Barry M. Lester, PhD Brown Center for the Study of Children at Risk

1. Prenatal Drug Exposure & Child Outcome: Time for Policy to Catch up with Research Barry M. Lester, PhD Brown Center for the Study of Children at Risk The Warren Alpert Medical School of Brown University Women, Pregnancy and Drug Use: Medical Facts, Practical Responses and the Well-Being of Children and Families Oklahoma City, November 14, 2007

2. Science and Prenatal Drug Exposure Are There Drug Effects? YES, BUT: They are smaller than initially thought Not all drug exposed children are affected They can be treated

3. History and Headlines COCAINE HURTS BABIES When drug babies reach school age Mothers Turned Into Monsters Pregnant cocaine user guilty of abuse Crack A Disaster of Historic Dimension, Still Growing Studies: Future bleak for crack babies Cocaine: a vicious assault on a child Crack’s Toll Among Babies: A Joyless View, Even of Toys In the 1980s, early reports on prenatal cocaine effects created a public frenzy about “unfit to parent” women and their damaged “crack babies."

4. History and Headlines COCAINE HURTS BABIES When drug babies reach school age Mothers Turned Into Monsters Pregnant cocaine user guilty of abuse Crack A Disaster of Historic Dimension, Still Growing Studies: Future bleak for crack babies Cocaine: a vicious assault on a child Crack’s Toll Among Babies: A Joyless View, Even of Toys Based on insufficient and inaccurate information, society over-reacted. Women were prosecuted, children were removed from their birth mothers, families were split up.

5. History and Headlines COCAINE HURTS BABIES When drug babies reach school age Mothers Turned Into Monsters Pregnant cocaine user guilty of abuse Crack A Disaster of Historic Dimension, Still Growing Studies: Future bleak for crack babies Cocaine: a vicious assault on a child Crack’s Toll Among Babies: A Joyless View, Even of Toys By the mid 1990s, the number of children in foster care reached an all-time high of over 500,000. Many of these children suffered emotional problems from multiple foster care placements.

6. History and Headlines Prenatal cocaine exposure has subtle effects on children’s ability to focus their attention Major Trial Finds Only Subtle Fetal Injury From Cocaine A mother’s cocaine use may not doom her childafter all “Crack Kids”: Not Broken A Rush toJudgment Hope for ‘SnowBabies’ Researchers debunk myth of the ‘crack baby’ But, later studies did not find that prenatal cocaine exposure was related to serious defects or medical complications in the newborn.

7. U. Tenn Memphis Wayne State U. Miami Brown U. MLS Cocaine: The Maternal Lifestyle Study

8. Medical Conditions(N>8,000) • Previously reportedmedical problems in the mothers were rare (<5%) and not related to cocaine • Previously reported physical damage to the infant was rare (<5%) and not related to cocaine

9. Medical Findings at Birth • Cocaine effects were found on infant gestational age (8.4 days), birthweight (536 grams) head circumference (1.5 cm), small for gestational age (29% vs 13%) • Cocaine exposed infants showed more “soft signs” and behavioral effects

10. Mental Development Ages 1-7 110 COMP EXP 100 90 80 IQ 70 4.4 IQ Pts 60 50 1 2 3 4 5 6 7 Age (Years) (Lester et al 2004)

11. 70 No Cocaine Mod Cocaine Hi Cocaine 65 60 Predicted CBCL Externalizing Score 55 50 45 40 3 4 5 6 7 8 9 Age (Years) Behavior Problems Ages 3-9

12. Behavior Problems at Age 7 MLS CBCL Externalizing >63

13. Special Education Referrals at Age 7

14. What is the Cost to Society? 120,000 drug exposed infants/year X 5% (extra 6000 drug exposed children per year needing special education services) X $9204 (cost special education services per child) = $55,224,000 per year additional funds

15. Brown Oklahoma California Hawaii IDEAL Iowa Methamphetamine: Infant Development Environment And Lifestyle Study

16. Research Is Just Beginning According to an NIH Expert Panel Report: in terms of the potential adverse reproductive and developmental effects of meth exposure “studies that focused upon humans were uninterpretable” … …due to such factors as a lack of control of potential confounding factors and the issue of the purity and contaminants of the methamphetamine used by the drug abusers” (p.191). NTP-CERHR, Monograph on the Potential Human Reproductive and Developmental Effects of Amphetamines, July 2005

