Risk and Reality: The Implications of Prenatal Exposure to Alcohol and Other Drugs

RISK AND REALITY:

THE IMPLICATIONS OF PRENATAL EXPOSURE TO ALCOHOL AND OTHER DRUGS

By Joanne P. Brady, Marc Posner, Cynthia Lang and Michael J. Rosati

The Education Development Center, Inc.

1994.

Risk and Reality is a joint project of the U.S. Department of Health and Human Services (DHHS) and the U.S. Department of Education (ED). Funding was provided by the Office of the Assistant Secretary for Planning and Evaluation, DHHS, the Office of Elementary and Secondary Education, ED, the Head Start Bureau, DHHS, the National Institute on Drug Abuse, DHHS, and the Center for Substance Abuse Prevention, DHHS.

All material in this document is in the public domain and may be used or reproduced without permission from DHHS or the authors. Citation of the source is appreciated.

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INTRODUCTION

The use of illicit drugs and abuse of alcohol exact a steep price from our society. The complicity of substance abuse in serious social ills such as crime, domestic violence, and traffic injuries is well established. Recently, however, another threat has come to the attention of the public. This is the threat to children born to women who abuse alcohol and other drugs during their pregnancy. Experts now estimate that one-half to three-quarters of a million infants are born each year who have been exposed to one or more illicit drugs in utero. When the legal drugs—alcohol and tobacco—are added, the figure rises to considerably more than one million substance exposed infants.

The onset of the crack epidemic during the 1980s gave rise to a number of rather dramatic articles in the press that often presented an image of drug-exposed infants and children as "hopeless" members of a "lost generation" (Toufexis 1991; Norris 1991). These articles, based largely on anecdotal accounts, helped to fuel a number of misperceptions. Among them are:

• There are an ever-increasing number of drug-exposed children who will in time overrun Head Start programs, early elementary classrooms, and social service agencies.
• There are permanent neurological, developmental, and behavioral consequences that are directly attributable to prenatal drug exposure.
• Preschools and schools are unprepared to effectively control and educate children who were prenatally exposed to drugs.

As a result of these portraits of children with intractable deficits, Head Start and public school staff have grown concerned about the unknown numbers of drug-exposed children who might enter their classrooms. In fact, teachers and administrators report increasing numbers of children who lack social skills and have difficulty keeping pace with routine demands. Some children are persistently withdrawn; others are prone to sudden episodes of violence. Primed by inaccurate media reports, educators have begun attributing these behaviors, as well as a wide range of other behaviors and developmental delays, to the effects of prenatal drug exposure.

Although prenatal drug exposure has captured a great deal of public attention, prenatal exposure to alcohol is more widespread and has perhaps an even more serious impact. The National Institute on Drug Abuse estimates that 60 percent of women of childbearing age consume alcoholic beverages despite the fact that alcohol consumption during pregnancy is implicated in a wide range of birth defects and developmental disabilities, including mental retardation, physical abnormalities, and visual and auditory impairments.

As they assess the threat that prenatal exposure to alcohol and other drugs presents to children and schools, policy makers and practitioners must separate myth from fact. The practice of labeling children should also be avoided since it can lead teachers and parents to have diminished expectations for educational success. Finally, educators and parents need assistance in creating an educational environment that will enable children to fulfill their potential.

OVERVIEW OF THE MONOGRAPH

This monograph is one in a series of products created by Education Development Center, Inc. (EDC) to address the needs of administrators and teachers for accurate, up-to-date information on the effects of prenatal exposure to alcohol and other drugs. This report also examines what is known about other risk factors that may amplify these effects or produce similar consequences.

The first chapter addresses what the research suggests about the short- and long-term effects of prenatal exposure to alcohol and other drugs.

The second chapter discusses environmental factors which, by themselves or in combination with the effects of prenatal exposure to alcohol or other drugs, can affect a child's development.

The third chapter explores the implications for education in preschool and primary grades and describes specialized programs that serve children identified as having been prenatally exposed to alcohol or other drugs, as well as the behavioral and developmental characteristics these children display.

Finally, this report sums up the central findings and suggests ways that this information can guide the development of strategies, techniques, and materials to help teachers and administrators provide children at risk with appropriate and effective educational experiences.

CHAPTER 1:

EFFECTS OF PRENATAL EXPOSURE TO ALCOHOL OR OTHER DRUGS

Research on the extent and effects of prenatal exposure to alcohol and other drugs is complex and sometimes contradictory. This chapter contains five major sections. It begins with a discussion of some important methodological issues. A second section examines data on the prevalence of prenatal exposure to alcohol and other drugs. A third section summarizes the current research on the effects of prenatal exposure to five widely used substances: cocaine, opiates, amphetamines and methamphetamines, phencyclidine hydrochloride (PCP), and marijuana, as well as research on "mixed" samples. Finally, the relationship between maternal use of alcohol and other drugs and the risk and developmental consequences of preterm and small-for-gestational-age (SGA) birth is examined. This chapter ends with some general conclusions on the effects of prenatal exposure to alcohol or other drugs.

