Perinatal Substance Exposure

Overview

The birth of children exposed to both licit and illicit substances constitutes a serious social problem. Results from a national survey conducted in 1994 by the National Institute on Drug Abuse (NIDA) suggest that up to 221,000 children are born each year having been exposed to illicit substances during gestation (as cited in Chasnoff & Lowder, 1999). Furthermore, findings from the NIDA survey indicate that the number of children who are prenatally exposed to alcohol far exceeds the number exposed to illicit substances, thereby placing the total number of children born each year exposed to alcohol and illicit drugs at over 1 million.

for California

Studies have long been thought to underestimate the numbers of affected infants because mothers may deny drug use, medical personnel may not ask certain groups of women about drug use, doctors may not recognize the signs of drug use, or the results of toxicological screens may be incorrect, as there are high rates of false negatives (Kronstadt 1989; Finkelstein, 1994).

The National Pregnancy and Health Survey, conducted by the National Institute on Drug Abuse (NIDA), and based on a national probability sample, reports that 6 percent of the 4 million women who gave birth in 1992 used illicit drugs, 19 percent drank alcohol, and 20 percent smoked cigarettes during pregnancy. About one-third of the illicit drug users also smoked and/or drank during pregnancy (NIDA, 1994a).

Using a multistage probability sampling design, Vega et al (1993) estimated the prevalence of perinatal substance exposures in California. Their results show that 5 percent of the women used illicit drugs and 7 percent drank alcohol. Another 9 percent smoked during pregnancy. The percentage of women testing positive for any drug, including alcohol, was 11 percent. These percentages may be higher for women living in urban areas.

Studies suggest that 11% to 40% of women who receive obstetric care in large teaching hospitals in inner cities have used at least one illicit drug during pregnancy (as cited in Jansson & Velez, 1999). It is likely that the prevalence rates of illicit substance use among pregnant women in urban areas is associated with socio-economic status. One study, which looked specifically at cocaine use among pregnant women, found significant differences in prevalence rates between private pay and public health clinic patients. For this study, urine samples were collected from all women delivering in a New York City hospital over a one week period and results demonstrate that whereas only 1.4% of the private pay women tested positive for cocaine, 14% of the public health clinic patients tested positive (Matera, Warren, Moomjy, Fink, & Fox, 1990).

Until recently, the interpretation of research on the prevalence of perinatal substance abuse has been plagued by weak samples. Based on these few studies, and better recent ones, the risk factors for women delivering a drug-exposed infant include poverty, little education, poor nutrition, little or no prenatal care, history of sexual and/or physical abuse, and being over 25, unmarried, uninsured or on Medicaid, and having other children (Gittler & McPherson, 1990; NIDA, 1994a; Vega et al, 1993). Maternal drug use during pregnancy occurs to differing degrees, however, across socioeconomic status, geographic region, and ethnicity (Gittler & McPherson, 1990; Weston, Ivins, Zuckerman, Jones, & Lopez, 1989).

Most pregnant, drug-involved women use various illicit drugs simultaneously (Worth, 1991), and often in conjunction with alcohol and/or cigarettes. The legal substances, alcohol and nicotine, are among the most teratogenic agents, associated with substantially increased risk of injury to the fetus (Hoegerman, Wilson, Thurmond, & Schnoll, 1990). Alcohol use causes structural, behavioral, and neurobiochemical changes. Nicotine may be responsible for much of the morbidity in children exposed to illicit drugs prenatally, as the perinatal death rate is 34 percent higher in infants of mothers who smoke (Hoegerman et al, 1990).

Fetal exposure to the Human Immunodeficiency Virus is inextricably linked to maternal drug use. Mothers are most commonly infected with HIV through their own intravenous drug use or sexual relations with an IV drug user (CDC, 1989; NIDA, 1994b), though more recent research has established a strong link between HIV infection and crack cocaine use (Edlin, et al, 1994).

According to the 1999 HIV/AIDS Surveillance Report, 91 percent of children under 13 who were ever reported with AIDS in this country contracted HIV prenatally (Department of Health and Human Services, 1999). Understanding and effectively addressing the problem of perinatal substance abuse will also reduce fetal HIV exposure.

