Thirty-six-month outcome of prenatal cocaine exposure for term or near-term infants: impact of early case management

The association of prenatal cocaine exposure with expressive and receptive language skills, phonological processing and reading ability at age 17

OBJECTIVE

Prenatal cocaine exposure (PCE) has been associated with small but significant effects on language development in childhood and early adolescence. This study examined whether this association persists into later adolescence and what relationship language skills may have with reading proficiency in this population.

METHODS

Enrolled were 338 (167 with PCE, 171 with NCE or no cocaine exposure) 17-year-olds recruited at birth who, together with their current caregiver, were seen as part of a 17-year follow-up. Participants were given assessments of reading achievement (WIAT-III), receptive and expressive language (CELF-IV), and phonological processing (CTOPP). Relationships between PCE status and language outcomes were modeled using multiple linear regression controlling for environmental and caregiver factors, and other prenatal substance exposures.

RESULTS

Adolescents with PCE scored lower in areas of phonological processing and reading related skills compared to adolescents with NCE. PCE by sex interactions were identified on language, memory and spoken language comprehension, with lower scores for girls with PCE compared to girls with NCE.

CONCLUSION

These findings suggest the persistence of PCE's relationship with phonological awareness well into adolescence. PCE was also associated with lower scores on measures of skills related to reading ability, which may be a manifestation of the observed deficits in phonological processing.

Sleep Environments of Children in an Urban U.S. Setting Exposed to Interpersonal Violence

This study investigated how violence influences children's sleep environments. Sixty-five children ages 8-16 years and a parent or guardian were recruited from agencies serving families experiencing violence. At baseline (5 weeks post-violent event), 6 months, and 12 months postbaseline, study staff collected sleep-behavior information and conducted systematic, qualitative assessments of sleep environments. Child sleep problems were generally frequent and persistent. However, 9 children reported improved sleep after the violent event, mainly because perpetrators were no longer present. Sleeping environments were dynamic via changes in location and modifications to improve safety and sleep. Incongruence between children's and parents' perceptions of environmental characteristics influencing sleep was common. Families' motivation to improve children's sleep represents a foundation to build upon when working with families victimized by violence.

A Preliminary Multimethod Comparison of Sleep Among Adolescents With and Without Generalized Anxiety Disorder

Previous studies suggest that youth with anxiety disorders experience their sleep as more disrupted and unsatisfying than their healthy peers. However, it is unclear whether these subjective complaints align with objective measures of sleep quantity and quality. The purpose of this preliminary study was to assess subjective and objective sleep parameters, and their relationships with anxiety symptomatology, among adolescents (62.8% female, 81.4% Caucasian), ages 12 to 18 (M = 15.29 years), with generalized anxiety disorder (n = 26) and controls without any psychopathology (n = 17). We measured sleep over 7 nights using sleep diaries and actigraphy and collected self- and parent-report questionnaires pertaining to sleep, anxiety, and depression. Repeated-measures mixed models were used to examine relationships between nightly sleep duration and morning anxiety. We found a number of differences in sleep between our anxious and healthy participants. Via sleep diary, our anxious participants had longer sleep onset latencies and lower satisfaction with sleep relative to controls, whereas via actigraphy we found longer sleep onset latencies but greater overall sleep duration among anxious versus control participants. Actigraphic measures of sleep disturbance were associated with parent-report of anxiety and depression. Our mixed-model analyses revealed that decreases in nightly sleep duration were associated with increased morning anxiety, but only among our participants with generalized anxiety disorder. Findings suggest that sleep disturbance among anxious adolescents can be detected using both subjective and objective measures and that, for these individuals, fluctuations in sleep duration may have real consequences for daytime anxiety.

Less Efficient Neural Processing Related to Irregular Sleep and Less Sustained Attention in Toddlers

The current study used event-related potentials to examine a candidate process through which sleep difficulties affect attentional processing in toddlers. Fifteen toddlers participated in an auditory Oddball task while neurophysiological data were collected. Sleep deficits were assessed using actigraphs, and attention was examined with a sustained attention task. A P3-like component was elicited from the toddlers, and longer target P3 latencies were associated with poorer sustained attention and irregular sleep. Findings suggest that irregular sleep is associated with less efficient attentional processing as reflected by the P3 component, and that longer target P3 latencies are associated with poorer sustained attention.

WITHDRAWN: Case management for persons with substance use disorders

The review has been withdrawn from publication because it is out of date and the authors are currently not available for updating it

The editorial group responsible for this previously published document have withdrawn it from publication.

Prevalence of sleep problems and relationship between sleep problems and school refusal behavior in school-aged children in children's and parents' ratings

OBJECTIVE

This cross-section study investigated the prevalence of sleep disorders and the relationship between sleep problems (insomnias, parasomnias, and daytime sleepiness) and school refusal behavior in school-age children (fourth grade elementary school in Cologne, Germany).

METHOD

A sample of 1,490 children (age range: 8-11 years) and their parents each completed a sleep questionnaire and the School Refusal Assessment Scale.

RESULTS

The results indicate that sleep problems in childhood are frequent. Furthermore, the results of the study clearly indicate that there is a relationship between sleep problems and school refusal behavior. Children suffering from insomnias (sleep onset problems, difficulties maintaining sleep), parasomnias (nightmares, night terrors), and daytime sleepiness showed without exception significantly higher scores in 3 out of 4 school refusal behavior maintaining conditions compared to children without sleep problems. These three conditions are all associated with anxiety disorders (anxiety or depressive disorder, as well as separation anxiety disorder). Only in the fourth condition, which is associated with oppositional defiant or conduct disorders, truancy, or no disorder at all, were there no significant differences between children with and children without sleep problems.

CONCLUSIONS

For research and clinical practice, it is important to view sleep problems and school refusal behavior in relation to each other rather than as isolated phenomena.

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.

Sleep Patterns in Children with Cystic Fibrosis

This study examined sleep patterns and the association between sleep and perceived health for children with and without CF. Ninety families (45 CF) completed questionnaires about the child's sleep and health. Significant group differences were found for sleep patterns (bedtime, wake time, total sleep time), symptoms of sleep disordered breathing, and sleep disturbances. Poorer perceived health was associated with sleep disturbances among children with CF, but not for children without CF. This study highlights the importance of including sleep in the evaluation of children with CF, as both medical and behavioral interventions can improve the sleep of children with CF.

