Children's intellectual and emotional-behavioral adjustment at 4 years as a function of cocaine exposure, maternal characteristics, and environmental risk

Early emotional caregiving environment and associations with memory performance and hippocampal volume in adolescents with prenatal drug exposure

Early adversities, including prenatal drug exposure (PDE) and a negative postnatal emotional caregiving environment, impact children's long-term development. The protracted developmental course of memory and its underlying neural systems offer a valuable framework for understanding the longitudinal associations of pre- and postnatal factors on children with PDE. This study longitudinally examines memory and hippocampal development in 69 parent-child dyads to investigate how the early caregiving emotional environment affects children with PDE's neural and cognitive systems. Measures of physical health, drug exposure, caregiver stress, depression, and distress were collected between 0 and 24 months At age 14 years, adolescents completed multiple measures of episodic memory, and at ages 14 and 18 years, adolescents underwent magnetic resonance imaging (MRI) scans. Latent constructs of episodic memory and the caregiving environment were created using Confirmatory Factor Analysis. Multiple regressions revealed a negative emotional caregiving environment during infancy was associated with poor memory performance and smaller left hippocampal volumes at 14 years. Better memory performance at 14 years predicted larger right hippocampal volume at 18 years. At 18 years, the association between the emotional caregiving environment and hippocampal volume was moderated by sex, such that a negative emotional caregiving environment was associated with larger left hippocampal volumes in males but not females. Findings suggest that the postnatal caregiving environment may modulate the effects of PDE across development, influencing neurocognitive development.

Latent Class Analysis of Prenatal Substance Exposure and Child Behavioral Outcomes

OBJECTIVES

To predict behavioral disruptions in middle childhood, we identified latent classes of prenatal substance use.

STUDY DESIGN

As part of the Environmental influences on Child Health Outcomes Program, we harmonized prenatal substance use data and child behavior outcomes from 2195 women and their 6- to 11-year-old children across 10 cohorts in the US and used latent class-adjusted regression models to predict parent-rated child behavior.

RESULTS

Three latent classes fit the data: low use (90.5%; n = 1986), primarily using no substances; licit use (6.6%; n = 145), mainly using nicotine with a moderate likelihood of using alcohol and marijuana; and illicit use (2.9%; n = 64), predominantly using illicit substances along with a moderate likelihood of using licit substances. Children exposed to primarily licit substances in utero had greater levels of externalizing behavior than children exposed to low or no substances (P = .001, d = .64). Children exposed to illicit substances in utero showed small but significant elevations in internalizing behavior than children exposed to low or no substances (P < .001, d = .16).

CONCLUSIONS

The differences in prenatal polysubstance use may increase risk for specific childhood problem behaviors; however, child outcomes appeared comparably adverse for both licit and illicit polysubstance exposure. We highlight the need for similar multicohort, large-scale studies to examine childhood outcomes based on prenatal substance use profiles.

Self-Recognition and Emotional Knowledge

Self-recognition emerges during the second year of life and represents the emergence of a reflective self, a metacognition which underlies self-conscious emotions such as embarrassment and shame, perspective taking, and emotional knowledge of others. In a longitudinal study of 171 children, two major questions were explored from an extant database: 1) Do early factors, including IQ, general environmental risk, mother-child attachment interaction, drug exposure, gender, and neonatal risk, relate to self-recognition?; 2) Does self-recognition, along with these earlier factors, predict the child's subsequent emotional knowledge? Consistent with previous data, 39% of children exhibited self-recognition by 18-months and few early factors explored were related to this ability. Moreover, path analysis revealed few effects of the earlier factors predicting self-recognition on children's emotional knowledge. Self-recognition did predict emotional knowledge at 4.5 years, such that children who showed early self-recognition showed greater emotional knowledge. Children from high risk environments also showed lower emotional knowledge. These findings indicate that self-recognition and environmental risk are related to children's later knowledge of emotions.

Gender Differences in the Outcome of Offspring Prenatally Exposed to Drugs of Abuse

Despite great efforts to warn pregnant women that drugs of abuse impact development of the embryo and the fetus, the use of legal and illegal drugs by childbearing women is still a major public health concern. In parallel with well-established teratogenic effects elicited by some drugs of abuse, epidemiological studies show that certain psychoactive substances do not induce birth defects but lead to subtle neurobehavioral alterations in the offspring that manifest as early as during infancy. Although gender differences in offspring susceptibility have not been fully investigated, a number of longitudinal studies indicate that male and female progeny exposed in utero to drugs of abuse show different vulnerabilities to deleterious effects of these substances in cognitive, executive, and behavioral domains. Here, we briefly review the existing literature focusing on gender differences in the neurobehavioral consequences of maternal exposure to drugs of abuse. Overall, the data strongly indicate that male exposed progeny are more susceptible than female to dysfunctions in cognitive processing and emotional regulation. However, insights into the mechanisms determining this natural phenomenon are not currently available. Our analysis prompts future investigations to implement clinical studies including the influence of gender/sex as a biological variable in the outcome of offspring prenatally exposed to drugs of abuse.

The Racialized Nature of Child Welfare Policies and the Social Control of Black Bodies

Black women are disproportionately involved in the child welfare system. This state-level intervention occurs at two levels-a higher likelihood of being (i) screened for drug use during pregnancy and (ii) reported to child welfare authorities after delivery. Consequently, they face further enmeshment in state-systems, including custody loss and lower reunification odds. Using evidence from the past forty years of research and media reports, we argue that systemic forces and policies largely contribute to racial disproportionality in the child welfare system, and assert this state intervention serves as a mechanism to control black reproduction.

Prenatal cocaine exposure: Direct and indirect associations with 21-year-old offspring substance use and behavior problems

BACKGROUND

Prenatal cocaine exposure (PCE) has been linked to child/adolescent behavior problems and substance use in several longitudinal cohort studies. It is unclear whether these effects extend into adulthood and influence young adult behavior problems and substance use and, if so, whether they are mediated by childhood and adolescent experiences.

METHODS

These data are from an ongoing longitudinal study of individuals born to women who were recruited early in pregnancy. Trimester-specific data on prenatal drug exposure were obtained. Caregivers and offspring were assessed at delivery and at 1, 3, 7, 10, 15, and 21 years postpartum. This report is from age 21, when 225 offspring (52% females; 54% African American, 46% Caucasian) reported on behavior problems, emotion regulation, and substance use.

RESULTS

There were significant direct associations between PCE and early initiation of marijuana, 21-year emotion regulation problems, arrest history, and Conduct Disorder. The relation between PCE and young adult internalizing behavior was mediated by adolescent mood symptoms. The association between PCE and 21-year marijuana use was mediated by early initiation of marijuana use.

CONCLUSIONS

PCE has both direct and indirect long-term associations with young adult development. Using statistical models that considered the complex interrelationships among PCE and adult outcomes, we demonstrated that the direct effects of PCE on young adult emotion regulation problems, arrest history, and Conduct Disorder are not completely explained by earlier adolescent behavior. Moreover, the analyses suggesting mediated pathways from PCE to young adult problems identify crucial variables to target interventions for exposed children and adolescents.