METHODOLOGICAL ISSUES

The difficulties of research on the extent and effects of prenatal exposure to alcohol and other drugs are those common to any medical research conducted under nonexperimental conditions, those particular to an investigation of illegal or disapproved-of activities, and those particular to an emotionally charged subject.

Some of the methodological challenges include finding an appropriate sample.

• Most hospitals lack protocols for identifying pregnant women who use alcohol and/or other drugs; in addition, such protocols have limited use because people often do not admit such behavior (McCalla et al. 1992; McNagny and Parker 1992; Cohen, Green, & Crombleholme 1991; Lurio, Younge, & Selwyn 1991; Wilkins-Haug & Gabow 1991; GAO 1990; Matera et al. 1990; Senate Office of Research 1990; Zuckerman et al. 1989; Zuckerman et al. 1985; Rouse, Kozel, & Richards 1985; Legislative Analyst n.d.).
• Toxicologic assessments can result in false positives or fail to reveal alcohol or other drug use because those substances have metabolized (Mayes et al. 1992; Szeto 1991; Larsen & Horowitz 1991; Matera et al. 1990; Hawks & Chiang 1986).
• Researchers frequently fail to base their prevalence estimates on samples representative of the general population (Mayes et al. 1992).
• Researchers often have trouble establishing a matched control group, especially when studying those groups most at risk of substance abuse (Chasnoff 1991; Strauss & Allred 1986).

Other problems concern the difficulty of isolating the effects of a particular substance and determining the relationship between the effects and both the amount of a substance used and when it was used during pregnancy.

• Researchers find it extremely difficult to control for the effects of other factors (such as prenatal care or nutrition) that influence perinatal and developmental outcomes (Mayes et al. 1992; Frank et al. 1988; Zuckerman & Hingson 1986; Neugut 1981).
• Polydrug use (including alcohol and tobacco) is common among women who use drugs (Chasnoff 1991; Streissguth et al. 1991a). Cigarette smoking has been linked to many of the perinatal and developmental effects also attributed to illicit drugs and alcohol (Zuckerman 1991b; Fried & Watkinson 1990; Haglund & Cnattingius 1990; Zuckerman 1988; Abel 1984; Pirani 1978).
• Toxicologic assessments reveal nothing about the overall pattern of the use of alcohol and other drugs (Day, Wagener, & Taylor 1985), and self-reports about this behavior lack reliability (Wilkins-Haug & Gabow 1991; Matera et al. 1990; Zuckerman et al. 1985; Rouse, Kozel, & Richards 1985; Legislative Analyst n.d.). It is possible that mixtures of illegal drugs, or combinations of illegal drugs and alcohol, have different effects than the use of a single substance (Randall 1992a).
• Illicit drugs vary greatly in dosage and purity (Chasnoff 1991).

Finally, individual studies and the pool of accessible research may reflect a bias. Koren et al. (1989), for example, found that reports concluding that there are minimal reproductive hazards associated with maternal use of cocaine were less likely to be accepted for presentation than reports finding greater hazards, regardless of methodological rigor. These methodological issues should be kept in mind when considering estimates of the extent of prenatal alcohol and other drug exposure and interpreting research results.

PREVALENCE

Estimates of the Extent of Prenatal Exposure to Alcohol and Other Drugs

Prevalence estimates vary. Chasnoff and Griffith (1989) estimate that 11 percent of all newborns, more than 459,690 children born each year, have been exposed to illicit drugs. Gomby and Shiono (1991) estimate that more than 739,000 women each year use one or more illegal substances during a pregnancy.

The dramatic increase in the popularity of cocaine (and especially crack) during the late 1980s prompted much of the contemporary concern with prenatal drug exposure. Estimates of the percentage of children born prenatally exposed to cocaine (including crack) each year range from 1 to 4.5 percent (Gomby & Shiono 1991; Besharov 1990; GAO 1990). Using these rates, it is estimated that women give birth to between 41,790 and 188,055 children each year who were exposed to cocaine. (Unless otherwise noted, National Center for Health Statistics estimates of live births for 1990 provide the basis for all statistical extrapolations.)

Despite the growing use of cocaine, marijuana remains the most widely used illicit drug. Rates of newborns prenatally exposed to marijuana have been estimated at levels from 3 to almost 20 percent (MacGregor et al. 1990; Gomby & Shiono 1991; Hingson et al. 1982), which would indicate that every year women give birth to between 125,370 and 835,800 children prenatally exposed to marijuana.

Prenatal exposure to alcohol far exceeds that of illicit drugs. Gomby and Shiono (1991) estimate that women give birth to more than 2.6 million infants exposed to alcohol each year. Fetal Alcohol Syndrome (FAS) annually affects between 1.3 and 2.2 children per 1,000 live births in North America (US DHHS 1990; Streissguth & Giunta 1988). Researchers estimate that cases of Alcohol-Related Birth Defects (ARBD) exceed those of FAS by a ratio of 2:1 to 3:1 (Streissguth & Giunta 1988; Abel & Dintcheff 1984). This would indicate that women in the U.S. annually give birth to between 16,548 and 22,064 children exhibiting the effects of prenatal exposure to alcohol.