Prenatal IV Cocaine: Alterations in Auditory Information Processing

One clue regarding the basis of cocaine-induced deficits in attentional processing is provided by the clinical findings of changes in the infants' startle response; observations buttressed by neurophysiological evidence of alterations in brainstem transmission time. Using the IV route of administration and doses that mimic the peak arterial levels of cocaine use in humans, the present study examined the effects of prenatal cocaine on auditory information processing via tests of the auditory startle response (ASR), habituation, and prepulse inhibition (PPI) in the offspring. Nulliparous Long-Evans female rats, implanted with an IV access port prior to breeding, were administered saline, 0.5, 1.0, or 3.0 mg/kg/injection of cocaine HCL (COC) from gestation day (GD) 8-20 (1×/day-GD8-14, 2×/day-GD15-20). COC had no significant effects on maternal/litter parameters or growth of the offspring. At 18-20 days of age, one male and one female, randomly selected from each litter displayed an increased ASR (>30% for males at 1.0 mg/kg and >30% for females at 3.0 mg/kg). When reassessed in adulthood (D90-100), a linear dose-response increase was noted on response amplitude. At both test ages, within-session habituation was retarded by prenatal cocaine treatment. Testing the females in diestrus vs. estrus did not alter the results. Prenatal cocaine altered the PPI response function across interstimulus interval and induced significant sex-dependent changes in response latency. Idazoxan, an α(2)-adrenergic receptor antagonist, significantly enhanced the ASR, but less enhancement was noted with increasing doses of prenatal cocaine. Thus, in utero exposure to cocaine, when delivered via a protocol designed to capture prominent features of recreational usage, causes persistent, if not permanent, alterations in auditory information processing, and suggests dysfunction of the central noradrenergic circuitry modulating, if not mediating, these responses.

Motor and cognitive outcomes through three years of age in children exposed to prenatal methamphetamine

BACKGROUND

Methamphetamine (MA) use among pregnant women is an increasing problem in the United States. The impact of prenatal MA exposure on development in childhood is unknown.

OBJECTIVE

To examine the effects of prenatal MA exposure on motor and cognitive development in children at 1, 2, and 3 years of age.

DESIGN/METHODS

IDEAL enrolled 412 mother-infant pairs at four sites (Tulsa OK, Des Moines IA, Los Angeles CA, and Honolulu HI). MA subjects (n=204) were identified by self report or GC/MS confirmation of amphetamine and metabolites in infant meconium. Comparison subjects (n=208) were matched (race, birth weight, maternal education, and type of insurance), denied amphetamine use, and had a negative meconium screen. Both groups included prenatal alcohol, tobacco and marijuana use, but excluded use of opiates, lysergic acid diethylamide, phencyclidine or cocaine only. The Peabody Developmental Motor Scales (PDMS-2) were administered to the infants at the 1 and 3 year visits. This analysis includes a subsample (n=350) of the IDEAL study with completed 1 and/or 3 year visits (n=330 and 281, respectively). At each annual visit we also conducted the Bayley Scales of Infant Development (BSID-II) as a general evaluation of mental and motor development. The BSID-II analysis includes a subsample (n=356) of the IDEAL study with completed 1, 2, and/or 3 year visits (n=331, 288, and 278 respectively). GLM analysis conducted on the PDMS-2 and BSID-II examined the effects of MA exposure and heavy MA exposure (≥3 days of use/week), with and without covariates. Longitudinal analyses were used to examine the effects of MA exposure on changes in motor and cognitive performance over time.

RESULTS

Heavy MA exposure was associated with significantly lower grasping scores than some and no use at 1 year (P=0.018). In longitudinal analysis, lower grasping scores associated with any MA exposure and heavy exposure persisted to 3 years. There were no effects of MA exposure, including heavy exposure, on the Bayley Mental Development Index (MDI) or Psychomotor Development Index (PDI) at any or across age.

CONCLUSIONS

There were no differences in cognition as assessed by the BSID-II between the groups. There was a subtle MA exposure effect on fine motor performance at 1 year with the poorest performance observed in the most heavily exposed children. By 3 years, no differences in fine motor performance were observed. These findings suggest MA exposure has modest motor effects at 1 year that are mostly resolved by 3 years.

Clinical management of behavioral insomnia of childhood: treatment of bedtime problems and night wakings in young children

Behavioral insomnia of childhood (BIC; more commonly known as bedtime problems and night wakings) commonly occurs in young children (<or=5 years). If left untreated, bedtime problems and night wakings can result in impairments in behavior, emotion regulation, and academic performance. Yet, treatments for bedtime problems and night wakings have been found to be efficacious and durable. This article begins with a review of the diagnostic criteria and clinical presentation of BIC. This is followed by a brief review of how operant theory is applied to behavioral interventions for BIC and a detailed discussion of how to apply these treatments for bedtime problems and night wakings in young children.

The effects of prenatal cocaine on language development at 10 years of age

OBJECTIVE

To examine the long term effects of prenatal cocaine exposure (PCE) on the language development of 10-year-old children utilizing a prospective design, controlling for confounding drug and environmental factors.

PARTICIPANTS

Children exposed to cocaine in utero (PCE; n=175) and non-exposed children (NCE; n=175) were followed prospectively to 10years of age and were compared on language subscales of the Test of Language Development-Intermediate 3rd Edition (TOLD-I:3) and phonological processing as measured by the Comprehensive Test of Phonological Processing (CTOPP).

METHODS

Multivariate analysis of covariance (MANCOVA), linear regression, and logistic regressions were used to evaluate the relationship of prenatal cocaine exposure to language development, while controlling for confounders.

RESULTS

After controlling for confounding variables, prenatal cocaine effects were observed for specific aspects of language including syntax (Sentence Combining subtest of the TOLD-I:3, p=0.001), semantics (Malopropism subtest of the TOLD-I:3, p=0.05) and phonological processing (Phonological Awareness subscale, p=0.01). The caregiver factors of vocabulary, HOME, and psychological symptoms also had consistent effects on language subtests and phonological processing scores. Children with PCE who experienced foster or adoptive care had enhanced language development compared to those living with birth mothers or in relative care. Cocaine exposed girls had lower scores on the phonological awareness subscale of the CTOPP than non-exposed girls.

CONCLUSIONS

PCE has subtle effects on specific aspects of language development and phonological processing at age 10, even after controlling for confounding variables. Environmental factors (i.e., postnatal lead exposure, home environment, and caregiver vocabulary and psychological symptoms) also impact language skills at 10years. Adoptive or foster care appears to enrich PCE children's linguistic environment and protects children against language delay in the PCE sample.

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.

The need for interdisciplinary pediatric sleep clinics

The purpose of this study was to describe the function and structure of an interdisciplinary outpatient pediatric sleep clinic. In addition, the frequency of individual and comorbid sleep diagnoses, the prevalence of comorbid medical or psychiatric disorders, and the types of treatment recommendations and referrals provided to patients at the end of their clinic visits was examined. Over a 4-month period, 265 consecutive patients were evaluated in the sleep clinic by trainees, nurses, and attendings in pulmonary medicine, neurology, and psychology. Obstructive sleep apnea was the most common diagnosis, followed by behavioral insomnia of childhood. Over half of the patients had a comorbid medical diagnosis, and 31% had a comorbid psychiatric diagnosis. Polysomnography was the most common recommendation, with 38% of patients receiving at least one behavioral recommendation. The results of this descriptive study support the need for an interdisciplinary approach to pediatric sleep medicine, providing broad training to trainees of all disciplines while improving the clinical care for children with sleep problems.