A better approach to in vivo developmental neurotoxicity assessment: Alignment of rodent testing with effects seen in children after neurotoxic exposures

High throughput screens for developmental neurotoxicity (DN) will facilitate evaluation of chemicals and can be used to prioritize those designated for follow-up. DN is evaluated under different guidelines. Those for drugs generally include peri- and postnatal studies and juvenile toxicity studies. For pesticides and commercial chemicals, when triggered, include developmental neurotoxicity studies (DNT) and extended one-generation reproductive toxicity studies. Raffaele et al. (2010) reviewed 69 pesticide DNT studies and found two of the four behavioral tests underperformed. There are now many epidemiological studies on children showing adverse neurocognitive effects, yet guideline DN studies fail to assess most of the functions affected in children; nor do DN guidelines reflect the advances in brain structure-function relationships from neuroscience. By reducing the number of test ages, removing underperforming tests and replacing them with tests that assess cognitive abilities relevant to children, the value of DN protocols can be improved. Testing for the brain networks that mediate higher cognitive functions need to include assessments of working memory, attention, long-term memory (explicit, implicit, and emotional), and executive functions such as cognitive flexibility. The current DNT focus on what can be measured should be replaced with what should be measured. With the wealth of data available from human studies and neuroscience, the recommendation is made for changes to make DN studies better focused on human-relevant functions using tests of proven validity that assess comparable functions to tests used in children. Such changes will provide regulatory authorities with more relevant data.

Evolution of Sex Differences in Trait- and Age-Specific Vulnerabilities

Traits that facilitate competition for reproductive resources or that influence mate choice generally have a heightened sensitivity to stressors. They have evolved to signal resilience to infectious disease and nutritional and social stressors, and they are compromised by exposure to man-made toxins. Although these traits can differ from one species or sex to the next, an understanding of the dynamics of competition and choice can in theory be used to generate a priori predictions about sex-, age-, and trait-specific vulnerabilities for any sexually reproducing species. I provide a review of these dynamics and illustrate associated vulnerabilities in nonhuman species. The age- and sex-specific vulnerability of such traits is then illustrated for stressor-related disruptions of boys’ and girls’ physical growth and play behavior, as well as for aspects of boys’ and girls’ and men’s and women’s personality, language, and spatial abilities. There is much that remains to be determined, but enough is now known to reframe trait sensitivity in ways that will allow scientists and practitioners to better identify and understand vulnerable human traits, and eventually ameliorate or prevent their expression.

Psychological Distress Among School-Aged Children with and Without Intrauterine Cocaine Exposure: Perinatal Versus Contextual Effects

Whether intrauterine cocaine exposure (IUCE) explains unique variance in psychiatric functioning among school age children, even after controlling for other biological and social risk factors, has not been fully delineated. As part of a longitudinal birth cohort study of children with and without IUCE, we conducted and analyzed data based on structured clinical interviews with 105 children (57% male) and their caregivers when the child was approximately 8.5 years old; 47% of the children had experienced IUCE. Interviews included past and current major psychological disorders and sub-threshold mental health symptoms. Potential covariates were ascertained by interviews of birth mothers and other caregivers from shortly after the child's birth until the 8.5-year visit. More than one-third of children met DSM-IV criteria for one or more mood, anxiety, attention deficit, or disruptive behavior disorders. IUCE was not significantly associated with children's history of psychological distress, in either bivariate or multiple logistic regressions. In contrast, birth mothers' acknowledgement of greater psychiatric distress at baseline and higher levels of alcohol consumption during pregnancy, and at 8.5 years caregivers' reports of their own psychological distress, and children's lower IQ were predictors of higher rates of psychological morbidity. Findings are consistent with prior reports suggesting that, regardless of IUCE status, children from low-income, urban backgrounds are at heightened risk for psychological distress. Results underscore the need for closer monitoring of the mental health of children living in low-income households, with or without intrauterine substance exposures, to facilitate access to appropriate services.

Differential responsiveness to a parenting intervention for mothers in substance abuse treatment

This study examines the relationship between levels of psychological distress in substance-dependent mothers and their differential response to a dyadic parent-child intervention. A sample of 66 mothers who were receiving treatment for substance abuse, as well as a simultaneous parenting intervention, were interviewed pre and post-treatment on measures of psychological distress, adult and child trauma history, parental reflective functioning, and child social-emotional development. Additionally, clinicians provided assessments of the parent-child relationships. As anticipated, trauma histories for mothers and children, children's social emotional development, and parental reflective functioning were associated with aspects of maternal psychological distress. Kruskal-Wallis and subsequent Wilcoxson signed rank tests revealed that women with highest levels of baseline psychological distress showed significant improvements in psychological functioning post-treatment while women with moderately elevated levels of psychological distress did not. Women who were most distressed at baseline showed increased levels of parental reflective functioning post-treatment while women with moderate and lower levels of baseline psychological distress showed improvements on clinician-rated assessments of parent-child relationships. Chi Square analyses showed that parents who endorsed the highest levels of distress at baseline reported that their children's risk status regarding social-emotional development decreased post-treatment. Despite similarities in substance dependence, mothers in this sample had different needs and outcomes in the context of this parenting intervention due to variation in mental health. Given this variation, parenting interventions for substance-dependent mothers need to account for the individual differences in levels of psychological distress.

Effects of prenatal substance exposure on infant temperament vary by context

This was a prospective longitudinal multisite study of the effects of prenatal cocaine and/or opiate exposure on temperament in 4-month-olds of the Maternal Lifestyle Study (N = 958: 366 cocaine exposed, 37 opiate exposed, 33 exposed to both drugs, 522 matched comparison). The study evaluated positivity and negativity during The Behavior Assessment of Infant Temperament (Garcia Coll et al., 1988). Parents rated temperament (Infant Behavior Questionnaire; Rothbart, 1981). Cocaine-exposed infants showed less positivity overall, mainly during activity and threshold items, more negativity during sociability items, and less negativity during irritability and threshold items. Latent profile analysis indicated individual temperament patterns were best described by three groups: low/moderate overall reactivity, high social negative reactivity, and high nonsocial negative reactivity. Infants with heavy cocaine exposure were more likely in high social negative reactivity profile, were less negative during threshold items, and required longer soothing intervention. Cocaine- and opiate-exposed infants scored lower on Infant Behavior Questionnaire smiling and laughter and duration of orienting scales. Opiate-exposed infants were rated as less respondent to soothing. By including a multitask measure of temperament we were able to show context-specific behavioral dysregulation in prenatally cocaine-exposed infants. The findings indicate flatter temperament may be specific to nonsocial contexts, whereas social interactions may be more distressing for cocaine-exposed infants.

Effects of prenatal cocaine exposure on adolescent development

The associations between prenatal cocaine exposure (PCE) and adolescent behavior, cognitive development, and physical growth were examined in 219 15-year-olds who have participated in a longitudinal study since their fourth gestational month. During the first trimester, 42% of the women used cocaine, with use declining across pregnancy. At the 15-year follow-up, the caregivers were, on average, 43 years old, had 13 years of education, and 50% were African American. First trimester PCE was not associated with global cognitive development or with measures of learning and memory. First trimester PCE was significantly related to adolescent-reported delinquent behavior, poorer problem solving and abstract reasoning, and reduced weight, height, and head circumference at 15 years. These results were significant after other factors that affect these domains were controlled in regression analyses. In addition, exposure to violence partially mediated the effect of PCE on delinquent behavior. These adolescent domains are important because they are predictors of poorer adult functioning.