Other evidence also indicates that the number of children born exposed to alcohol and other drugs is high.

• 4.5 million (7.7 percent) of the women of childbearing age in the U.S. have used an illicit drug in the past month, including 601,000 cocaine users and 3.3 million who have used marijuana. Many more are heavy drinkers (NIDA, 1991).
• Childbearing-age women comprise the majority of women who use drugs (Yamaguchi & Kandel 1987).
• Women who use illicit drugs other than marijuana have a premarital pregnancy rate twice that of those who do not (Yamaguchi & Kandel 1987).
• The majority of women entering drug treatment programs have children (Deren 1986).

Research on a woman's consumption of alcohol and other drugs, once she knows she is pregnant, is inconclusive. Factors such as substance, age, socioeconomic status, and the presence of prenatal care may all affect consumption (Sarvela & Ford 1992; Poole 1992; Marques & McKnight 1991; Zambrana et al. 1991; Ihlen et al. 1990; Gilchrist, Gillmore, & Lohr 1990; Pletsch 1988; Johnson, McCarter, & Ferencz 1987; Eriksson, Steneroth, & Zetterstrom 1986; Day, Wagener, & Taylor 1985; Fried, Innes, & Barnes 1984). Serdula et al. (1991) found that, while the overall rate of women who drink during pregnancy declined during the mid-1980s, the rate among less-educated women or those under the age of 25 remained the same.

EFFECTS OF PRENATAL EXPOSURE TO ILLICIT DRUGS

This review is restricted to drugs with a relatively substantial body of research data: cocaine, opiates (primarily heroin and methadone), amphetamine and methamphetamine, phencyclidine hydrochloride (PCP), and marijuana.

Animal models have proved useful for the type of controlled experimental research impossible in humans for methodological and ethical reasons. Such studies have cast much light on issues such as placental transfer of drugs, fetal and intrauterine distribution, fetal drug metabolism, and pharmacological effects (Rudolph 1985) and can provide supporting evidence for clinical findings under experimental conditions (see, for example, Hutchings 1985).

Cocaine

Much of the current research on prenatal exposure to drugs focuses on cocaine. Despite this, the perinatal and developmental effects of such exposure remain topics of controversy.

One study has implicated prenatal exposure to cocaine in an increased risk of stillbirth (Handler et al. 1991). Cocaine's involvement in Sudden Infant Death Syndrome (SIDS), however, remains inconclusive, largely because of the difficulties in controlling for possible confounding factors (Bancalari 1991; Durand, Espinoza, & Nickerson 1990; Ward et al. 1990; Chasnoff et al. 1989c; Bauchner et al. 1988; Riley, Brodsky, & Porat 1988). Some studies have implied that cocaine may be implicated in irregular neonatal respiratory patterns that may be related to an elevated rate of SIDS (McCann & Lewis 1991; Sylvestri et al. 1991). Other studies question this finding (Zuckerman, Maynard, Cabral 1991; Kelley, Walsh, & Thompson 1991).

More generalized findings associate prenatal cocaine exposure to increased risks of

• preterm delivery (Feldman et al. 1992; Cohen, Green, & Crombleholme 1991; Chasnoff 1991; Handler et al. 1991; Spence et al. 1991; Mastrogiannis et al. 1990; Dixon 1989; Cherukuri et al. 1988; Finnegan 1988; Chasnoff, Burns, & Burns 1987; MacGregor et al. 1987)
• abruptio placentae, the premature detachment of a placenta (Cohen, Green, & Crombleholme 1991; Dombrowski et al. 1991; Handler et al. 1991; Mastrogiannis et al. 1990; Dixon 1989; Cherukuri et al. 1988; Chasnoff 1985; Acker et al. 1983)
• meconium staining (Meconium is a term used to describe the dark green mucilaginous material in the intestine of the full-term fetus.) (Mastrogiannis et al. 1990; Livesay et al. 1988)
• smaller-than-normal head size and low birthweight (Coles et al. 1992; Chasnoff et al. 1992; Cohen, Green, & Crombleholme 1991; Dombrowski et al. 1991; Kelley, Walsh & Thompson 1991; McCalla et al. 1991; Handler et al. 1991; Little & Snell 1991; Petitti & Coleman 1990; Burkett, Yasin, & Palow 1990; Fulroth, Phillips, & Durand 1989; Chasnoff et al. 1989a; Zuckerman et al. 1989; Dixon 1989; Cherukuri et al. 1988; Finnegan 1988; Chouteau, Namerow, & Leppert 1988; Livesay et al. 1988; LeBlanc et al. 1987; MacGregor et al. 1987; Oro & Dixon 1987)
• low scores on the Apgar, which assesses the condition of newborns (Spence et al. 1991; McCalla et al. 1991; Finnegan 1988)
• disorganized behavioral states in the prenate and neonate, which may reflect central nervous system damage (Coles et al. 1992; Magnano, Gardner, & Karmel 1992; Chasnoff et al. 1989; Dixon 1989; Hume et al. 1989; Chasnoff & Griffith 1989; Griffith 1988; Doberczak et al. 1988; Chasnoff, Burns, & Burns 1987)