Effects of In Utero Drug Exposure

All drugs can cross into the placenta to some extent, especially if introduced into the mother's body in large quantities over a prolonged period of time. The time during gestation that the drugs are taken is extremely important, as the first eight weeks of pregnancy are the most critical for fetal development (Hoegerman et al, 1990; Robins & Mills, 1993). Severe consequences also can result from exposure later in the pregnancy, depending on which organs are under development, and the particular genetic vulnerabilities of the fetus (Weston et al, 1989).

Not all infants exposed prenatally to drugs and alcohol will be affected in the same way (Weston et al, 1989; Zuckerman, 1993). Some opiate-exposed infants experience drug withdrawal at birth but then develop more or less normally. For example, by 3 years of age, catch-up growth is usually completed so that smaller infants have similar weight, height, head circumference, and level of cognitive development as babies not prenatally exposed to drugs (Robins & Mills, 1993).

It is therefore uncertain whether developmental delays or learning disabilities are attributable primarily to prenatal exposure to drugs, as opposed to chaotic, impoverished home environments (Hoegerman et al, 1990; Jessup, 1990; Zuckerman, 1993). Outcomes are very likely a product of physical vulnerability and environmental failings (Sameroff & Chandler, 1975).

Though it is difficult to separate prenatal effects from other factors, such as poor maternal health, inadequate nutrition, and lack of prenatal care, exposure to drugs in utero may cause: spontaneous abortion, premature birth, low birthweight, damage to the central nervous system, mild to severe withdrawal symptoms, congenital physical malformations, stillbirth, fetal strokes, upper respiratory infections, respiratory abnormalities, visual, auditory, and/or motor impairments, and significantly increased risk of Sudden Infant Death Syndrome (Hoegerman et al, 1990; Jessup, 1990; Kronstadt 1989; Free, Russell, Mills, & Hathaway, 1990; O'Connor, Kilbride, & Hayen, 1993; Robins & Mills, 1993; Vega et al, 1993).

Prenatal exposure to drugs may also affect an infant's behavior at birth, thereby interfering with their ability to interact with their environment, to respond to stimuli, and to interact appropriately with the mother or caretaker (Chasnoff & Lowder, 1999). Whereas physical difficulties occur among drug exposed infants in 25% to 30% of cases, neurobehavioral problems are more common and these problems vary according to the types of substances to which the infant was exposed (Jansson & Velez, 1999).

In the literature, neurobehavioral deficiencies are generally divided into three key areas: motor behavior, orientation, and state control. The motor behaviors of substance-exposed infants may include: stiffness; poor or hyperactive reflexes; limpness and lethargy; and poor coordination of the suck and swallow response. Prenatal exposure to substances can also affect the newborn's orientation (their ability to respond to visual and auditory stimulation). These newborns, although their hearing may be intact, have difficulty with response to sound. Additionally, they may have trouble focusing their gaze, even for brief periods of time.

State control, which refers to one's ability to regulate his or her behavior and to calm oneself in response to environmental demands, may be impaired in prenatally exposed infants. For example, these infants may fall into a deep, self-protective and prolonged sleep in response to external stimuli. State changes for these infants also tend to be abrupt and inappropriate, such that they may move from a state of sleep to crying for no apparent reason (Chasnoff & Lowder, 1999).

Lastly, at birth, the drug-exposed neonate may be at higher risk for cerebral palsy and mental retardation, have increased yawning, sneezing, low-grade fevers, skin mottling, diarrhea, vomiting; and may fail to thrive (Hoegerman et al, 1990; Kronstadt, 1989).

Screening newborns for effects of drug exposure may underrepresent deficits, as these become more apparent over time (Hoegerman et al, 1990). Damage to the genitourinary and/or cardiovascular systems, for example, may not produce symptoms until as late as adolescence, so that the newborn may appear to be free of any physical symptoms of drug exposure (Weston et al, 1989). Long term developmental effects of drug exposure may include learning disabilities; delayed motor, speech, and language development; and mental retardation

Substance exposed children are also at higher risk of neglect and abuse than non-substance exposed children (Chasnoff & Lowder, 1999; Jansson & Velez, 1999). This risk is heightened for a child who is being reared by parents who are actively abusing substances. For example, the combination of a substance abusing mother, with her concomitant social-emotional and medical problems, and the demands placed upon her by a drug-exposed infant is fraught with disaster (Jansson & Velez, 1999). This risk is heightened even further in families living in poverty because these families lack the social and economic supports which tend to mitigate the strain placed upon substance-affected families.