Level of intrauterine cocaine exposure and neuropsychological test scores in preadolescence: subtle effects on auditory attention and narrative memory

Neuropsychological processes such as attention and memory contribute to children's higher-level cognitive and language functioning and predict academic achievement. The goal of this analysis was to evaluate whether level of intrauterine cocaine exposure (IUCE) alters multiple aspects of preadolescents' neuropsychological functioning assessed using a single age-referenced instrument, the NEPSY: A Developmental Neuropsychological Assessment (NEPSY) (Korkman et al., 1998), after controlling for relevant covariates. Participants included 137 term 9.5-year-old children from low-income urban backgrounds (51% male, 90% African American/Caribbean) from an ongoing prospective longitudinal study. Level of IUCE was assessed in the newborn period using infant meconium and maternal report. 52% of the children had IUCE (65% with lighter IUCE, and 35% with heavier IUCE), and 48% were unexposed. Infants with Fetal Alcohol Syndrome, HIV seropositivity, or intrauterine exposure to illicit substances other than cocaine and marijuana were excluded. At the 9.5-year follow-up visit, trained examiners masked to IUCE and background variables evaluated children's neuropsychological functioning using the NEPSY. The association between level of IUCE and NEPSY outcomes was evaluated in a series of linear regressions controlling for intrauterine exposure to other substances and relevant child, caregiver, and demographic variables. Results indicated that level of IUCE was associated with lower scores on the Auditory Attention and Narrative Memory tasks, both of which require auditory information processing and sustained attention for successful performance. However, results did not follow the expected ordinal, dose-dependent pattern. Children's neuropsychological test scores were also altered by a variety of other biological and psychosocial factors.

Prenatal cocaine exposure: the role of cumulative environmental risk and maternal harshness in the development of child internalizing behavior problems in kindergarten

This study examined the associations between prenatal exposure to cocaine and other substances and child internalizing behavior problems at kindergarten. We investigated whether maternal harshness or cumulative environmental risk mediated or moderated this association. Participants consisted of 216 (116 cocaine exposed, 100 non-cocaine exposed) mother-infant dyads participating in an ongoing longitudinal study of prenatal cocaine exposure. Results indicated that, as hypothesized, maternal harshness moderated the association between prenatal cocaine exposure to child internalizing in kindergarten such that prenatal cocaine exposure increased risk for internalizing problems at high levels of maternal harshness from 7 to 36months and decreased risk at low levels of harshness. Contrary to hypothesis, the association between prenatal cocaine exposure and child internalizing in kindergarten was not mediated by maternal harshness or cumulative environmental risk. However, cumulative environmental risk (from 1month of child age to kindergarten) was predictive of child internalizing behavior problems at kindergarten. Results have implications for parenting interventions that may be targeted toward reducing maternal harshness in high risk samples characterized by maternal substance use in pregnancy.

Prenatal cocaine exposure and trajectories of externalizing behavior problems in early childhood: examining the role of maternal negative affect

This study examined the association between prenatal cocaine exposure (PCE) and developmental trajectories of externalizing behavior problems from 18 to 54 months of child age. A hypothesized indirect association between PCE and externalizing trajectories via maternal negative affect was also examined. Caregiving environmental risk and child sex were evaluated as moderators. This study consisted of 196 mother-child dyads recruited at delivery from local area hospitals (107 PCE, 89 non-PCE) and assessed at seven time points across the toddler to preschool periods. Results revealed no direct associations between PCE and externalizing behavior problem trajectories. However, results did indicate that PCE shared a significant indirect relationship with externalizing behavior problem trajectories via higher levels of maternal negative affect. The association between PCE and externalizing problem trajectories was also moderated by caregiving environmental risk such that PCE children in high-risk caregiving environments did not experience the well-documented normative decline in externalizing behavior problems beginning at around 3 years of age. This study suggests potential pathways to externalizing behavior problems among high-risk children.

Child behavior problems among cocaine-exposed toddlers: indirect and interactive effects

This study examined the role of maternal psychopathology and maternal warmth as mediators of the association between prenatal cocaine and other substance exposure and toddler behavior problems. It was also hypothesized that infant cortisol reactivity and environmental risk may moderate these associations. Participants were 220 caregiver-infant dyads (119 cocaine exposed, 101 not cocaine exposed; 49% boys). Mother-infant dyads were recruited at delivery with assessments at 4-8 weeks and 7, 13, and 18 months of child ages. Results yielded no direct associations between prenatal cocaine/other substance exposure and toddler behavior problems, but significant indirect associations between prenatal cigarette/alcohol exposure and toddler behavior problems at 18 months. With regard to moderation, results indicated an indirect association between prenatal cocaine exposure and toddler behavior problems via lower maternal warmth for children with higher, but not lower, cortisol reactivity at 7 months. Results suggest potential pathways to toddler behavior problems among children at high biological risk.

Effects of prenatal cocaine exposure on child behavior and growth at 10 years of age

We examined physical growth and behavioral outcomes in 226 10-year-old children who were participants in a longitudinal study of prenatal cocaine exposure (PCE), while controlling for other factors that affect development. During the first trimester, 42% of the women used cocaine, with use declining across pregnancy. At the 10-year follow-up, the caregivers were 37years old, had 12.8years of education, and 50% were African American. First trimester cocaine exposure predicted decreased weight, height, and head circumference at 10years. First trimester cocaine use also predicted maternal ratings of less sociability on the EAS Temperament Survey and more withdrawn behavior problems on the Child Behavior Checklist, more anxious/depressed behaviors on the Teacher Report Form, and more self-reported depressive symptoms on the Children's Depression Inventory. In addition, exposure to violence mediated the effect of PCE on child and teacher reports of depressive symptoms, but not of maternal reports of sociability and withdrawn behaviors. These behaviors may be precursors of later psychiatric problems.

Prenatal substance abuse: short- and long-term effects on the exposed fetus

Prenatal substance abuse continues to be a significant problem in this country and poses important health risks for the developing fetus. The primary care pediatrician's role in addressing prenatal substance exposure includes prevention, identification of exposure, recognition of medical issues for the exposed newborn infant, protection of the infant, and follow-up of the exposed infant. This report will provide information for the most common drugs involved in prenatal exposure: nicotine, alcohol, marijuana, opiates, cocaine, and methamphetamine.

Prenatal tobacco exposure predicts differential brain function during working memory in early adolescence: a preliminary investigation

Children prenatally exposed to tobacco exhibit higher rates of learning and emotional-behavioral problems related to worse working memory performance. Brain function, however, among tobacco exposed children while performing a working memory task has not previously been examined. This study compared the brain function of tobacco-exposed (n = 7) and unexposed (n = 11) 12-year-olds during a number N-back working memory task using an event-related functional magnetic resonance imaging (fMRI) design. Prenatal alcohol exposure, neonatal medical problems, environmental risk, and sex were statistically controlled. Tobacco-exposed children showed greater activation in inferior parietal regions, whereas unexposed children showed greater activation in inferior frontal regions. These differences were observed in the context of correct responses, suggesting that exposed and unexposed children use different brain regions and approaches to succeed in working memory tasks. Implications for future research and intervention are discussed.

Externalizing problems in late childhood as a function of prenatal cocaine exposure and environmental risk

OBJECTIVE

To examine whether prenatal cocaine exposure (PCE) predicts externalizing problems in late childhood.