Delivery of pediatric sleep services via telehealth: the Alberta experience and lessons learned

Concerns regarding a child's sleep, identified by a caregiver or by the health care practitioner, are commonly raised but often left unexplored. Families in geographically isolated areas, with limited access to specialty services such as pediatric sleep medicine, are at increased risk for unmet treatment needs. Telehealth is a potential vehicle for delivery of these specialty services and overcoming barriers in diagnosing and treating sleep disorders in children by improving access and enhancing support for the families in their communities. This article describes the initiation of a pilot program in the delivery of multidisciplinary pediatric sleep medicine services via telehealth in Alberta, Canada.

Children's cognitive ability from 4 to 9 years old as a function of prenatal cocaine exposure, environmental risk, and maternal verbal intelligence

This study examined the effects of prenatal cocaine exposure, environmental risk, and maternal verbal intelligence on children's cognitive ability. Gender and age were examined as moderators of potential cocaine exposure effects. The Stanford-Binet IV intelligence test was administered to 231 children (91 cocaine exposed, 140 unexposed) at ages 4, 6, and 9 years. Neonatal medical risk and other prenatal exposures (alcohol, cigarettes, and marijuana) were also examined for their unique effects on child IQ. Mixed models analysis indicated that prenatal cocaine exposure interacted with gender, as cocaine-exposed boys had lower composite IQ scores. Age at assessment did not moderate this relation, indicating that cocaine-exposed boys had lower IQs across this age period. A stimulating home environment and high maternal verbal IQ also predicted higher composite IQ scores. Cocaine-exposed boys had lower scores on the Abstract/Visual Reasoning subscale, with trends for lower scores on the Short-Term Memory and Verbal Reasoning subscales, as exposure effects were observed across domains. The findings indicate that cocaine exposure continues to place children at risk for mild cognitive deficits into preadolescence. Possible mechanisms for the Exposure x Gender interaction are discussed.

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.

Use of Melatonin in Children and Adolescents: Clinicians' and Parents' Perspective

BACKGROUND

  There is a paucity of research on professionals' and parents' views on melatonin use in children and adolescents with sleep problems.

METHOD

  A two-stage survey was employed. First stage: Child psychiatrists and community paediatricians working in a health district were surveyed. Second stage: Parents/carers of children currently on melatonin under the care of these clinicians completed questionnaires.

RESULTS

  Eighty-seven per cent of the participating clinicians prescribed melatonin, with most of them prescribing melatonin for chronic and treatment resistant cases. Differences in prescribing practices between child psychiatrists and community paediatricians were noted. All children were prescribed either 3 mgs or 6 mgs melatonin. None of them experienced any significant side effects.

CONCLUSIONS

  This research highlights that clinicians recognise melatonin as an effective treatment of childhood insomnia and parents value its usefulness too.

The effects of prenatal cocaine use on infant development

This study examined the effect of prenatal cocaine use on infant physical, cognitive, and motor development, and temperamental characteristics, controlling for other factors that affect infant development. Women were, on average, 26.8 years old, had 12 years of education, and 46% were African American. During the first trimester, 18% were frequent users of cocaine (> or =1 line/day). The infants were, on average, 14.6 months old at this follow-up phase. Women who used cocaine during pregnancy rated their infants as more fussy/difficult and unadaptable than did women who did not use cocaine. Cocaine use in the second trimester was associated with significantly lower motor scores on the Bayley Scales of Infant Development (BSID) [N. Bayley, Manual for the Bayley Scales of Infant Development, Psychological Corporation, New York, 1969.]. There was no effect of prenatal cocaine use on BSID mental performance or on growth. These findings are consistent with other reports in the literature and with the hypothesis that prenatal cocaine exposure affects development through changes in neurotransmitter systems.

Prenatal drug exposure: effects on cognitive functioning at 5 years of age

The goal of this cross-sectional study was to compare cognitive functioning at age 5 years in prenatal drug-exposed children with nondrug-exposed children from a comparable inner-city environment. Children with prenatal drug exposure scored significantly lower on measures of language, school readiness skills, impulse control, and visual attention span/sequencing than controls matched for age and socioeconomic status. Intelligence, visual-motor, manual dexterity, and sustained attention scores were not significantly different between groups. The total sample scored significantly below the normative mean on standardized measures of intelligence, language, school readiness, visual-motor skills, impulse control, and sustained attention, with 40% scoring at least 1 standard deviation below the mean (IQ < 85) on a measure of intelligence. Findings suggest that children with prenatal drug exposure are at increased risk for learning and attention problems and are in need of close developmental surveillance and possible intervention to support school success and improve behavioral outcome.

Comparison between reported and recorded total sleep time and sleep latency in 6- to 11-year-old children: the Tucson Children's Assessment of Sleep Apnea Study (TuCASA)

Research comparing parental report of sleep times to objectively obtained polysomnographic evidence of sleep times in schoolchildren is lacking. This report compares habitual sleep time and objectively recorded sleep time and sleep latency with parental reports of sleep time immediately after a night of polysomnography in elementary schoolchildren. Unattended home polysomnograms (PSG) were obtained from 480 children. On the night of the PSG, a parent was asked to complete a Sleep Habits Questionnaire, which inquired about the habitual total sleep time (HABTST) and habitual sleep onset latency (HABSOL) of his/her child on both school days and nonschool days. On the morning after the PSG, the parent was asked to estimate the total sleep time (ESTTST) and sleep onset latency (ESTSOL) of his/her child on the night of the recording. Comparisons were made to actual total sleep time (PSGTST) and sleep latency (PSGSOL) on the PSG. The sample was comprised of 50% girls, 42.3% Hispanic, and 53% aged 6-8 years. The mean HABTST, ESTTST, and PSGTST were 578, 547, and 480 min, respectively. HABTST was greater than both ESTST and PSGTST (p < 0.001). Moreover, ESTTST was greater than PSGTST (p < 0.001). The mean HABSOL, ESTSOL, and PSGSOL were 15, 17, and 11 min. ESTSOL was longer than PSGSOL (p < 0.001). There were no gender differences. However, Hispanic parents reported significantly less HABTST in their children than Caucasian parents (566 vs 587 min, p < 0.001). Parents of schoolchildren in this population-based sample substantially overestimated their children's actual total sleep time and sleep onset latency.

Case management for persons with substance use disorders

BACKGROUND

Patients with alcohol and other drug use disorders (AOD) frequently have multiple social, physical, and mental health treatment needs, yet have difficulty accessing community services, including drug abuse treatment. One strategy for linking patients with AOD with relevant services is case management, where a single case manager is responsible for linking patients with multiple relevant services.