One study implies that infants exposed to cocaine in utero may have an increased risk of motor dysfunction (Schneider & Chasnoff 1992). Some researchers suggest that prenatal cocaine exposure can increase the risk of intravenicular hemorrhages (Dixon & Bejar 1989). Others maintain that such hemorrhages do not affect cocaine-exposed neonates at rates differing from the general population (Sweidan et al. 1990). Questions also exist concerning the relationship of such hemorrhages to developmental outcomes (Vohr et al. 1992; Kosofsky 1991; Greenberg & Crnic 1988). Another study of the neurological implications of prenatal cocaine exposure did indicate that exposure may be related to Central Nervous System (CNS) abnormalities (Heier et al. 1991).

Fulroth, Phillips, and Durand (1989) indicated that some babies prenatally exposed to cocaine undergo withdrawal. However, a review of the research by Zuckerman (1991b) concluded that "a withdrawal symptom has not been identified and, therefore, at this time it is inaccurate to describe a cocaine-exposed newborn as crack addicted."

While some studies indicate that the effects of prenatal cocaine exposure (including suspected neurological abnormalities, low birthweight, and the consequences of withdrawal) normalize within the first year after birth (Doberczak et al. 1988; Black & Schuler n.d.), preliminary reports from one longitudinal study found that 30 to 40 percent of a sample of cocaine-exposed children had language development and attention problems through at least their fourth year of life (Griffith 1991, testimony).

The results of the studies summarized in this section are not entirely consistent. Some studies find effects that other studies do not (see, for example, Richardson & Day 1991). At least one study of Canadian social cocaine users found no effects on perinatal outcomes (Graham et al. 1992). Such discrepancies are often attributed to differences in samples, sample size, and the purity and dosage of drugs used by subjects.

A recent commentary in the Journal of the American Medical Association concluded that "available evidence from the newborn period is far too slim and fragmented to allow any clear predictions about the effects of intrauterine exposure to cocaine on the course and outcome of child growth and development" and that "significantly, no prospective study of unique long-term consequences of intrauterine cocaine, nonopiate exposure has been published in the peer-review literature" (Mayes et al. 1992). A recent meta-analysis of research on prenatal cocaine exposure came to similar conclusions (Lutiger 1991).

Opiates

While the "crack epidemic" has drawn public attention away from other drugs, heroin remains a widespread social problem. Prenatal heroin exposure is associated with

• preterm delivery (Maas et al. 1990; Gregg, Davidson, & Weindling 1988; Finnegan 1988)
• miscarriages (Suffet & Brotman 1984)
• smaller-than-normal head size and low birthweight (Fulroth, Phillips, & Durand 1989; Zuckerman et al. 1989; Pasto et al. 1988; Householder et al. 1982; Stimmel et al. 1982)
• meconium staining (Pasto et al. 1988; Householder et al. 1982)

Some evidence associates heroin with an increased risk for SIDS (McCance-Katz 1991; Deren 1986; Householder et al. 1982).

The majority of babies born to women addicted to heroin (or on methadone maintenance) suffer from neonatal abstinence syndrome. (McCance-Katz 1991; Mas et al. 1990; Fulroth, Phillips, & Durand 1989; Rosen & Johnson 1985). This condition includes neurologic signs (hypertonia, tremors, sleep disturbances, seizures), autonomic nervous system dysfunctions, gastrointestinal abnormalities, and respiratory problems (Hoegerman & Schnoll 1991).

Some long-term studies indicate that children prenatally exposed to heroin suffer from below-average weight and length, adjustment problems, and psycholinguistic and other ability deficits through six years of age (and, in Olofsson et al. [1983] through age 10) (Deren 1986; Olofsson et al. 1983; Wilson et al. 1979).

However, as with much of the research on prenatal drug exposure, many of the cognitive and behavioral effects could result from confounding environmental influences. One review of the literature on opiates concluded that: "In general, [the infants of opiate-addicted women] have a number of behavioral disturbances early in life, but lasting cognitive-developmental differences between these children and controls have not regularly been found" (Strauss & Allred 1986).

Studies of prenatal methadone exposure report some association with initial developmental deficits. Researchers have not identified consistent long-term effects of prenatal methadone exposure and speculate that these effects largely depend on a combination of biologic and environmental factors (Rosen & Johnson 1985; Chasnoff 1985; Johnson, Rosen, & Glassman 1983).

Methadone maintenance programs result in improved birth outcomes for addicted women (Maas et al. 1990; Stimmel et al. 1982; Ramer & Lodge 1975). Such programs often include improved prenatal and medical care, as well as improved maternal nutrition, which suggests that some of the consequences of prenatal opiate exposure result from a lack of prenatal care and poor maternal health rather than represent a direct effect of the drug.

Amphetamines and Methamphetamines

Some of the research on the prenatal effects of amphetamines or methamphetamines demonstrates perinatal results similar to those found in studies of cocaine or heroin. However, most researchers express reservations concerning their inability to control for the effects of variables such as poor prenatal care or foster-care placement (Dixon 1989; Little, Snell, & Gilstrap 1988; Eriksson, Larsson, & Zetterstrom 1981; Billing et al. 1980).