METHODS

Externalizing problems were assessed using caregiver, teacher, and child ratings and a laboratory task when children (N = 179; 74 cocaine exposed) were aged 8-10 years. PCE, environmental risk, sex, neonatal health, other prenatal exposures, and foster care history were examined as predictors of externalizing problems.

RESULTS

Multiple regression analyses indicated that PCE, environmental risk, and male sex explained significant variance in externalizing problems in late childhood. Models varied by source of information. PCE predicted externalizing problems for child laboratory behavior and interacted with sex because males with PCE reported more externalizing problems. PCE did not predict caregiver or teacher ratings of externalizing problems.

CONCLUSIONS

The effect of PCE on externalizing problems may persist into late childhood. The findings highlight the potential importance of including child-based measures of externalizing problems in studies of prenatal exposure.

Protective factors can mitigate behavior problems after prenatal cocaine and other drug exposures

BACKGROUND

We determined the role of risk and protective factors on the trajectories of behavior problems associated with high prenatal cocaine exposure (PCE)/polydrug exposure.

METHODS

The Maternal Lifestyle Study enrolled 1388 children with or without PCE, assessed through age 15 years. Because most women using cocaine during pregnancy also used other substances, we analyzed for the effects of 4 categories of prenatal drug exposure: high PCE/other drugs (OD), some PCE/OD, OD/no PCE, and no PCE/no OD. Risks and protective factors at individual, family, and community levels that may be associated with behavior outcomes were entered stepwise into latent growth curve models, then replaced by cumulative risk and protective indexes, and finally by a combination of levels of risk and protective indexes. Main outcome measures were the trajectories of externalizing, internalizing, total behavior, and attention problems scores from the Child Behavior Checklist (parent).

RESULTS

A total of 1022 (73.6%) children had known outcomes. High PCE/OD significantly predicted externalizing, total, and attention problems when considering the balance between risk and protective indexes. Some PCE/OD predicted externalizing and attention problems. OD/no PCE also predicted behavior outcomes except for internalizing behavior. High level of protective factors was associated with declining trajectories of problem behavior scores over time, independent of drug exposure and risk index scores.

CONCLUSIONS

High PCE/OD is a significant risk for behavior problems in adolescence; protective factors may attenuate its detrimental effects. Clinical practice and public health policies should consider enhancing protective factors while minimizing risks to improve outcomes of drug-exposed children.

Developmental and behavioral consequences of prenatal cocaine exposure: a review

Substance use among pregnant women continues to be a major public health concern, posing potential risk to their drug-exposed children as well as burdens on society. This review is intended to discuss the most recent literature regarding the association between in utero cocaine exposure and developmental and behavioral outcomes from birth through adolescence across various domains of functioning (growth, neurobiology, intelligence, academic achievement, language, executive functioning, behavioral regulation and psychopathology). In addition, methodological limitations, associated biological, sociodemographic and environmental risk factors and future directions in this area of research are discussed. Given the large number of exposed children in the child welfare system and the increased need for medical, mental health and special education services within this population, more definitively documenting associations between prenatal cocaine exposure and later child outcomes is essential in order to be able to prospectively address the many significant public health, economic and public policy implications.

Understanding the diverse needs of children whose parents abuse substances

In this review, we consider the potential service needs of children of substance abusing parents based on what we know about the risk outcomes faced by these children and the parenting deficits often present in these families. Importantly, our review does not address the etiological role of parental substance abuse in children's negative outcomes but instead we discuss the complex inter-related risk factors that often co-occur with and exacerbate risk associated with parental alcohol and drug use. We first review studies showing the elevated risk that children of substance abusing parents face in general for poorer academic functioning; emotional, behavioral, and social problems; and an earlier onset of substance use, faster acceleration in substance use patterns, and higher rates of alcohol and drug use disorders. We then review studies showing contextual risk factors for children of substance abusing parents, including parenting deficits (less warmth, responsiveness, and physical and verbal engagement as well as harsher and more over-involved interaction styles), greater risk for child maltreatment, and less secure attachment patterns. We conclude with a discussion of future directions for research and guidelines for professionals working with children and their families where parental substance abuse is present.

Behaviour among children of substance-abusing women attending a Special Child Welfare Clinic in Norway, as assessed by Child Behavior Checklist (CBCL)

BACKGROUND

A Special Child Welfare Clinic (SCWC) in Norway provides care for pregnant women with substance abuse problems. Treatment is given without substitution. This investigation assesses the behaviour of the children between the ages 6 and 13 years of women who attended the clinic. It also explores the correlation between the behaviour and a neuropsychological screening performed one and a half year earlier. The study was set up to investigate the influence of prenatal substance exposure.

METHOD

Thirty-eight SCWC children and 63 children in a comparison group were scored by Child Behavior Check List (CBCL). Twenty-one (55%) SCWC mothers were classed as short-term users (ceased substance abuse before the end of first trimester), and 17 (45%) were classed as long-term users (continued a moderate substance abuse throughout pregnancy). Thirteen (77%) of the children of the long-term users were living in foster homes at the time of the investigation.

RESULTS

SCWC children were scored within normal ranges for most items, but their scores were significantly worse than those of the comparison group. Children of short-term users were given lower scores than comparisons on more issues in CBCL than were children of long-term users. The SCWC children were breastfed for a shorter time (p = 0.023) and had moved house more often (p < 0.001) than comparisons. SCWC children living with their biological mothers received more special education or remedial classes (p ≤ 0.001) than children of the comparisons.

CONCLUSION

Most children of long-term users were living in foster homes. Notably, children of short-term users, that is, children living with their biological mothers, were given lower scores than comparisons in CBCL. Children of short-term users were more likely to receive special education than children of comparisons. More research is needed on how to reveal parenting problems and how to guide mothers with previous or present substance abuse problems.

Psychopathology and special education enrollment in children with prenatal cocaine exposure

OBJECTIVE

This study evaluated how enrollment in special education services in 11-year-old children relates to prenatal cocaine exposure (PCE), psychopathology, and other risk factors.

METHODS

Participants were 498 children enrolled in The Maternal Lifestyle Study, a prospective, longitudinal, multisite study examining outcomes of children with PCE. Logistic regression was used to examine the effect of PCE and psychopathology on enrollment in an individualized education plan (IEP; a designation specific to children with special education needs), with environmental, maternal, and infant medical variables as covariates.

RESULTS

PCE, an interaction of PCE and oppositional defiant disorder, child attention-deficit hyperactivity disorder, parent-reported internalizing behaviors, and teacher-reported externalizing behaviors, predicted enrollment in an IEP. Other statistically significant variables in the model were male gender, low birth weight, being small for gestational age, white race, caregiver change, low socioeconomic status, low child intelligence quotient, caregiver depression, and prenatal marijuana exposure.

CONCLUSIONS

PCE increased the likelihood of receiving an IEP with adjustment for covariates. Psychopathology also predicted this special education outcome, in combination with and independent of prenatal cocaine exposure.

Female juvenile delinquency, motherhood, and the intergenerational transmission of aggression and antisocial behavior

The current study explored the intergenerational transmission of aggression and antisocial behavior by examining mothers' juvenile delinquency, their pregnancies, and its impact on their children's aggressive behavior. The sample consisted of the first 181 biological mothers recruited as part of the Vancouver Longitudinal Study on the Psychosocial Development of Children (British Columbia, Canada). Results indicated that mothers who were juvenile delinquents were more likely to experience social adversity, to use substances during pregnancy and to offend in adulthood. Furthermore, mothers who reported juvenile delinquency had children who were more physically aggressive and had an earlier onset of physical aggression. This pattern of association held when controlling for sociodemographics, social adversities, prenatal substance exposure, and criminal involvement in adulthood. The study findings highlighted the importance of understanding the role and impact of female delinquency and motherhood on the intergenerational transmission of antisocial behavior.