OBJECTIVES

To conduct a systematic review of all RCTs on the use of case management for helping drug abusers in or out of treatment. Outcome criteria included successful linkage with other services, illicit drug use outcomes, and a range of related outcomes.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register (Cochrane Library, issue 4, 2006), MEDLINE (1966 - 2006), EMBASE (1980 - 2006), LILACS (1982 - 2006), PsycINFO (1973 - 2006), Biological Abstracts (1982 t- 2000). Reference searching; personal communication; conference abstracts; book chapters on case management.

SELECTION CRITERIA

Randomized controlled studies that compared a specific model of case management with either treatment as usual or another treatment model, included only patients with at least one alcohol or drug related problem.

DATA COLLECTION AND ANALYSIS

Two groups of reviewers extracted the data independently . Standardized mean difference was estimated.

MAIN RESULTS

In total, we could extract results from 15 studies. Outcome on illicit drug use was reported from 7 studies with 2391 patients. The effect size for illicit drug use was not significant, and small (standardized mean difference (SMD)=0.12, confidence interval=-0.09,0.29, p=0.20). Substantial heterogeneity was found (I(2)=69.9%). Linkage to other treatment services was reported in 10 studies with 3132 patients. The effect size for linkage was moderate (SMD=0.42, 95% confidence interval=0.21 to 0.62, p<0.001), but substantial heterogeneity was found (I(2)=85.2%). Moderator analyses suggested that a part of the heterogeneity found in linkage studies could be explained by the presence or absence of a treatment manual for case management. A single, large trial of case management with two arms, showed that case management was superior to psychoeducation and drug counselling in reducing drug use.

AUTHORS' CONCLUSIONS

There is current evidence supporting that case management can enhance linkage with other services. However, evidence that case management reduces drug use or produce other beneficial outcome is not conclusive.

Effectiveness of different models of case management for substance-abusing populations

Case management has been implemented in substance abuse treatment to improve (cost-) effectiveness, but controversy exists about its potential to realize this objective. A systematic and comprehensive review of peer-reviewed articles (n = 48) published between 1993 and 2003 is presented, focusing on the effects of different models of case management among various substance-abusing populations. Results show that several studies have reported positive effects, but only some randomized and controlled trials have demonstrated the effectiveness of case management compared with other interventions. Longitudinal effects of this intervention remain unclear. Although no compelling evidence was found for the effectiveness of case management, some evidence is available about the (differential) effectiveness of intensive case management and assertive community treatment for homeless and dually-diagnosed substance abusers. Strengths-based and generalist case management have proven to be relatively effective for substance abusers in general. Most positive effects concern reduced use of inpatient services and increased utilization of community-based services, prolonged treatment retention, improved quality of life, and high client satisfaction. Outcomes concerning drug use and psychosocial functioning are less consistent, but seem to be mediated by retention in treatment and case management. Further research is required to learn more about the extent of the effects of this intervention, how long these are sustained and what specific elements cause particular outcomes.

Developmental outcome in children with intrauterine exposure to substances

The developmental outcome of children born to Swiss substance-dependent mothers in a residential treatment program was studied in a sample of 61 children ranging from infancy to preadolescence (mean age = 5.10, SD = 3.10 years) by use of age-appropriate tests of intelligence. A large list of biological and psychosocial risk factors was tested for associations with outcome in the children. The mean profile of test findings across all age ranges was significantly lower than population norms and there was an excess of children with subnormal intellectual functioning. Performance IQ was associated negatively only with intrauterine substance exposure, but with none of the other risk factors. Among the various substances, predominantly heroin or methadone were responsible for this association when controls for nicotine or cannabis consumption were made. The study provides further evidence that intrauterine exposure to heroin and methadone negatively affects the developmental outcome in the offspring of substance-dependent mothers.

Impact of prenatal chlorpyrifos exposure on neurodevelopment in the first 3 years of life among inner-city children

OBJECTIVE

The purpose of this study was to investigate the impact of prenatal exposure to chlorpyrifos on 3-year neurodevelopment and behavior in a sample of inner-city minority children.

METHODS

As part of an ongoing prospective cohort study in an inner-city minority population, neurotoxicant effects of prenatal exposure to chlorpyrifos were evaluated in 254 children through the first 3 years of life. This report examined cognitive and motor development at 12, 24, and 36 months (measured with the Bayley Scales of Infant Development II) and child behavior at 36 months (measured with the Child Behavior Checklist) as a function of chlorpyrifos levels in umbilical cord plasma.

RESULTS

Highly exposed children (chlorpyrifos levels of >6.17 pg/g plasma) scored, on average, 6.5 points lower on the Bayley Psychomotor Development Index and 3.3 points lower on the Bayley Mental Development Index at 3 years of age compared with those with lower levels of exposure. Children exposed to higher, compared with lower, chlorpyrifos levels were also significantly more likely to experience Psychomotor Development Index and Mental Development Index delays, attention problems, attention-deficit/hyperactivity disorder problems, and pervasive developmental disorder problems at 3 years of age.

CONCLUSIONS

The adjusted mean 36-month Psychomotor Development Index and Mental Development Index scores of the highly and lower exposed groups differed by only 7.1 and 3.0 points, respectively, but the proportion of delayed children in the high-exposure group, compared with the low-exposure group, was 5 times greater for the Psychomotor Development Index and 2.4 times greater for the Mental Development Index, increasing the number of children possibly needing early intervention services.

School-age outcome of children with prenatal cocaine exposure following early case management

The impact of prenatal cocaine exposure on neurodevelopmental outcome in childhood continues to be in question. Objectives of this study were to determine if there are differences in growth, behavioral, cognitive or verbal functioning or caregiver-child dyad interactions for inner-city, school-aged children with and without prenatal cocaine exposure, and if these measures would be affected by early family case management. From an initial sample of 118 cocaine-exposed children who were evaluated to 36 months of age, 47 were able to be contacted and 39 (83%) completed a follow-up evaluation at 84 +/- 11 months of age. Subjects had been assigned at birth to early case management (CM, 24) and routine care (RC, 15). Eighteen children from the initial non-cocaine-exposed comparison sample of 41 children were able to be contacted and 12 (67%) were evaluated at 85 +/- 16 months of age. Evaluation included growth measurements, Stanford-Binet IQ, receptive and expressive language quotients, parent-reported Child Behavior Checklists (CBCL), and assessment of caregiver-child interactions by scored videotaped free-play sessions. No differences were found in growth, mean IQ, language quotients, CBCL scores or videotaped caregiver-child play interactions as a function of cocaine exposure. Within the cocaine-exposed group, there were no outcome differences between CM and RC children. However, during the play sessions, CM caregivers had more positive affect in interactions with the child than RC. Within the RC dyads, birthmothers had significantly more positive interactions than non-birthmothers. In summary, no differences in growth, behavioral, cognitive, or language function were evident for inner-city, school-aged children related to prenatal cocaine exposure or early case management. CM caregivers demonstrated more positive interactions during a play session than RC; within the RC group, non birthmothers had the least positive affective interactions. Further study of influences on caregiver-child interactions may lead to effective intervention strategies for drug-exposed infants.