Impact on Health and Social Services Systems

While the number of drug-exposed infants is relatively small, they are among the most expensive babies for whom to care. Costs of hospital care for these infants can be as much as ten times the cost of care for non-exposed children (Calhoun & Watson, 1991; Ellwood, Adams, Crown, & Dodds, 1993; Jessup, 1990). If these infants are abandoned by their parents, they may end up boarding in hospitals, further inflating costs. Approximately 80 percent of abandoned babies are prenatally exposed to illicit drugs (Abedin, Young, & Beeram, 1992; James Bell & Associates, 1993; Marcenko, Seraydarian, Huang, & Rohweder, 1992).

According to the U.S. General Accounting Office (1998), approximately two-thirds of all children in foster care in both California and Illinois, or 84,600 children combined, had at least one parent who abused drugs or alcohol. The majority of these parents had been abusing drugs or alcohol for at least five years and most had used one or more hard drugs such as cocaine, methamphetamines, and heroin.

The prevention and treatment of drug and alcohol abuse during pregnancy thus has great economic benefits. However, the growth in the numbers of drug-affected children has not led to a concomitant growth in the numbers of drug treatment and prevention programs available for women (Finkelstein, 1994; Gittler & McPherson 1990).

Intervention Strategies

Perhaps as few as 11 percent of pregnant addicts receive drug treatment because many programs do not accept pregnant women and/or women with children, and some women avoid treatment for fear that punitive action will be taken against them (Gustavsson, 1992). Because addiction is a progressive and chronic illness, however, all efforts must be made to identify and treat it as early as possible (Jessup, 1990). Early alcohol and drug treatment and prenatal care have been shown to improve fetal outcomes (Kronstadt, 1989; Robins & Mills, 1993; Weiner & Morse, 1990).

Several approaches to the treatment of substance abusing pregnant women have been attempted. Much of the research suggests that one core ingredient for effective treatment involves the recognition of the gender-specific treatment needs of women and mothers. One gender-specific approach (as cited in Chasnoff & Lowder, 1999) suggests that substance abuse treatment should attend to the following four factors: the role of men in women's substance abuse problems; a woman's connection to her children; the ways in which a woman's social support network can both support and frustrate her attempt to address a substance abuse problem; the importance of a positive social support system in increasing a woman's self-efficacy and self-esteem.

It is also important to recognize that substance abusing women require a multitude of services which include: substance abuse and mental health treatment, obstetrics/gynecology/family planning, pediatrics, and nursing (Jansson & Velez, 1999). The barriers to treatment for substance abusing pregnant women are numerous but may be overcome by: providing treatment soon after the initial contact, providing transportation to and from services, the coordination of multidisciplinary services, providing culturally appropriate and gender specific services, and providing child care (Jansson & Velez, 1999).

A review of the literature suggests that the following interventions are also effective in treating substance abusing pregnant women: individual, group, and family counseling, education on the effects of drug and alcohol use on the fetus, prenatal care, case management, parenting classes, residential treatment, supportive services for the extended family, transitional services, relapse prevention services, and systematic follow-up using a community-based, family-centered approach. (Egelko et al., 1996; Finkelstein, 1994; Howell, Heiser, & Harrington, 1999; McCurtrie, 1999; Stevens & Arbiter, 1995).

Substance abusing women have a high prevalence of co-occuring mental illness and these women are in particular need of evaluation and treatment. One study suggests that among cocaine and alcohol abusing women seeking treatment, 70% had a comorbid affective or anxiety disorder (as cited in Jansson & Velez, 1999). This population requires specialized treatment and substance abuse services are vital for this population. The range of treatments which should be made available to this population includes outpatient therapy, residential treatment, medical detoxification, and methodone maintenance for those women who are opiate dependent (Jansson & Velez, 1999).