In one study of eight year olds whose mothers had abused amphetamines during pregnancy, Eriksson et al. (1989) did not find any significant differences from children whose mothers had not used drugs, on measures of physical health (including growth), IQ, and performance on psychometric tests. This research team suggested that the differences found (including increased levels of aggression and problems relating to peers) may result from socioenvironmental factors. (See also Little, Snell, & Gilstrap 1988 for a report of no effects.) Thus, although some of the research indicates that prenatal exposure to amphetamines or methamphetamines may have some short-term consequences for the neonate, most of the research on this group of drugs remains inconclusive.

Phencyclidine Hydrochloride (PCP)

The research on prenatal exposure to PCP describes a number of consequences, including intrauterine growth retardation, preterm delivery, neonatal withdrawal, meconium staining, and poor consolability. Neurobehavioral symptoms associated with prenatal exposure to PCP include irritability, tremors, jitteriness, extreme sensitivity to stimuli, poor visual tracking, and hypertonicity (Tabor, Smith-Wallace, & Yonekura 1990; Howard, Kropenske, & Tyler 1986; Golden et al. 1984; Chasnoff et al. 1983; Strauss, Modanlou, & Bosu 1981). With one exception, these studies take the form of case reports with severely limited sample sizes (one to seven infants) and a lack of controls for other variables (most notably, the mother's heavy consumption of other substances).

Marijuana

Much of the research on the prenatal effects of marijuana has associated heavy use with the following:

• low birthweight (Zuckerman et al. 1989; Kline, Stein, & Hutzler 1987; Fried et al. 1987; Hatch & Bracken 1986)
• a shortened gestational period (Fried, Watkinson, & Willan 1984)
• meconium staining and complications in delivery (Greenland et al. 1982)
• neonatal neurobiological abnormalities (Lester & Dreher 1989; Fried 1985)

Differences between children of marijuana-using and nonusing mothers often disappear when demographic characteristics and other confounding factors are controlled for (O'Connell & Fried 1991; Linn et al. 1983; Gibson, Bayhurst, & Collry 1983). For example, Fried (1985) found no significant differences between matched marijuana-using and nonusing samples in terms of miscarriage rates, birth presentations, Apgar scores, and frequency of birth complications or major abnormalities. (See also Day et al. [1991] and Abel [1985] for lack of consequential effects.)

Fried and Watkinson (1990) reported that:

At 48 months, significantly lower scores in verbal and memory domains were associated with maternal marijuana use after adjusting for confounding variables. This negative relationship is the first reported association beyond the prenatal stage, and may represent a long-term effect of the drug upon complex behavior that, at a younger age, had not developed and/or could not be assessed.

Contradictory findings resulting from the research on prenatal exposure to marijuana may arise from an inability to control dosage and the purity (and strength) of the marijuana being used. (See, for example, the discussion of comparative results in Tennes et al. [1985]).

Mixed Samples of Illicit Drug Users

Studies of samples composed of a mix of users of cocaine, amphetamines, methamphetamines, and PCP tend to replicate the generalized findings of studies of individual drugs. Ward et al. (1990) suggested that abnormal sleeping ventilatory patterns in the infants of mothers who abuse alcohol and other drugs may increase the risk of SIDS. However, this study also confirmed the difficulties of eliminating the effects of confounding variables revealed in some of the drug-specific studies. Still, there are other studies that link prenatal substance exposure to respiratory difficulties (McCann & Lewis 1991).

Other adverse effects found in mixed samples include increased rates of low birthweight, small birth size, and signs of neurobehavioral disturbances (Dominquez et al. 1991; Van Baar et al. 1989; Gillogley et al. 1990; Kaye et al. 1989; Dixon & Bejar 1989; Fulroth, Phillips, & Durand 1989; Oro & Dixon 1987; Chasnoff 1985). Some of these studies also seem to substantiate the finding that most consequences of prenatal drug exposure resolve within a year (Van Baar, Fleury, & Ultee 1989; Chasnoff 1985), although some

indicated the possibility of longer-term language acquisition difficulties (Van Baar 1990; Rodning, Beckwith, & Howard 1989).

EFFECTS OF PRENATAL EXPOSURE TO ALCOHOL

Research implicates alcohol in a wide range of perinatal effects including:

• an increased risk of spontaneous abortion and stillbirth (Abel 1981)
• shorter gestation periods (Hingson et al. 1982)
• reduced birth size and weight (Autti-Ramo & Granstrom 1991)

Researchers normally divide the long-term effects of prenatal exposure to alcohol into two categories: (1) Fetal Alcohol Syndrome (FAS) and (2) Alcohol-Related Birth Defects (ARBD, sometimes called Fetal Alcohol Effects or FAE).