Prenatal cocaine exposure and children's language functioning at 6 and 9.5 years: moderating effects of child age, birthweight, and gender

OBJECTIVE

To evaluate whether prenatal cocaine exposure (PCE), or the interaction between PCE and contextual variables, is associated with children's language at age 6 and 9.5 years, adjusting for relevant covariates.

METHODS

Analyses were based on 160 low-income, urban children from a prospective study who completed a standardized language assessment at 6 and 9.5 years. PCE was determined using neonatal meconium assays and maternal self-report.

RESULTS

Significant interaction effects of PCE on language outcomes were found in multivariate longitudinal analyses using generalized estimating equations (GEE). Children with PCE had lower receptive language than unexposed children at 6 but not at 9.5 years, lower expressive language if they had lower birthweight, and lower expressive and total language if they were female. Other risk (e.g., violence exposure) and protective factors (e.g., preschool experience) were related to language outcomes regardless of PCE status.

CONCLUSIONS

Age, birthweight, and gender moderated the relation between PCE and school-aged children's language.

Level of prenatal cocaine exposure and 48-month IQ: importance of preschool enrichment

OBJECTIVE

This analysis was designed to determine whether prenatal cocaine exposure is related to children's standardized cognitive test scores at age 4 years after control for relevant covariates.

METHODS

Masked examiners using the WPPSI-R assessed ninety-one 4-year-old children with prenatal cocaine exposure and 79 children of comparable demographic background who were not exposed. Level of cocaine exposure was documented by postpartum interviews of mothers and assays of the infants' meconium.

RESULTS

Prenatal cocaine exposure, analyzed as exposed/unexposed or as an ordinal dose variable, was not associated in bivariate or multivariate models with decrements in full-scale IQ, performance IQ, verbal IQ, or in any of the subtests. In bivariate analyses, we found significant differences between exposure groups defined as "unexposed", "lighter", and "heavier" in mean scores of the WPPSI-R subtests Object Assembly (P=0.04) and Picture Completion (P=0.03). For these scores, children with heavier exposure attained higher scaled scores. Birth mother's education and child's experience with preschool enrichment were both associated with higher verbal IQ scores.

CONCLUSION

These findings suggest that prenatal cocaine exposure does not exert negative effects on the cognitive competence of preschool-aged children. Children with a history of prenatal cocaine exposure benefit from preschool programs that have been shown to enhance outcomes for other low-income children.

Outcome from a prospective, longitudinal study of prenatal cocaine use: preschool development at 3 years of age

OBJECTIVE

To determine the effects of prenatal cocaine exposure on child development.

METHODS

This prospective, longitudinal study recruited 154 pregnant cocaine users who were matched on race, parity, socioeconomic status, and perinatal risk to 154 noncocaine users. Drug use status was determined by maternal history and urine screening. At 3 years of age, the child subjects were assessed by an evaluator blinded to maternal drug use history. During a home visit at age 3, caregiver, family, and home assessments were administered.

RESULTS

Structural equation modeling showed a direct effect of the amount of prenatal cocaine exposure on the adjusted birth head circumference which in turn directly affected preschool development.

CONCLUSIONS

We could not demonstrate a direct effect of prenatal cocaine exposure on preschool development, a result that is consistent with that of earlier work and now extending findings to age 3. However, cocaine continued to exert an indirect effect on development through its direct effect on the head circumference at birth.

Methadone maintenance program in pregnancy in a Swiss perinatal center (II): neonatal outcome and social resources

BACKGROUND

The aim of the study was to analyze the neonatal impact of a methadone maintenance program in pregnancy, and the social resources of the families involved.

METHODS

Descriptive analysis of neonatal data in live births after 24 weeks of gestation in pregnant women enrolled in a methadone maintenance program. The data of 86 babies were analyzed.

RESULTS

Median gestational age was 38 (0)/(7) (31-41) weeks; 21 babies (24%) were premature. Median birthweight was 2662 (1340-4050) g; 27% of babies were growth retarded (<3rd centile), and 13% had microcephaly (<3rd centile). Sixty-two percent developed abstinence syndrome requiring pharmacological treatment for a median 47 days. Child Protective Services (CPS) were involved in 56% of cases, and 42% of newborns required placement outside the mother's home.

CONCLUSIONS

Babies born to women on methadone had a fourfold higher incidence of prematurity, a ninefold higher incidence of intrauterine growth retardation (IUGR), and a fourfold higher incidence of microcephaly compared with the normal population. Sixty-two percent required pharmacological treatment for abstinence syndrome and 42% required placement.

Prenatal cocaine exposure: a comparison of 2-year-old children in parental and nonparental care

Effects of prenatal cocaine exposure and parental versus nonparental care on outcome at 2 years of age were examined. The sample included 83 cocaine-exposed and 63 nonexposed children and their caregivers; 49 and 34 of the cocaine-exposed children experienced parental and nonparental care, respectively. Prenatal drug exposure was not related directly to children's outcome at 2 years of age. However, compared with cocaine-exposed children in parental care, those in nonparental care experienced a more optimal environment and performed better in several developmental domains at 2 years of age in spite of being at greater neonatal risk. Further analyses suggested that this protective effect of nonparental care was in part due to nonkin rather than kin care.

Four-year language outcomes of children exposed to cocaine in utero

A large cohort of children exposed to cocaine in utero (n=189) were followed prospectively from birth to 4 years of age and compared to nonexposed children (n=185) on the Clinical Evaluation of Language Fundamentals-Preschool (CELF-P), a measure of receptive and expressive language abilities. Children exposed to cocaine in utero performed more poorly on the expressive and total language measures than nonexposed children after controlling for confounding variables, including prenatal exposure to alcohol, marijuana, and tobacco, as well as medical and sociodemographic variables. Children exposed to cocaine had more mild receptive language delays than nonexposed children and were less likely to have higher expressive abilities. Also, maternal factors such as language ability, performance IQ, race, and education correlated with child language abilities. Prenatal cigarette and marijuana exposure were related to deficits in specific language skills. Children placed in adoptive or foster care who were cocaine exposed demonstrated superior language skills compared to children exposed to cocaine who remained in biological relative or mother's care. These findings support a cocaine-specific effect on language skills in early childhood that may be modified with an enriched environment.

