services

Families adopting children exposed to alcohol and illicit drugs in utero will find post-adoption services necessary, before, during, and after the time of placement. Practitioners promoting best practices for the permanent placement or adoption of these children should encourage making the following services available to their families:

• adoption and/or medical subsidy
• continuing information about support or educational services
• health and child development follow-up, at least through preschool years
• early intervention services
• behavioral management
• special education services
• tutoring for academic underachievement
• assessment and intervention for neuropsychological problems
• counseling services for all family members
• support groups for parents
• education and guidance for dealing with childhood and adolescent behaviors
• respite care
• legal assistance for parents in finalizing the adoption and pursuing services.

Be aware of risk factors

Practitioners should educate themselves about maternal risk factors for the use of alcohol and illicit drugs during pregnancy and evaluate the probability of usage during pregnancy. In addition to medical and social risk factors, practitioners should learn about cultural and ethnic environments where the risk of prenatal exposure is increased. Practitioners should strive for professional improvement in the following areas:

• knowledge of alcoholism and addiction and the impact of chemical dependency in families
• knowledge of potential effects of prenatal substance exposure on children
• awareness of the agencies and disciplines that are involved in serving substance abusers, including child welfare, medicine, nursing, education, child development, psychology, substance abuse treatment, and the legal system
• skill in assessment and continuing relationships with birth parents, relatives, foster parents, and adoptive parents.

Keep an open mind

Even in the face of known alcohol and drug use, practitioners should be open to all possible alternative diagnoses for developmental and neurological disabilities.

Promote education

Practitioners should encourage widespread education about the effects of prenatal drug exposure among all professionals in contact with these children:

• health care professionals
• substance abuse counselors
• social workers
• attorneys, guardians ad lidem, and court appointed special advocates.

Bibliography

Abel, E., and Dintcheff, B. (1984). Factors affecting the outcome of maternal alcohol exposure: I. Parity. Neurobehavioral Toxicology and Teratology, 6: 373-377.

Aronson, J.E. (1997). FAS and International Adoption. Presentation at Adoption and Prenatal Alcohol and Drug Exposure: The Research, Policy, and Practice Challenges. October 25.

Barth, R.P. (1991). Adoption of drug-exposed children. Child and Youth Services Review, 13, 323-342.

Barth, R.P. (1991). Trends and issues: Educational implications of prenatally drug-exposed children. Social Work in Education, 13, 130-136.

Chasnoff, I.J. (1989). Drug use in women: Establishing a standard of care. Annals of the New York Academy of Science, 562, 208-210.

Edelstein, S. (1995). Children with prenatal alcohol and/or other drug exposure: Weighing the risks of adoption. Washington, DC: Child Welfare League of America, Inc.

Goldwater, J. (1997). Adoption: Preparation, education, and assessment of prospective adoptive parents. Presentation, Presentation, Adoption and Prenatal Alcohol and Drug Exposure: The Research, Policy, and Practice Challenges, October 24.

Gomby, D., and Shiono, P. (1991). Estimating the number of substance-exposed infants. The Future of Children, 1 (1), 17.

Legg, K. (1997). Personal communication. Executive Director, Spence-Chapin Services to Families and Children. 15 June.

Myers, B.J., Olson, H.C., and Kaltenback, K. (1992). Cocaine-exposed infants: Myths and misunderstandings. Zero to Three, 13 (1) 1-5.

Schipper, W. (1991, July 30). Testimony before the U.S. House of Representatives Select Committee on Narcotics Abuse and Control.

Streissguth, A., and Giunta, C. (1988). Mental health and health needs of infants and preschool children with fetal alcohol syndrome. International Journal of Family Psychiatry: 29-47.

US Department of Health and Human Services. (1990). Fetal alcohol syndrome and other effects of alcohol on pregnancy. In Seventh Special Report to the US Congress on Alcohol and Health from the Secretary of Health and Human Services (pp. 139-161). Rockville, MD: US Department of Health and Human Services.

Walker, C.D. (1994). African American children in foster care. In D.J. Besharov (Ed.) When drug addicts have children: Reorienting child welfare's response (pp. 145-152). Washington, DC: Child Welfare League of America, Inc.

This material may be reproduced and distributed without permission; however, appropriate citation must be given to the National Adoption Information Clearinghouse.