Fetal Alcohol Syndrome (FAS)

In 1973, K.L. Jones, D.W. Smith, and their colleagues realized that a substantial number of children affected by prenatal exposure to alcohol exhibited a characteristic set of facial abnormalities, growth deficiencies, and psychomotor disorders. They labelled this characteristic covariance Fetal Alcohol Syndrome (FAS) (Jones et al. 1973). Since that time, researchers have developed a number of competing diagnostic definitions for FAS (Weiner & Morse 1988; Burd & Martsolf 1989; Clarren & Smith 1978). The Fetal Alcohol Study Group of the Research Society on Alcoholism (Rosett 1980) requires the presence of signs in each of three categories:

• prenatal and/or postnatal growth retardation (weight, length, and/or head circumference below the tenth percentile corrected for gestational age)
• central nervous system involvement (indications of neurological abnormality, developmental delay, or intellectual impairment)
• facial abnormalities (with at least two of the following signs: head circumference below the third percentile; narrow eye slits; flat and long upper lip; underdeveloped midface; and flattened nose bridge)

The FAS facial features described above create a characteristic look that has been described by other researchers as well (Russell 1991; Jessup & Green 1987; Nelson et al. 1990; Umbreit & Ostrow 1980; Overholser 1990; US DHHS 1990; McCance-Katz 1991). While these facial anomalies appear less pronounced over time, deficits and impairments in the other categories do not. Victims of FAS never catch up in size or cognitive ability to their nonaffected peers (Streissguth et al. 1991b; US DHHS 1990; Jessup & Green 1987; Streissguth, Clarren, & Jones 1985; Rosett & Weiner 1984; Iosub et al. 1981; Streissguth, Herman, & Smith 1978a,b; Hanson, Jones, & Smith 1976).

Other physical abnormalities associated with FAS include cardiovascular problems, cardiac murmurs, kidney troubles, respiratory dysfunction, hernias, shortened fingers, and profusion of facial hair (Burd & Martsolf 1989; Holzman 1983; Weiner & Morse 1988). Delayed motor development also characterizes many children with FAS and, in many cases, motor development never normalizes (Sparks 1984; Warren & Bast 1988). Physical abnormalities related to FAS can affect linguistic and cognitive development. Abnormal palates and other oral structures can cause articulation difficulties (Iosub et al. 1981). A significant proportion of children with FAS have impaired vision and/or hearing (Stromland 1987; Streissguth & Giunta 1988; Church & Gerkin 1988), which can affect learning ability.

Central Nervous System (CNS) disorders related to FAS include acute sensitivity to sound, irritability, little body activity, attention problems, and jitteriness (Pierog, Chandavasu, & Wexler 1977; Streissguth & Giunta 1988).

Cognitive impairments associated with FAS include deficits in the ability to use and comprehend language and process and store information (Becker, Warr-Leeper, & Leeper 1990). Streissguth, Herman, and Smith (1978a,b) found that children with FAS had IQ scores ranging from normal to severely mentally retarded, with a mean score of 65. These scores do not appear to improve over time (Streissguth, Randels, & Smith 1991). FAS may surpass Down syndrome and spina bifida as a leading cause of mental retardation (Abel & Sokol 1987; Abel & Sokol 1986a; CDC 1982; Clarren & Smith 1978; Jones & Smith 1973).

Research shows that FAS results from chronic maternal drinking (although not all women who drink heavily during their pregnancy produce children with FAS) (Weiner & Morse 1988; US DHHS 1987; Abel 1985; Streissguth & Martin 1983). The effects of

limited social drinking by pregnant women remain a subject of controversy (Autti-Ramo & Granstrom 1991; Russel 1991; Overholser 1990; Ernhart et al. 1989; Warren & Bast 1988; Jessup & Green 1987; Abel 1984; Lochry et al. 1982; Edwards 1979).

Alcohol-Related Birth Defects (ARBD)/Fetal Alcohol Effects (FAE)

Researchers have estimated that, among the children prenatally exposed to alcohol, the number suffering potentially severe developmental effects without diagnostic signs of FAS is twice the number of those with FAS indicators (Streissguth & Giunta 1988; Weiner & Morse 1988). These effects include alcohol-related physical features (alcohol dysmorphia), growth retardation, and various cognitive deficits (Coles et al. 1991) and may represent the effects of lower levels of alcohol consumption by the mother, different usage patterns, the influence of confounding factors, and/or genetic differences in susceptibility.

Failure to take account of FAE underestimates the dangers of alcohol use for pregnant women and their children. Barr et al. (1990) found that prenatal exposure to alcohol affected fine and gross motor performance at four years of age. The same research team discovered that social and binge drinking "predicts a pattern of neurobehavioral deficit that includes attention and memory deficits . . . a variety of 'process' variables reflecting poor integration and quality of responses; behavior patterns involving distractibility and poor organization; and an inflexible approach to problem solving (Streissguth et al. 1989 a,b; See also Sampson et al. 1989). This research also revealed that consumption of an average of two drinks a day by pregnant women was related to a seven-point decrease in IQ at age seven. However, they noted that environmental factors were associated with outcomes and "these patterns should not be interpreted as biologic thresholds" (Streissguth, Barr, & Sampson 1990).