Cocaine use during pregnancy assessed by hair analysis in a Canary Islands cohort

BACKGROUND

Drug use during pregnancy is difficult to ascertain, and maternal reports are likely to be inaccurate. The aim of this study was to estimate the prevalence of illicit drug use among pregnant women by using maternal hair analysis.

METHODS

A toxicological analysis of hair was used to detect chronic recreational drug use during pregnancy. In 2007, 347 mother-infant dyads were included from the Hospital La Candelaria, Santa Cruz de Tenerife, Canary Islands (Spain). Data on socioeconomic characteristics and on substance misuse during pregnancy were collected using a structured questionnaire. Drugs of abuse: opiates, cocaine, cannabinoids and amphetamines were detected in maternal hair by immunoassay followed by gas chromatography-mass spectrometry for confirmation and quantitation.

RESULTS

Hair analysis revealed 2.6% positivity for cocaine and its metabolites. Use of cocaine during pregnancy was associated with unusual behaviour with potentially harmful effects on the baby.

CONCLUSIONS

The results of the study demonstrate significant cocaine use by pregnant women in Canary Islands. The data should be used for the purpose of preventive health and policy strategies aimed to detect and possibly to avoid in the future prenatal exposure to drugs of abuse.

Estimated effect of prenatal cocaine exposure on examiner-rated behavior at age 7 years

Prenatal cocaine exposure has been linked to increased child behavior difficulties in some studies but not others.

OBJECTIVE

The primary aim was to estimate the relationship between in utero cocaine exposure and child behavioral functioning at age 7 years with ratings made by blinded examiners during a structured testing session. A second aim was to examine whether caregiver drug use and psychological problems might mediate suspected relationships between prenatal cocaine exposure and aspects of examiner-rated behavior.

METHODS

407 children (212 cocaine-exposed, 195 non-exposed) participating in the longitudinal Miami Prenatal Cocaine Study (MPCS) were rated with regard to their behavior during a neuropsychological assessment conducted at age 7 years. Raters were trained research psychometricians blinded to drug exposure status. Individual behavioral items were summarized and the cocaine-behavior relationship was estimated within the context of latent variable modeling, using Mplus software.

RESULTS

Two latent variables, Behavioral Regulation and Sociability, were derived via exploratory latent structure analysis with promax rotation. Prenatal cocaine exposure, statistically controlling for child sex, test age, and prenatal exposure to alcohol, tobacco, and marijuana, was associated with Behavioral Regulation (estimated slope ß=-0.25; 95% CI=-0.48, -0.02; p=0.04) but not Sociability (estimated slope ß=-0.03; 95% CI=-0.26, 0.20; p=0.79). Neither postnatal drug use by caregivers nor the severity of their psychological problems at age 5 follow-up predicted levels of child Behavioral Regulation or Sociability at age 7 years (p>0.10).

CONCLUSIONS

Examiner ratings of child behavior at age 7 revealed less optimal behavioral regulation for prenatally cocaine-exposed compared to non-exposed children, in contrast with what had been previously found from parent-report data. This evidence highlights the potential value of trained observers in assessing behavioral outcomes of children exposed in utero to drugs and other toxicants.

Caregiver and self-report of mental health symptoms in 9-year old children with prenatal cocaine exposure

OBJECTIVE

To assess the effect of prenatal cocaine exposure on mental health symptoms in 9-year old children controlling for potential confounders.

METHODS

332 children (170 prenatally cocaine-exposed (PCE), 162 non cocaine-exposed (NCE) were assessed using self (Dominic Interactive; DI) and caregiver report (Child Behavior Checklist; CBCL).

RESULTS

Higher levels of PCE were associated with caregiver report of clinically elevated aggressive and delinquent behavior. With each increased unit of PCE, children were 1.3 times more likely to be rated as aggressive (OR=1.30, 95% CI: 1.02-1.67, p<0.04). For each increased unit of PCE, girls were 2 times more likely to be rated as having delinquent behavior (OR=2.08, 95% CI: 1.46-2.96, p<0.0001). PCE status was also associated with increased odds of delinquent behavior (OR=2.41; 95% CI: 1.16-4.97, p=0.02), primarily due to the increased risk among girls with PCE. While girls with PCE status were 7 times more likely than NCE girls to have delinquent behaviors (OR=7.42; 95% CI: 2.03-27.11, p<0.002) boys with PCE did not demonstrate increased risk (OR=0.98; 95% CI: 0.36-2.65, p>0.97). Foster or adoptive parents were more likely to rate their PCE children as having more thought problems, inattention, delinquent behavior, aggression, externalizing and overall problems (p<0.05) than biologic mothers or relative caregivers. Higher 2nd trimester tobacco exposure was associated with increased odds of caregiver reported anxiety (OR=1.73; 95% CI 1.06-2.81, p<0.03) and marijuana exposure increased the odds of thought problems (OR=1.68; 95% CI 1.01-2.79, p<0.05). Children with PCE self-reported fewer symptoms of oppositional defiant disorder (ODD) compared to NCE children (OR=0.44, 95% CI: 0.21-0.92, p<0.03). Greater tobacco exposure was associated with increased odds of child reported ODD (OR=1.24; 95% CI 1.03-1.78, p<0.03).

CONCLUSION

Higher PCE was associated with disruptive behaviors including aggression and delinquent behavior among girls by caregiver report, but not child report. These findings highlight the need for early behavioral assessment using multiple informants in multi-risk children.

Prenatal cocaine exposure: An examination of childhood externalizing and internalizing behavior problems at age 7 years

Aim – This study examines the relationship between prenatal cocaine exposure and parent-reported child behavior problems at age 7 years. Methods – Data are from 407 African-American children (210 cocaine-exposed, 197 non-cocaine-exposed) enrolled prospectively at birth in a longitudinal study on the neurodevelopmental consequences of in utero exposure to cocaine. Prenatal cocaine exposure was assessed at delivery through maternal self-report and bioassays (maternal and infant urine and infant meconium). The Achenbach Child Behavior Checklist (CBCL), a measure of childhood externalizing and internalizing behavior problems, was completed by the child's current primary caregiver during an assessment visit scheduled when the child was seven years old. Results – Structural equation and GLM/GEE models disclosed no association linking prenatal cocaine exposure status or level of cocaine exposure to child behavior (CBCL Externalizing and Internalizing scores or the eight CBCL sub-scale scores). Conclusions – This evidence, based on standardized ratings by the current primary caregiver, fails to support hypothesized cocaine-associated behavioral problems in school-aged children with in utero cocaine exposure. A next step in this line of research is to secure standardized ratings from other informants (e.g., teachers, youth self-report).

Declaration of Interest: This research was conducted in the context of an ongoing longitudinal study funded by the National Institutes of Health National Institute on Drug Abuse (R01 DA 06556). Support was also provided by a NIDA career development award (K01 DA 16720), a NIDA research training award (T32 DA 07292), the General Clinical Research Center (MOI RR 16587), and the Health Foundation of South Florida.