The maternal lifestyle study: cognitive, motor, and behavioral outcomes of cocaine-exposed and opiate-exposed infants through three years of age

OBJECTIVE

To evaluate the direct effects of prenatal cocaine exposure and prenatal opiate exposure on infant mental, motor, and behavioral outcomes longitudinally between 1 and 3 years old.

METHODS

As part of a prospective, longitudinal, multisite study, the Bayley Scales of Infant Development II were administered to 1227 infants who were exposed to cocaine (n = 474), opiates (n = 50), cocaine and opiates (n = 48), and neither substance (n = 655) at 1, 2, and 3 years of corrected age by certified, masked examiners. Hierarchic linear modeling of the 1-, 2-, and 3-year scores was conducted using cocaine and opiate exposure as predictors with and without controlling for covariates.

RESULTS

Overall retention was 88.4% and did not differ by cocaine or opiate exposure. Overall (at 1, 2, and 3 years), cocaine-exposed infants scored 1.6 Mental Development Index points below infants who were not exposed to cocaine. Opiate-exposed infants scored 3.8 Psychomotor Development Index points below infants who were not exposed to opiates. Neither the cocaine nor the opiate effect remained significant after controlling for covariates. Neither cocaine nor opiate exposure was associated with the Behavioral Record Score during the examination. Low birth weight and indices of nonoptimal caregiving were associated with lower Mental Development Index, Psychomotor Development Index, and Behavioral Record Score scores for all groups of infants.

CONCLUSIONS

In the largest at-risk sample observed longitudinally to date, infant prenatal exposure to cocaine and to opiates was not associated with mental, motor, or behavioral deficits after controlling for birth weight and environmental risks.

Children prenatally exposed to cocaine: developmental outcomes and environmental risks at seven years of age

Data are equivocal regarding the long-term consequences of prenatal exposure to cocaine on school-aged children. We compared 101 children exposed prenatally to cocaine with 130 unexposed children on measures of intelligence, visual motor, and motor abilities at age 7 years. Bivariate analyses revealed that cocaine-exposed children scored significantly lower than comparison children on the abbreviated Wechsler Intelligence Scale for Children-Third Edition Verbal and Full Scale IQ scores, the Visual Motor Integration and Motor Coordination standardized scores, and the Bruininks-Oseretsky Fine Motor Composite score. Regression analyses indicated that the biological mother's vocabulary and home environment assessed at the same 7-year visit were stronger predictors of developmental outcome than prenatal drug exposure. Level of cocaine exposure, however, predicted visual motor and motor skills. The results indicate that although prenatal cocaine exposure may confer some degree of developmental disadvantage in the visual motor domain, it frequently occurs in the context of an inadequate rearing environment, which may be a stronger determinant than prenatal cocaine exposure of children's outcome.

Developmental outcome of drug-exposed children through 30 months: a comparison of Bayley and Bayley-II

This study examined the effects of the Bayley Scales of Infant Development (BSID) version on developmental outcomes among drug-exposed children, some of whom received an intervention. Developmental outcome was evaluated with the BSID at 12 and 18 months and with the BSID-II at 24 and 30 months. In the repeated measures analyses, children scored higher on the BSID Mental Developmental Index (MDI; p < .01) and Psychomotor Developmental Index (PDI; p < .01) than on the BSID-II MDI and PDI. Version x Time (p < .01) and Version x Group (p < .01) interactions were also found for the MDI but not the PDI. PDI scores decreased on both the BSID and the BSID-II (p < .01). Over the first 2 years postpartum, mean MDI and PDI scores decreased among these high-risk, drug-exposed children.

Severity of prenatal cocaine exposure and child language functioning through age seven years: a longitudinal latent growth curve analysis

The current study estimates the longitudinal effects of severity of prenatal cocaine exposure on language functioning in an urban sample of full-term African-American children (200 cocaine-exposed, 176 noncocaine-exposed) through age 7 years. The Miami Prenatal Cocaine Study sample was enrolled prospectively at birth, with documentation of prenatal drug exposure status through maternal interview and toxicology assays of maternal and infant urine and infant meconium. Language functioning was measured at ages 3 and 5 years using the Clinical Evaluation of Language Fundamentals--Preschool (CELF-P) and at age 7 years using the Core Language Domain of the NEPSY: A Developmental Neuropsychological Assessment. Longitudinal latent growth curve analyses were used to examine two components of language functioning, a more stable aptitude for language performance and a time-varying trajectory of language development, across the three time points and their relationship to varying levels of prenatal cocaine exposure. Severity of prenatal cocaine exposure was characterized using a latent construct combining maternal self-report of cocaine use during pregnancy by trimesters and maternal and infant bioassays, allowing all available information to be taken into account. The association between severity of exposure and language functioning was examined within a model including factors for fetal growth, gestational age, and IQ as intercorrelated response variables and child's age, gender, and prenatal alcohol, tobacco, and marijuana exposure as covariates. Results indicated that greater severity of prenatal cocaine exposure was associated with greater deficits within the more stable aptitude for language performance (D = -0.071, 95% CI = -0.133, -0.009; p = 0.026). There was no relationship between severity of prenatal cocaine exposure and the time-varying trajectory of language development. The observed cocaine-associated deficit was independent of multiple alternative suspected sources of variation in language performance, including other potential responses to prenatal cocaine exposure, such as child's intellectual functioning, and other birth and postnatal influences, including language stimulation in the home environment.

c-fos and cleaved caspase-3 expression after perinatal exposure to ethanol, cocaine, or the combination of both drugs

Poly-drug abuse during pregnancy is a major public health concern. The combined effects of cocaine and ethanol may be more injurious to the fetal nervous system than either drug alone. In order to identify areas of the brain vulnerable to concurrent exposure, we examined the expression of the immediate-early gene (IEG), c-fos, and cleaved caspase-3, the 'executioner' caspase in apoptosis. Pregnant rats were treated with either ethanol diet, cocaine binge, or both. At birth, the brains of fetuses exposed to cocaine exhibited an increase in Fos immunoreactivity in many brain regions. Prenatal exposure to ethanol did not increase Fos expression above that observed in control rats at early points after birth. However, Fos expression at 24 h after birth was higher after ethanol diet treatment in several brain regions, such as the amygdala, ventromedial hypothalamus, and medial thalamus. Only in the striatum did the combination of ethanol and cocaine cause greater Fos expression than either prenatal cocaine or ethanol alone. Increased cleaved caspase-3 expression was observed at the 24-h time point for both ethanol- and cocaine-exposed brains, most notably in the septum, retrosplenial cortex, and the hippocampus. Concurrent ethanol and cocaine exposure did not elevate cleaved caspase-3 expression beyond that of either drug alone. Analysis of the extent of c-fos and caspase-3 induction did not indicate a consistent relationship of expression in any of the drug treatment groups nor in any brain region. These results indicate that both prenatal cocaine and prenatal ethanol exposure increase Fos and cleaved caspase-3 expression in the developing brain in a time- and region-dependent manner, but that the combination of low-dose, chronic ethanol, and binge cocaine does not cause greater apoptosis.