PRETERM AND SMALL-FOR-GESTATIONAL-AGE (SGA) BIRTH

The research shows that:

Low birthweight is the most frequent and clearly documented adverse outcome associated with gestational exposure to narcotics and other toxic addictive substances including nicotine, alcohol, marijuana, and cocaine. While decreased birthweight can be attributed primarily to impaired fetal growth, an increased occurrence of premature birth, as reported with maternal use of heroin and cocaine, may also play a role (Lifschitz & Wilson 1991).

If prenatal exposure to alcohol or other drugs elevates the risk of preterm or small-for-gestational-age (SGA) birth, then it also elevates any consequent perinatal or developmental risks.

Risk Factors for Preterm and SGA Birth

Many factors in addition to drug and alcohol consumption contribute to an elevated risk of preterm and SGA births. These include stress, low weight, age, inadequate prenatal care, hypertension, poor nutrition, and smoking (National Commission to Prevent Infant Mortality 1990; Hughes et al. 1988; National Center for Health Statistics 1988; Samuels 1986). Except in extreme cases (such as chronic malnutrition), the interaction and complexity of these risk factors makes it difficult to identify an individual cause for specific cases of preterm or SGA birth (Cassady & Strange 1987; Holmes, Nagy Reich, & Pasternack 1984).

The 1980s saw an increase in the risk factors that contribute to preterm and SGA birth. The percentage of women who received no prenatal care increased by half. The number of infants born to unmarried women rose by 40 percent (National Commission to Prevent Infant Mortality 1990). The National Commission to Prevent Infant Mortality concluded that the concentration of extreme poverty, drug use, inadequate health care, and other factors have turned some communities into "infant mortality disaster areas" (National Commission to Prevent Infant Mortality 1990).

Prenatal care can reduce the risks of preterm or SGA birth even in the presence of these risk factors (Hughes et al. 1988). As Margaret Boone (1989) wrote in her study of infant mortality and morbidity in America: "Prenatal care emerges as a critical element. . . . The inner-city women who obtain care clearly have infants with higher birthweight than women who do not get care, regardless of any other characteristics."

Evidence also exists that improved prenatal and neonatal care can alleviate many of the effects of prenatal drug or alcohol exposure (Broekhuizen, Utrie, & Van Mullem 1992; Feldman et al. 1992; Randall 1991; Greene et al. 1991; Griesbach & Polloway 1990; MacGregor et al. 1989; Finnegan 1988; Bingol et al. 1987; Fitzsimmons et al. 1986; Suffet & Brotman 1984; Rosner, Keith, & Chasnoff 1982). However, women who abuse drugs and alcohol tend to receive less prenatal care than others (Abma & Mott 1991; McCalla et al. 1991; Kelley, Walsh, & Thompson 1991; Burkett, Yasin, & Palow 1990; Matera et al. 1990; Dixon 1989; Keith, MacGregor, & Sciarra 1988; Cherukuri et al. 1988).

Perinatal and Long-Term Risks Associated with Preterm and SGA Birth

Infants born too soon or too small can face serious and fatal threats, including elevated risks of Respiratory Distress Syndrome, intrauterine hypoxia, birth asphyxia, perinatal infections, and Sudden Infant Death Syndrome. Low-birthweight infants die in the neonatal period at a rate 40 times that of other infants and represent two-thirds of all neonatal deaths in the United States (Samuels 1986; also see Overpeck, Hoffman, & Prager, [1992]). Other perinatal risks associated with preterm and SGA birth include nutritional disturbances, intraventricular hemorrhaging, and meconium staining (Werthmann 1981). All of these risks have also been attributed to prenatal drug or alcohol exposure and demonstrate the difficulty of determining the precise causal linkages between prenatal risk factors and postnatal status.

Some evidence exists that preterm and SGA birth (especially in cases of very low birthweight) can result in subtle cognitive and language acquisition delays and impairments and differences in IQ (Hack et al. 1991; Largo et al. 1986; Aylward et al. 1989; Wilson 1985; Cohen & Parmelee 1983; Hunt 1981). Whether these differences mean anything in terms of a child's actual linguistic and cognitive abilities remains unclear. Some studies indicate that preterm and very SGA birth can have consequences throughout childhood (Smedler et al. 1992; McCormick et al. 1992; Menyuk et al. 1991; Hoy et al. 1992; Seidman et al. 1992; Lagerstrom et al. 1991a; Lagerstrom et al. 1991b; Ross, Lipper, & Auld 1991; Lagerstrom et al. 1991c; Hack et al. 1991; Saigal et al. 1991). Most studies agree that preterm and SGA birth have little, if any, long-term effects on intelligence, language skills, or temperament (Casiro, et al. 1991; Ludman et al. 1987; Wilson 1985; Greenberg & Crnic 1988; Menyuk et al. 1991; Watt 1987; Riese 1988; Oberklaid, Prior, Sanson 1986). Sameroff (1981) concluded that:

The single most potent factor influencing developmental outcome turns out to be the cultural environment of the child, as expressed in socioeconomic status and parental education level. . . . In all the studies there was a significant overlap between the outcomes for the preterm groups and the control groups. No single factor, either birthweight alone or accompanying physical problems, clearly predicted a specific developmental outcome.