Maternal cocaine use and mother-toddler aggression

This study examined the direct and indirect associations between maternal cocaine use during pregnancy and mother-toddler aggression in an interactive context at 2 years of child age. We hypothesized that in addition to direct effects of cocaine exposure on maternal and child aggression, the association between maternal cocaine use and mother-toddler aggression may be indirect via higher maternal psychiatric symptoms, negative affect, or poor infant autonomic regulation at 13 months. Participants consisted of 220 (119 cocaine exposed, 101 non-cocaine exposed) mother-toddler dyads participating in an ongoing longitudinal study of prenatal cocaine exposure. Results indicated that mothers who used cocaine during pregnancy displayed higher levels of aggression toward their toddlers compared to mothers in the control group. Results from model testing indicated significant indirect associations between maternal cocaine use and maternal aggression via higher maternal negative affect as well as lower infant autonomic regulation at 13 months. Although there were no direct associations between cocaine exposure and toddler aggression, there was a significant indirect effect via lower infant autonomic regulation at 13 months. Results highlight the importance of including maternal aggression in predictive models of prenatal cocaine exposure examining child aggression. Results also emphasize the important role of infant regulation as a mechanism partially explaining associations between cocaine exposure and mother-toddler aggression.

Infant temperament and high-risk environment relate to behavior problems and language in toddlers

OBJECTIVE

This study examined the role that easy infant temperament and cumulative environmental risk play in predicting cognitive, language, and behavioral outcomes in 3-year-old children at high social risk.

METHODS

Subjects were 412 mother-infant dyads, recruited at birth, participating in a longitudinal study examining the effects of prenatal methamphetamine on child development. This analysis includes a subsample (n = 290) of the study with a completed 3-year visit. Temperament was assessed by the Infant Behavior Questionnaire at 12 months. Factor analysis from well-validated measures generated “easy” and “difficult” temperament profiles and a profile for high-risk environment. Caretaker receptive vocabulary served as a proxy for intelligence quotient. Outcomes at 3 years included motor and mental development, behavior problems, and language. Linear regression and hierarchical linear modeling examined the effects of temperament, high-risk environment, and caregiver receptive language on outcomes adjusting for maternal drug use and demographic and socioeconomic covariates.

RESULTS

Internalizing and externalizing behaviors were lower in children with easy temperament and higher with increased environmental risk. Easy temperament attenuated behavioral problems only in the setting of lower environmental risk. Caregiver receptive language was associated with lower internalizing scores. High-risk environment and temperament factors were not related to cognitive or motor outcomes. Prenatal methamphetamine exposure was not associated with 3-year-old outcomes, nor did it alter the protective effects of an easier temperament on child behavior.

CONCLUSIONS

CHILDREN growing up in adverse social environments had increased behavioral problems and compromised language development. Conversely, an easy temperament acts as a protective factor for social-emotional development and could be related to resilience.

Neuropsychological screening of children of substance-abusing women attending a Special Child Welfare Clinic in Norway

Background

Exposure to alcohol and illicit substances during pregnancy can have an impact on the child for the rest of his/her life. A Special Child Welfare Clinic (SCWC) in Norway provides care for pregnant women with substance abuse problems. Treatment and support are provided without replacement therapy.

Methods

We performed a neuropsychological screening of 40 children aged four to 11 years whose mothers had attended the SCWC during pregnancy, and of a comparison group of 80 children of women without substance abuse problems. The children were presented with tests chosen from Wechsler Intelligence Scale for Children, third version (WISC-III), Nepsy, Halstead-Reitan and Raven's Progressive Matrices, Coloured Version. The tests were grouped into five main domains; (1) learning and memory, (2) visual scanning, planning and attention, (3) executive function, (4) visuo-motor speed and dexterity and (5) general intellectual ability

Results

No children in the study had test results in the clinical range in any domain. Bivariate analyses revealed that children of short-term substance-abusing mothers (who stopped substance abuse within the first trimester) had significantly lower test scores than the comparison group in three out of five domains (domain 2,3,4). Children of long-term substance abusers (who maintained moderate substance abuse throughout pregnancy) had significantly lower test results than the comparison group in one domain of the test results (domain 1). All but one child in the long-term group were or had been in foster homes. Most children in the short-term group stayed with their mothers. Multivariate regression analyses revealed that foster care minimum 50% of life time was associated with better scores on domains (1) learning and memory, (2) visual scanning, planning and attention, and (3) executive functions, while no significant associations with test scores was found for substance abuse and birth before 38 weeks of gestation.

Conclusion

Children raised by former substance abusing mothers scored worse on the neuropsychological screening than children who had substance abusing mothers and mostly were raised in foster homes. This indicates that it is important to focus on the environment in cases where help and support are provided to presently or formerly addicted women raising children.

Cumulative hardship and wellness of low-income, young children: multisite surveillance study

OBJECTIVES

The goals were to generate a cumulative hardship index and to evaluate its association with the well-being of children 4 to 36 months of age without private health insurance.

METHODS

Cross-sectional surveys were linked to anthropometric measures and medical record review at 5 urban medical centers (July 1, 2004, to December 31, 2007). Cumulative hardship index scores ranged from 0 to 6, with food, housing, and energy each contributing a possible score of 0 (secure), 1 (moderately insecure), or 2 (severely insecure) to generate scores indicating no hardship (score of 0), moderate hardship (scores of 1-3), or severe hardship (scores of 4-6). The outcome was a composite indicator of child wellness, including caregivers' reports of children's good/excellent heath, no hospitalizations, not being developmentally at risk, and anthropometric measurements within normal limits. Covariates were selected a priori and through association with predictors and outcomes.

RESULTS

Of 7141 participants, 37% reported no material hardship, 57% moderate hardship, and 6% severe hardship. Multivariate logistic regression analyses showed ordinal association between the cumulative hardship index and children's adjusted odds of wellness (severe versus no hardship, adjusted odds ratio [AOR]: 0.65 [95% confidence interval [CI]: 0.51-0.83]; severe versus moderate hardship, AOR: 0.73 [95% CI: 0.58-0.92]; moderate versus no hardship, AOR: 0.89 [95% CI: 0.79-0.99]).

CONCLUSION

Increasing levels of a composite measure of remediable adverse material conditions correlated with decreasing adjusted odds of wellness among young US children.

Children of addicted women

The purpose of this article was to review follow up studies of children with prenatal drug exposure from preschool through adolescence. Specifically, the authors focus on the effects of prenatal exposure to cocaine, methamphetamine, and opiates on behavior and development. The largest number of studies have examined cocaine-exposed children. The authors identified 42 studies that suggest that there are unique effects of prenatal cocaine exposure on 4- to 13-year-old children, particularly in the areas of behavior problems, attention, language, and cognition. In addition, studies make reasonable attempts to control for possible confounding factors. Systematic research on the long-term effects of prenatal methamphetamine exposure is just beginning but seems to be showing similar effects to that of cocaine. The literature on the on the long-term effects of children with prenatal opiate exposure is more substantial than the methamphetamine literature but it is still relatively sparse and surprising in that there is little recent work. Thus, there are no studies on the current concerns with opiates used for prescription mediation. There is a growing literature using neuroimaging techniques to study the effects of prenatal drug exposure that holds promise for understanding brain/behavior relationships. In addition to pharmacological and teratogenic effects, drugs can also be viewed from a prenatal stressor model. The author discuss this "fetal origins" approach that involves fetal programming and the neuroendocrine system and the potential implications for adolescent brain and behavioral development.