17. IDEAL: Medical Conditions(N=408) • No increase in maternal medical problems in mothers who used Meth during pregnancy (e.g. placental abruption) • No increase in physical damage in Meth exposed infants

18. Medical Findings at Birth • Meth effects were found on infant gestational age (1.4 weeks), birthweight (200 grams) and small for gestational age (19% vs 8.5%)

19. Newborn Behavior • Lower arousal • More stress signs • Similar to cocaine

20. Mental Development Ages 1-3

21. Mental Development Problems at Age 3 IDEAL Bayley <77

22. Behavior Problems at Age 3 IDEAL CBCL Externalizing>63

23. Policy Responses 2 parallel policy responses towards drug use by women Punitive Treatment

24. Punitive • Drug use by mothers as legal/criminal issue • Criminal justice system - Child welfare system • Harming child by using drugs • Child abuse in its most destructive form • Favors imprisonment, child removal

25. Treatment • Drug use by pregnant women viewed as a mental health (medical) issue • Harm reduction • Reproductive health care, substance abuse and mental health treatment, relationship with child

26. Problems With Punitive Approach • Fear of being reported drives women away from health care system (e.g. prenatal care) • Denies the opportunity to parent for those who can/want to parent

27. Problems With Punitive Approach • Overburdens foster care system • Child’s ability to form attachments is jeopardized by multiple foster placements

28. Addiction Can Be Treated 3 0 ml/gm METH Abuser (1 month detox) Normal Control METH Abuser (24 months detox)

29. 50 to 70% 50 to 70% 40 to 60% 30 to 50% Similar Relapse Rates for Drug and Other Medical Problems 100 90 80 70 60 Percent of Patients Who Relapse 50 40 30 20 10 0 Drug Dependence Type I Diabetes Hypertension Asthma

30. Model Programs • Family centered • Comprehensive • Interdisciplinary staff • Nonjudgmental, nonpunitive, nurturing, culturally appropriate • Parenting programs • Mental health and women’s issues • Child care • Transportation

31. What Have We Learned? • Addiction is a disease – a medical condition that can be treated • Mothers don’t use drugs because they are evil people who don’t care about their baby • They use drugs because they have a mental disorder

32. What Have We Learned? Community Violence Violent Friends A bad environment can worsen drug effects Domestic Violence

33. What Have We Learned? • Environment is key A good environment can overcome drug effects

34. The Brain is the Ultimate “Use-It or Lose-It” Machine Synapses • At birth – 50 trillion • At 1 year – 1000 trillion • At age 20 – 500 trillion

35. The human brain is shaped by experience Experience, in turn, leads to neural changes in the brain The remolded brain facilitates taking in new experiences

36. Current Headlines The Meth Epidemic: Hype vs Reality New drug wave delivers 'crank babies' Crack Then, Meth Now Generation of Meth Babies We are in a similar situation today with methamphetamine as we were 20 years ago with cocaine

37. Current Headlines meth babies” “could make the crack baby look like a walk in the nursery” Children of meth users are filling foster homes Meth Infants Called the New “Crack Babies” Only Future Will Tell Full Damage Speed Wreaks on Kids

38. Avoid Labeling Top Medical Doctors, Scientists & Specialists Urge Major Media Outlets Not to Create “Meth Baby” Myth Signatories from Leading Hospitals and Research Institutes In US and Abroad Agree That Term Lacks Scientific Basis as Does the Claim That Treatment Does Not Work   July 25, 2005

39. Avoid Labeling “The use of stigmatizing terms, such as ice babies and meth babies, lack scientific validity and should not be used. Experience with similar labels applied to children exposed parentally to cocaine demonstrates that such labels harm the children to which they are applied, lowering expectations for their academic and life achievements, discouraging investigation into other causes for physical and social problems the child might encounter, and leading to policies that ignore factors, including poverty, that may play a much more significant role in their lives.”

40. Final Thought… We have made tremendous strides in the past 20 years when it comes to our understanding drug addiction and treatment. The effects of prenatal drug exposure are milder than initially thought. A good environment can help overcome drug effects.

41. Final Thought… While there are drug users who are inadequate mothers, there are also drug users who are competent mothers who, with treatment, can care for their children. Families can be preserved. Failure to take advantage of what we have learned is not only a missed opportunity but a giant step backward.

42. http://www.brown.edu/Departments/Children_at_Risk/Links.htm