Four-year follow-up study of sleep and psychiatric symptoms in preadolescents: relationship of persistent and temporary sleep problems to psychiatric symptoms

The course of sleep disturbances in preadolescents was assessed during a 4-year follow-up, and psychiatric problems associated with persistent and temporary sleep problems were investigated in an epidemiological setting. A representative random sample of 1,290 children, their parents, and school teachers filled out various questionnaires when the children were aged 8 and 12 years. Response rates to the relevant items varied between 66.8% and 81.2%. Parental reports of sleep problems decreased from 23.4% to 9.1% during the 4-year period, whereas children's reports remained steady at 18%. Persistent sleep disturbances were found in 12% of children, and 33.3% of sleep problems reported at age 8 were continued. Both current and persistent sleep disturbances were associated with the broad range of mental health problems reported by teachers. However, multivariate modeling suggested that especially current sleep problems were associated with an increased risk for psychiatric problems (odds ratio [OR] 2.45; 95% confidence interval [CI] 1.20-4.99), particularly emotional problems (OR 2.92; 95% CI 1.58-5.38).

Comparison of intelligence, school readiness skills, and attention in in-utero drug-exposed and nonexposed preschool children

Children with in-utero drug exposure (IUDE) may be at risk for poor neurodevelopmental outcomes. The objective of this study was to determine the association between IQ, school readiness skills, and self-regulation behavior in IUDE children (n=103) and non IUDE-exposed children (n=33) at age 4 years. Mean IQ or school readiness scores did not significantly differ by IUDE exposure; however, both groups scored approximately 1 standard deviation below the mean for both IQ and school readiness skills. The IUDE group earned a significantly higher mean score (thereby performing poorer) than the nonexposed group on focusing and inattentive behavior. Factors associated with poor school readiness skills for all children (IUDE exposed and nonexposed) were not attending a preschool program and lower caregiver education level. Assuring high-risk children are identified and referred for early intervention services as well as treated for inattention behavior is crucial for their academic success.

Effectiveness of melatonin in the treatment of sleep disturbances in children with Asperger disorder

Sleep disturbances are common in patients with Asperger disorder. Although these sleep problems are often persistent and may significantly impair the child's daytime well-being, no treatment studies have been reported. In this open clinical trial, the effectiveness of melatonin was studied in a sample of 15 children with Asperger disorder (13 boys, 2 girls) aged 6-17 years using several questionnaires and actigraph measurements. They included assessments of sleep quality, tiredness, and behavior. Melatonin (3 mg/day) was used for 14 days. All the measurements were made three times: before the treatment period, during the treatment (days 12-14), and 3 weeks after the discontinuation of the treatment. The sleep patterns of all the children improved, and half of them displayed excellent responses to melatonin. In particular, actigraphically measured sleep latency decreased from 40.02 +/- 24.09 minutes to 21.82 +/- 9.64 minutes (p = 0.002), whereas sleep duration remained steady at 477.40 +/- 55.56 minutes and 480.48 +/- 50.71 minutes. Despite the short duration of the treatment, behavioral measures also displayed a significant improvement, and most of the effect disappeared after the discontinuation of the melatonin (p = 0.001). In conclusion, melatonin may provide an interesting new and well-tolerated treatment option for children with Asperger disorder suffering from chronic insomnia. However, these results must be confirmed in a controlled study.

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

The authors examined 223 children at age 4 years for the effects of prenatal cocaine exposure, exposure to other substances, maternal and environmental risk factors, and neonatal medical problems on IQ, externalizing problems, and internalizing problems. Regression analyses showed that maternal verbal IQ and low environmental risk predicted child IQ. Cocaine exposure negatively predicted children's overall IQ and verbal reasoning scores, but only for boys. Cocaine exposure also predicted poorer short-term memory. Maternal harsh discipline, maternal depressive symptoms, and increased environmental risk predicted externalizing problems. In contrast, only maternal depressive symptoms predicted internalizing problems. These findings indicate that early exposure to substances is largely unrelated to subsequent IQ or adjustment, particularly for girls.

Influence of prenatal cocaine exposure on early language development: longitudinal findings from four months to three years of age

The influence of prenatal cocaine exposure on children's language functioning was evaluated longitudinally at six time points from 4 months to 3 years of age. The Miami Prenatal Cocaine Study prospectively enrolled 476 full-term African-American infants at birth, categorized as cocaine-exposed (n = 253) or non-cocaine-exposed (n = 223) by maternal self-report and bioassays (maternal/infant urine, meconium). The Bayley Scales of Infant Development, scored using the Kent Scoring Adaptation for language, was administered at 4, 8, 12, 18, and 24 months. The Clinical Evaluation of Language Fundamentals-Preschool was administered at 3 years. In longitudinal analyses using Generalized Estimating Equations, cocaine-exposed children had lower overall language skills than non-cocaine-exposed children (D = -0.151; 95% CI = -0.269, -0.033; p =.012). Longitudinal findings remained stable after evaluation of potential confounding influences including other prenatal substance exposures and sociodemographic factors. Preliminary evidence also indicated possible mediation through an intermediary effect involving cocaine-associated deficits in fetal growth.

Level of prenatal cocaine exposure and scores on the Bayley Scales of Infant Development: modifying effects of caregiver, early intervention, and birth weight

OBJECTIVES

The objectives of this study were 1) to assess whether there is an independent association between the level of prenatal cocaine exposure and infants' developmental test scores after control of potential confounding variables; and 2) if such an association exists, to determine which biological and social variables, individually and in interaction with each other, may modify it.

METHODS

In a prospective, longitudinal study of 203 urban term infants, 3 cocaine exposure groups were defined by maternal report and infant meconium assay: unexposed, heavier cocaine exposure (>75th percentile self-reported days of use or meconium benzoylecognine concentration), or lighter cocaine exposure (all others). Examiners, masked to exposure history, tested infants at 6, 12, and 24 months of age with the Bayley Scales of Infant Development.