Infant neurobehavioral dysregulation: behavior problems in children with prenatal substance exposure

OBJECTIVE

The objective of this study was to test a developmental model of neurobehavioral dysregulation relating prenatal substance exposure to behavior problems at age 7.

METHODS

The sample included 360 cocaine-exposed and 480 unexposed children from lower to lower middle class families of which 78% were black. Structural equation modeling was used to test models whereby prenatal exposure to cocaine and other substances would result in neurobehavioral dysregulation in infancy, which would predict externalizing and internalizing behavior problems in early childhood. Structural equation models were developed for individual and combined parent and teacher report for externalizing, internalizing, and total problem scores on the Child Behavior Checklist.

RESULTS

The goodness-of-fit statistics indicated that all of the models met criteria for adequate fit with 7 of the 9 models explaining 18% to 60% of the variance in behavior problems at age 7. The paths in the models indicate that there are direct effects of prenatal substance exposure on 7-year behavior problems as well as indirect effects, including neurobehavioral dysregulation.

CONCLUSIONS

Prenatal substance exposure affects behavior problems at age 7 through 2 mechanisms. The direct pathway is consistent with a teratogenic effect. Indirect pathways suggest cascading effects whereby prenatal substance exposure results in neurobehavioral dysregulation manifesting as deviations in later behavioral expression. Developmental models provide an understanding of pathways that describe how prenatal substance exposure affects child outcome and have significant implications for early identification and prevention.

Continued effects of prenatal cocaine use: preschool development

The relationship between prenatal cocaine use and preschooler's physical and cognitive development and behavioral characteristics was examined, controlling for other influences on child development. On average, children were 38.5 months old, women were 29.4 years old, had 12.3 years of education, and 47% were African American. During the first trimester, 18% of the women were frequent cocaine users (> or = 1 line/day). First trimester cocaine exposure predicted decreased head circumference at 3 years and lower scores on the short-term memory subscale of the Stanford-Binet Intelligence Scale (SBIS) [74]. There was no significant relationship between prenatal cocaine use and the other SBIS scales. First trimester cocaine use also predicted more total, internalizing, and externalizing behavior problems on the Child Behavior Checklist [3] and higher scores on the fussy/difficult scale of the Infant Characteristics Questionnaire [6]. Children who were exposed to cocaine throughout pregnancy had more behavior problems and were more fussy compared to children of women who never used cocaine prenatally. A repeated measures analysis showed that children of first trimester cocaine users became more fussy over time. These detrimental effects on growth and behavior are consistent with other reports in the literature and with the hypothesis that prenatal cocaine exposure affects development through changes in neurotransmitter systems.

Children with and without gestational cocaine exposure: a neurocognitive systems analysis

BACKGROUND

Concern for effects of gestational cocaine exposure (GCE) on human neurocognitive (NC) development is based on effects of cocaine on blood flow to the fetus and impact of cocaine on developing monoaminergic systems. GCE has been shown to affect language, attention and perceptual reasoning skills.

OBJECTIVE

Our objective was to investigate effects of GCE on 7 NC systems, assessed behaviorally in middle school-aged, low socioeconomic status subjects followed prospectively since birth.

METHODS

55 GCE and 65 non-exposed Control subjects were tested with a battery of 14 tasks adapted from neuroimaging and lesion literature designed to tap 3 frontal systems (Cognitive Control, Working Memory, and Reward Processing) and 4 non-frontal systems (Language, Memory, Spatial Cognition, and Visual Cognition). Using multivariate analysis of covariance, we assessed the relation between NC functioning and GCE status with the following covariates: age at testing; gender; gestational exposure to cigarettes, alcohol and marijuana; foster care placement; caregiver current cocaine use; and two indices of childhood environment.

RESULTS

None of the analyses showed an effect of GCE on NC function. In contrast, child characteristics, including age at testing and childhood environment, were associated with NC function.

CONCLUSIONS

In this cohort there is either no effect of GCE on NC function at middle school age, or that effect is less pronounced than the effect of age or childhood environment.

Cognitive development and low-level lead exposure in poly-drug exposed children

The impact of early postnatal lead exposure measured at age 4 on children's IQ and academic achievement at and 11 years of age was examined. The sample consisted of 278 inner-city, primarily African American children who were polydrug exposed prenatally. Regression analyses indicated a linear effect of lead exposure on outcomes and no moderating effects of polydrug exposure. An IQ loss of about 4.1-5.4 Full Scale IQ points was estimated for each 10 microg/dL increase in blood lead level at ages 4, 9, and 11 years as a function of blood lead level at age 4. Decrements in scores on tests of non-verbal reasoning were consistently associated with higher lead levels at age 4, while verbal decrements became apparent only at age 11. Lower reading summary scores at 9 and 11 years were consistently associated with higher lead exposure, while decrements in mathematics were not apparent until 11 years. Subgroup analyses on children with blood lead levels <10 microg/dL showed detrimental lead effects even at the 5 microg/dL level, providing additional evidence of adverse effects occurring at blood lead levels below the current 10 microg/dL public health blood lead action level.

Estimated Risk of Developing Selected DSM-IV Disorders Among 5-Year-Old Children with Prenatal Cocaine Exposure

This study estimated childhood risk of developing selected DSM-IV Disorders, including Attention-Deficit Hyperactivity Disorder (ADHD), Oppositional Defiant Disorder (ODD), and Separation Anxiety Disorder (SAD), in children with prenatal cocaine exposure (PCE). Children were enrolled prospectively at birth (n=476) with prenatal drug exposures documented by maternal interview, urine and meconium assays. Study participants included 400 African-American children from the birth cohort, 208 cocaine-exposed (CE) and 192 non-cocaine-exposed (NCE) who attended a 5-year follow-up assessment and whose caregiver completed the Computerized Diagnostic Interview Schedule for Children. Under a generalized linear model (logistic link), Fisher's exact methods were used to estimate the CE-associated relative risk (RR) of these disorders. Results indicated a modest but statistically robust elevation of ADHD risk associated with increasing levels of PCE (p<0.05). Binary comparison of CE versus NCE children indicated no CE-associated RR. Estimated cumulative incidence proportions among CE children were 2.9% for ADHD (vs 3.1% NCE); 1.4% for SAD (vs 1.6% NCE); and 4.3% for ODD (vs 6.8% NCE). Findings offer suggestive evidence of increased risk of ADHD (but not ODD or SAD) in relation to an increasing gradient of PCE during gestation.

Effects of prenatal cocaine exposure on infant reactivity and regulation

The purpose of this study was to examine the role of prenatal cocaine exposure and associated risk factors on infant reactivity and regulation at 7 months of infant age. Participants consisted of 167 mother-infant dyads participating in an ongoing longitudinal study of prenatal cocaine exposure, who completed the arm restraint procedure at the 7-month assessment (87 cocaine exposed, 80 non-cocaine exposed). We hypothesized that cocaine exposed infants would display higher arousal or reactivity and lower regulation during a procedure designed to arouse anger/frustration. Results indicated that cocaine exposed infants were more reactive to increases in the level of stress from trial 1 to trial 2 but exhibited no change in the number of regulatory strategies as stress increased, unlike the control group infants. Infant birth weight moderated the association between cocaine exposure and infant regulation. Among cocaine exposed infants, those with lower birth weight displayed higher reactivity compared to those with higher birth weight. Contrary to expectations, there were no indirect effects between cocaine exposure and infant reactivity/regulation via environmental risk, parenting, or birth weight. Results are supportive of a teratological model of prenatal cocaine exposure for infant reactivity/regulation in infancy.