Because the postnatal environment is probably more important than prenatal drug exposure in determining developmental outcomes in children, appropriate early intervention services and stable home environments can help mitigate some of the damaging effects of prenatal drug and alcohol exposure on infants (Abedin et al, 1993; Barth, 1994; O'Connor et al, 1993; Zuckerman, 1993). Unlike children with Fetal Alcohol Syndrome who have noticeable cognitive impairments and typically require special education, other drug and alcohol exposed children may fair as well as non-exposed children when benefiting from early intervention services (Robins & Mills, 1993).

Conclusion

Pregnancy provides a window of opportunity for intervention services that may help avoid the devastating individual, familial, and social costs of maternal drug and alcohol abuse. The challenge for the medical and social service fields is to design and implement effective programs that are preventive, comprehensive, culturally competent, community based, and family centered.

References

Abedin, M., Young, M., Beeram, M. (1993). Infant abandonment: Prevalence, risk factors, and cost analysis. American Journal of Diseases in Children, 147, 714-716.

Barth, R.P. (1994). Protecting the children of heavy drug-users at home. In D. Besharov (Ed.). When drug addicts have children: Reorienting child welfare's response. Washington, D.C.: Child Welfare League of America.

Calhoun, B., and Watson, P. (1991). The cost of maternal cocaine abuse. Obstetrics and Gynecology, 78(5 Pt 1), 731-734.

Chasnoff, I. (1988). A first: National hospital incidence study. Chicago: National Association for Perinatal Addiction Research and Education.

Chasnoff, I.J. & Lowder, L. (1999). Prenatal alcohol and drug use and risk for child maltreatment: A timely approach to intervention. In Neglected Children, Research, Practice and Policy. Ed Howard Dubowitz. Thousand Oaks: Sage Publications.

Centers for Disease Control (1989). First 100,000 cases of acquired immunodeficiency syndrome - United States. JAMA, 262, 1453-1456.

Department of Health and Human Services (1994). HIV/AIDS surveillance report, Washington D.C.

Edlin, B., Irwin, K., Faruque, S., McCoy, C., Word, C., Serrano, Y., Inciardi, J., Bowser, B., Schilling, R. Holmberg, S. (1994). Intersecting epidemics: Crack cocaine use and HIV infection among inner-city young adults. New England Journal of Medicine, 331(21): 1422-1427.

Egelko, S., Galanter, M., Dermatis, H., & DeMaio, C. (1996). Evaluation of a multisystems model for treating perinatal cocaine addiction. Journal of Substance Abuse Treatment, 15(3), 251-259.

Egelko, S., Galanter, M., Edwards, H., & Marinelli, K. (1996). Treatment of perinatal cocaine addiction: Use of a modified therapeutic community. American Journal of Drug and Alcohol Abuse, 22, 185-202.

Ellwood, M., Adanis, E., Crown, W., Dodds, S. (1993). An exploratory analysis of the Medicaid expenditures of substance exposed children under two years of age in California. Cambridge, MA: SysteMetrics.

Finkelstein, N. (1994). Treatment issues for alcohol-and drug- dependent pregnant and parenting women. Health and Social Work,19, (1): 7-15.

Gittler, J. and McPherson, M. (1990). Prenatal substance abuse. Children Today, July-August: 3-7.

Hoegerman, G., Wilson, C., Thurmond, E., Schnoll, S. (1990). Drug-exposed neonates: Addiction medicine and the primary care physician. The Western Journal of Medicine, 152: 559-564.

Howell, E.M., Heiser, N., & Harrington, M. (1999). A review of recent findings on substance abuse treatment for pregnant women. Journal of Substance Abuse Treatment, 16(3), 195-219.

James Bell & Associates (1993). Report to congress: National estimates in the number of boarder babies, the cost of their care, and the number of abandoned infants. Washington, D.C.: U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth, and Families, Children's Bureau.

Jansson, L.M., & Velez, M. (1999). Understanding and treating substance abusers and their infants. Infants and Young Children, 11(4), 79-89.