RESULTS

The final mixed linear regression model included as fixed covariates level of prenatal exposure to cocaine, alcohol, and cigarettes; prenatal marijuana exposure; gestational age and birth weight z score for gestational age; and gender. Age at test, caregiver at time of each test (biological mother, kinship caregiver, unrelated foster caregiver), and any previous child-focused early intervention were included as time-dependent covariates. There were no significant adverse main effects of level of cocaine exposure on Mental Development Index (MDI), Psychomotor Development Index (PDI), or Infant Behavior Record. Child-focused early intervention interacted with level of cocaine exposure such that heavily exposed children who received such intervention showed higher adjusted mean MDI scores than all other groups. Although the sample was born at or near term, there was also a significant interaction of cocaine exposure and gestational age on MDI scores, with those in the heavier exposure group born at slightly lower gestational age having higher mean MDI scores compared with other children born at that gestational age. There was also a significant interaction on MDI between child's age and caregiver. At 6 months, the adjusted MDI of children living with a kinship caregiver was 15.5 points lower than that of children living with their biological mother, but this effect was diminished and was no longer significant at 24 months (difference in means: 4.3 points). The adjusted mean MDI of children in unrelated foster care at 6 months was 8.2 points lower than children of biological mothers, whereas it was 7.3 points higher at 24 months. Early intervention attenuated the age-related decline in PDI scores for all groups. Birth weight <10th percentile was associated with lower PDI scores for children with heavier cocaine exposure and with lower MDI scores for all groups.

CONCLUSIONS

Heavier prenatal cocaine exposure is not an independent risk factor for depressed scores on the Bayley Scales of Infant Development up to 24 months of age when term infants are compared with lighter exposed or unexposed infants of the same demographic background. Cocaine-exposed infants with birth weight below the 10th percentile for gestational age and gender and those placed with kinship caregivers are at increased risk for less optimal developmental outcomes. Pediatric clinicians should refer cocaine-exposed children to the child-focused developmental interventions available for all children at developmental risk.

Foster-placed and adopted children exposed in utero to opiates and other substances: prediction and outcome at four and a half years

This article presents a Norwegian prospective, longitudinal study of children prenatally exposed to opiates and other substances under conditions of minimal postnatal social risk. Outcome at 4(1/2) years of age is presented. The study reports on the prediction of later intellectual performance, on the basis of the children's prenatal, perinatal, and early developmental status, as well as the foster or adoptive parents' socioeconomic level. Significant differences were found between the substance-exposed group and the comparison group on the Bayley Scales at age 1 year and on the McCarthy Scales at age 4(1/2) years. The findings showed that although the mean cognitive scores were within normal limits at age 4(1/2) years, a special weakness in the area of visual-motor and perceptual abilities was detected among the substance-exposed children. It is indicated that these areas of performance are especially sensitive to the effect of prenatal adversity. A special vulnerability among the substance-exposed boys, detected at an earlier age, persisted at 4(1/2) years. The study indicates that even if children experience adequate caregiving, the accumulation of biomedical risk factors associated with prenatal substance exposure is still a potential determinant of developmental problems, especially in the area of perceptual-performance functions. The study also hints at differential influences of biomedical and environmental variables on outcome at age 4(1/2) years.

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

The authors examined 223 children at age 4 years for the effects of prenatal cocaine exposure, exposure to other substances, maternal and environmental risk factors, and neonatal medical problems on IQ, externalizing problems, and internalizing problems. Regression analyses showed that maternal verbal IQ and low environmental risk predicted child IQ. Cocaine exposure negatively predicted children's overall IQ and verbal reasoning scores, but only for boys. Cocaine exposure also predicted poorer short-term memory. Maternal harsh discipline, maternal depressive symptoms, and increased environmental risk predicted externalizing problems. In contrast, only maternal depressive symptoms predicted internalizing problems. These findings indicate that early exposure to substances is largely unrelated to subsequent IQ or adjustment, particularly for girls.

Are there neurologic correlates of in utero cocaine exposure at age 6 years?

At age 6 years, a cohort of non-asphyxiated children, 52 with gestational cocaine exposure and 63 control subjects, underwent a neurologic examination. Groups did not differ on any aspect of the examination. This finding, while reassuring, does not exclude the possibility of more subtle deficits.

Teacher-assessed behavior of children prenatally exposed to cocaine

OBJECTIVE

Prenatal cocaine exposure has been associated with alterations in neonatal behavior and more recently a dose-response relationship has been identified. However, few data are available to address the long-term behavioral effects of prenatal exposures in humans. The specific aim of this report is to evaluate the school-age behavior of children prenatally exposed to cocaine.

METHODS

All black non-human immunodeficiency virus-positive participants in a larger pregnancy outcomes study who delivered singleton live born infants between September 1, 1989 and August 31, 1991 were eligible for study participation. Staff members of the larger study extensively screened study participants during pregnancy for cocaine, alcohol, cigarettes, and other illicit drugs. Prenatal drug exposure was defined by maternal history elicited by structured interviews with maternal and infant drug testing as clinically indicated. Cocaine exposure was considered positive if either history or laboratory results were positive. Six years later, 665 families were contacted; 94% agreed to participate. The child, primary caretaker (parent), and, when available, the biologic mothers were tested in our research facilities. Permission was elicited to obtain blinded teacher assessments of child behavior with the Achenbach Teacher's Report Form (TRF). Drug use since the child's birth was assessed by trained researchers using a structured interview.

RESULTS

Complete laboratory and teacher data were available for 499 parent-child dyads, with a final sample size for all analyses of 471 (201 cocaine-exposed) after the elimination of mentally retarded subjects. A comparison of relative Externalizing (Aggressive, Delinquent) to Internalizing (Anxious/Depressed, Withdrawn, Somatic Complaints) behaviors of the offspring was computed for the TRF by taking the difference between the 2 subscales to create an Externalizing-Internalizing Difference (T. M. Achenbach, personal communication, 1998). Univariate comparisons revealed that boys were significantly more likely to score in the clinically significant range on total TRF, Externalizing-Internalizing, and Aggressive Behaviors than were girls. Children prenatally exposed to cocaine had higher Externalizing-Internalizing Differences compared with controls but did not have significantly higher scores on any of the other TRF variables. Additionally, boys prenatally exposed to cocaine were twice as likely as controls to have clinically significant scores for externalizing (25% vs 13%) and delinquent behavior (22% vs 11%). Gender, prenatal exposures (cocaine and alcohol), and postnatal risk factors (custody changes, current drug use in the home, child's report of violence exposure) were all related to problem behaviors. Even after controlling for gender, other prenatal substance exposures, and home environment variables, cocaine-exposed children had higher Externalizing-Internalizing Difference scores. Prenatal exposure to alcohol was associated with higher total score, increased attention problems, and more delinquent behaviors. Prenatal exposure to cigarettes was not significantly related to the total TRF score or any of the TRF subscales. Postnatal factors associated with problem behaviors included both changes in custody status and current drug use in the home. Change in custody status of the cocaine-exposed children, but not of the controls, was related to higher total scores on the TRF and more externalizing and aggressive behaviors. Current drug use in the home was associated with higher scores on the externalizing and aggressive subscales.

CONCLUSIONS

Results of this study suggest gender-specific behavioral effects related to prenatal cocaine exposure. Prenatal alcohol exposure also had a significant impact on the TRF. Postnatal exposures, including current drug use in the home and the child's report of violence exposure, had an independent effect on teacher-assessed child behavioral problems. (ABSTRACT TRUNCATE