The impact of environmental risk factors on HIV-associated cognitive decline in children

Both the human immunodeficiency virus (HIV) and environmental stress have been independently associated with decreased cognitive functioning in children. Given that they are also known to have a strong relationship with each other, the present study sought to test the hypothesis that children in conditions of high environmental risk would be at greater risk for the cognitive complications related to immunosuppression. A retrospective review was conducted to examine the records of 141 children treated at a large pediatric AIDS clinic from 1993 to 2000. CD4+ lymphocyte levels were recorded from laboratory results and IQ scores were recorded from routine psychological evaluations. Key indicators of environmental risk were collected and combined into one measure of overall environmental risk. Pearson product moment correlations were conducted to examine the relationship between environmental risk, age-adjusted CD4 and IQ. Results indicated a significant correlation between CD4 and IQ, with higher levels of immunocompetence predicting higher IQ scores. When subjects were dichotomized based on their environmental risk score, there was no relationship between CD4 count and IQ in the low environmental risk group. In contrast, CD4 was positively associated with IQ in the high environmental risk group. It is proposed that this may be due to gp120 levels in immunocompromised children being particularly toxic to the hippocampus and cortex under conditions of high stress but not so under conditions of low stress.

Treatment of challenging behavior exhibited by children with prenatal drug exposure

A large body of literature exists describing the harmful effects of prenatal drug exposure on infant and child development. However, there is a paucity of research examining strategies to ameliorate sequelae such as externalizing behavior problems. In the present study, functional analysis procedures were used to assess challenging behavior exhibited by two children who were prenatally exposed to drugs of abuse. Results for both children indicated that challenging behavior was maintained by access to positive reinforcement (adult attention and tangible items). For one child, challenging behavior was also maintained by negative reinforcement (escape from activities of daily living). Function-based interventions were effective in reducing challenging behavior for both children. Implications for utilizing methods of applied behavior analysis in research with children with prenatal drug exposure are discussed.

A systematic review of challenging behaviors in children exposed prenatally to substances of abuse

A review of the existing literature on the occurrence of challenging behavior among children with prenatal drug exposure was conducted. While a large number of studies were identified that evaluated various outcomes of prenatal drug exposure, only 37 were found that directly evaluated challenging behaviors. Of the 37 studies, 23 focused on prenatal cocaine exposure, and 14 focused on prenatal alcohol exposure; most studies relied on broadband measures such as the CBCL for the assessment of challenging behavior. Among the 37 studies, a clear role for the postnatal environment on developing challenging behaviors was evident; however, prenatal alcohol exposure showed a much clearer independent effect upon challenging behaviors than was noted in the prenatal cocaine studies. Additionally, only 3 of the 37 studies addressed interventions for challenging behaviors, each of which showed an improvement in child behavior or parent-child interactions. As researchers have continued to show the importance of the postnatal environment, it is likely that interventions addressing specific environmental risk factors will be helpful to reduce or prevent challenging behaviors among this population.

Effects of prenatal cocaine exposure on special education in school-aged children

OBJECTIVE

The objective of this study was to evaluate the effects of prenatal cocaine exposure on special education at age 7 with adjustment for covariates.

METHODS

As part of the prospective, longitudinal, multisite study of children with prenatal cocaine exposure (Maternal Lifestyle Study), school records were reviewed for 943 children at 7 years to determine involvement in special education outcomes: (1) individualized education plan; (2) special education conditions; (3) support services; (4) special education classes; and (5) speech and language services. Logistic regression was used to examine the effect of prenatal cocaine exposure on these outcomes with environmental, maternal, and infant medical variables as covariates, as well as with and without low child IQ.

RESULTS

Complete data for each analysis model were available for 737 to 916 children. When controlling for covariates including low child IQ, prenatal cocaine exposure had a significant effect on individualized education plan. When low child IQ was not included in the model, prenatal cocaine exposure had a significant effect on support services. Male gender, low birth weight, white race, and low child IQ also predicted individualized education plan. Low birth weight and low child IQ were significant in all models. White race was also significant in speech and language services. Other covariate effects were model specific. When included in the models, low child IQ accounted for more of the variance and changed the significance of other covariates.

CONCLUSIONS

Prenatal cocaine exposure increased the likelihood of receiving an individualized education plan and support services, with adjustment for covariates. Low birth weight and low child IQ increased the likelihood of all outcomes. The finding that white children were more likely to get an individualized education plan and speech and language services could indicate a greater advantage in getting educational resources for this population.

Prenatal cocaine exposure: drug and environmental effects at 9 years

OBJECTIVE

To assess school-age cognitive and achievement outcomes in children with prenatal cocaine exposure, controlling for confounding drug and environmental factors.

STUDY DESIGN

At age 9 years, 371 children (192 cocaine exposure [CE]; 179 non-cocaine exposure [NCE]) were assessed for IQ and school achievement in a longitudinal, prospective study from birth. An extensive number of confounding variables were controlled, including quality of caregiving environment, polydrug exposure, blood lead level, iron-deficiency anemia (IDA), and foster/adoptive care.

RESULTS

Prenatal cocaine exposure predicted poorer perceptual reasoning IQ, with a linear relationship of the concentration of the cocaine metabolite benzoylecgonine to the degree of impairment. Effects were mediated through birth head circumference, indicating a relationship with fetal brain growth. Negative effects of alcohol, lead, and marijuana exposure and positive effects of the home environment were additive. The CE children in foster/adoptive care had better home environments and lower lead levels. School achievement was not affected.

CONCLUSIONS

Persistent teratologic effects of CE on specific cognitive functions and additive effects of alcohol, lead, and marijuana exposure; IDA; and the home environment were identified. Documenting environmental factors in behavioral teratology studies is important, because in this sample, CE was associated with better home environment and lower environmental risk in a substantial number of children.

Preadolescent health risk behavior as a function of prenatal cocaine exposure and gender

OBJECTIVE

To examine the effect of prenatal cocaine exposure on health risk behaviors during preadolescence.

METHODS

The present study examined prenatal cocaine exposure, gender, and environmental risk as predictors of self-reported substance use, aggression, and a disregard for safety precautions on the Youth Risk Behavior Survey in a sample of 10.5 year olds (n = 154, including 60 who were prenatally exposed to cocaine).

RESULTS

Gender tended to moderate the effects of prenatal cocaine exposure because exposure effects were found for boys but not girls. Boys who were prenatally exposed to cocaine reported engaging in more high-risk behavior. In examining individual outcomes, cocaine exposed boys had the highest scores for aggression, substance use, and a disregard for safety precautions, although these differences were significant only for the composite health risk behavior measure.

CONCLUSIONS

The findings extend earlier work showing that prenatal cocaine exposure places boys at risk for problems of inhibitory control, emotional regulation, and antisocial behavior. Research is needed to examine whether the effects of prenatal cocaine on health risk behaviors persist into adolescence, when such behaviors tend to increase.