Jessup, M. (1990). The treatment of perinatal addiction: Identification, intervention, and advocacy. The Western Journal of Medicine, 152(2), 553-558.

Kronstadt, D. (1989). Pregnancy and cocaine addiction: An overview of impact and treatment. Drug Free Pregnancy Project. San Francisco: Far West Laboratory for Educational Research and Development.

Marcenko, M., Seraydarian, L., Huang, K., Rohweder, C. (1992). Hospital boarder babies and their families: An exploratory study.

McMurtrie, C., Rosenberg, K.D., Kerker, B.D., Kan, J., & Graham, E.H. (1999). A unique drug treatment program for pregnant and postpartum substance-using women in New York City: Results of a pilot project, 1990-1995. American Journal of Drug and Alcohol Abuse, 25(4), 701-713.

Melnick, V. (1992). Boarder babies and drug affected children in the District of Columbia. Washington, D.C.: Center for Applied Research and Urban Policy, University of the District of Columbia.

National Association for Family Addiction Research and Education (1989). Innocent addicts: High rate of prenatal drug abuse found. ADAMHA News.

National Institute on Drug Abuse (1994a). National Pregnancy and Health Survey. Rockville, MD.

National Institute on Drug Abuse (1994b). Women and drug abuse. NIDA Capsules. Rockville, MD.

O'Connor, T., Kilbride, H, Hayen, L (1993). Incidence of fetal alcohol syndrome among infants with intrauterine cocaine exposure. Journal of Maternal-Fetal Investigation, 3: 29-31.

Robins, L, & Mills, J. (1993). The effects of in utero exposure to street drugs. American Journal of Public Health, 93 (December supplement): 1-32.

Sameroff, A.J. and Chandler, M.J. (1975). Reproductive risk and the continuum of caretaking casualty. In F.D. Horowitz (Ed.). Review of child development research (Vol. 4, pp. 187-244). Chicago: University of Chicago Press.

Stevens, S., & Arbiter, N. (1995). A therapeutic community for substance-abusing pregnant women and women with children: Process and outcome. Journal of Psychoactive Drugs, 27, 49-56.

U.S. General Accounting Office (1990). Drug-exposed infants: A generation at risk. Washington, D.C.: Human Resources Division, 90-139, June.

Vega, W., Noble, A., Kolody, B., Porter, P., Hwang, J., Bole, A. (1993). Prevalence and Magnitude of perinatal substance exposures in California. New England Journal of Medicine, 329: 850-954.

Weiner, L. and Morse, B.A. (1990). Alcohol, pregnancy, and fetal development. In R.C. Enger (Ed.). Women: Alcohol and other drugs. Dubuque, IA: Kendall/Hunt Publishing Company.

Weston, D., Ivins, B., Zuckerman, B., Jones, C., Lopez, R. (1989). Drug exposed babies: Research and clinical issues. Zero to Three: Bulletin of the National Center for Clinical Infant Programs, 9(5).

Worth, D. (1991). American women and polydrug use. In P. Roth (Ed.). Alcohol and drugs are women's issues. Mettuchen, NJ: Scarecrow Press.

Zuckerman, B. (1993). Developmental considerations for drug- and HIV-affected infants. In R. Barth, R.M. Ramier, J. Pietrzak (Eds.). Families living with drugs and HIV. New York: Guilford Press.

Resources for additional information

African-American Family Services/Institute on Black Chemical Abuse. 2616 Nicollet Avenue South, Minneapolis, MN 55408, (612) 871-7878.www.aafs.net

Clearinghouse for Drug Exposed Children, Division of Behavioral and Developmental Pediatrics, University of California at San Francisco, 400 Parnassus Avenue, Room A203, San Francisco, CA 94143, (415) 353-7766.

Maternal and Child Health Bureau Clearinghouse. 2070 Chain Bridge Road, Suite 450 Vienna, Virginia, 22182 (703) 821-8955 ext. 254.

National Abandoned Infants Assistance Resource Center, 1950 Addison, Suite 104, Berkeley, CA 94704, (510) 643-8390.

National Institute on Drug Abuse, 5600 Fishers Lane, IOA-54 Parklawn Building, Rockville, MD 20857, (800) 662-4357.