Another review stated that "the major biological markers of prematurity made little direct contribution in predicting their later developmental status" (Greenberg & Crnic 1988). The fact that early postnatal intervention can make major differences in the developmental outcomes of preterm and SGA infants (Brooks-Gunn, Liaw, & Klebanov 1992; Infant Health and Development Program 1990; Achenbach et al. 1990) provides additional evidence for the strength of environmental, rather than biologic, factors.

Social factors can predict the long-term developmental performance of preterm and SGA children better than biologic indicators (Carter et al. 1992; Cohen et al. 1986; Cohen & Parmelee 1983). The poor suffer the consequences of vulnerable birth status more than those of higher income. The developmental deficits that normalize by school age in most children tend to persist longer in those from low-income families (Largo et al. 1986; Wilson 1985). Beckwith (1984) found that the developmental scores of preterm children born to middle-class families and families of higher socioeconomic status improved as the child progressed to school age, while those of lower socioeconomic status children actually declined. This decline may be associated with biologic risks in the infant's postnatal environment, such as inadequate nutrition, lead poisoning, and lack of access to health care. However, the research also shows that preterm or SGA birth itself affects an infant's relationship with its parents in ways that have developmental consequences.

Preterm and SGA Birth and Parent-Child Interaction

Beckwith (1984) identified three elements essential for normal infant development:

• verbal interaction
• mutual visual regard
• parents' rapid response to the infant's indication of stress

A lack of such stimulation and interaction can have profound consequences for cognitive and linguistic development (Holmes, Nagy Reich, & Pasternack 1984; Cohen, Beckwith, & Parmelee 1978; Rocissano & Yatchmink 1983). Infants behave in ways that stimulate caretakers to pick them up, cuddle them, and provide verbal interaction, mutual visual regard, and response to stress. But babies born preterm, SGA, or with the neonatal abstinence syndrome often undergo extensive stays in hospital neonatal intensive care units and cannot interact easily with their caregivers (Mundal et al. 1991).

The high-risk infant is forced to spend his initial weeks or months in an environment that is not only overstimulating, but disorganized. It is an environment characterized by few contingencies between the behavior of the infant and environmental response. . . . There are many reasons to believe that such an environment is far from optimal for infant development and may be responsible for some of the behavioral deficits observed in these children (Holmes, Nagy Reich, & Pasternack 1984).

Like many of the other factors that can delay neonatal development, the effects on the infant of a stay in a neonatal intensive care unit seem to dissipate after six months. However, the effects of this experience on parents seem longer-lived. Spungen and Farran (1986) concluded that a stay by a preterm infant in a neonatal intensive care unit "was more pervasive on parents' perceptions of their infants" than on the infants themselves. Seeing a very small and fragile-looking infant hooked to a maze of wires and tubes in an incubator may frighten parents. They resist emotional involvement with a child who they believe may suffer some irreparable damage. Their perception of the child's fragile condition may result in a reluctance to pick up the infant unless absolutely necessary (Holmes, Nagy Reich, & Pasternack 1984).

Preterm babies sleep more than fullterm babies. This allows them to complete some of the development that should have taken place in the womb. However, while asleep they do not demand the attention and interaction necessary for normal development (Holmes, Nagy Reich, & Pasternack 1984).

Having a preterm or SGA infant places a great deal of stress upon parents, especially mothers. They need higher levels of formal and informal support than other parents (Affeckt 1986). The presence or absence of this support can have critical consequences for parental interaction and child development.

Crnic, Greenberg, and Slough (1986) found that "early stress was associated with less positive maternal attitudes and mother-infant interactive behavior, as well as less secure infant attachment to the mother." They also found that "intimate support provided by the mother's spouse or partner was the most powerful predictor with the greatest breadth of effect across both mother and infant functioning" and that professional support has profound consequences for parenting and infant development.

Mothers of preterm and SGA infants often receive increased levels of support from husbands, relatives, friends, and medical professionals. However, single, poor women often lack such a support system (Beckman et al. 1986). Thus, the same group of women faces both an elevated risk of giving birth to a preterm or SGA infant and an increased chance that postnatal factors will compromise the child's long-term developmental status. Research indicates that the presence or absence of such support can be critical for family-child relations and child health outcomes (Saylor, Lippa, & Lee 1991).

CONCLUSION

While precise data is lacking, it appears that a fairly substantial number of women use alcohol and other drugs during their pregnancies. Many of these women face additional biologic risks to the health of their babies because of inadequate prenatal care and other risk factors associated with poverty and chronic abuse of alcohol and other drugs.

Methodological challenges make it difficult to investigate the consequences of prenatal drug and alcohol exposure. The research has demonstrated that:

• The use of alcohol during pregnancy can lead to Fetal Alcohol Syndrome (FAS) and other permanent physical and cognitive defects.
• Heroin, and possibly other illicit drugs, can result in the neonatal abstinence syndrome. While the long-term effects of this condition remain uncertain, it places substantial stress on both the infant and parents and requires extensive and expensive medical care.
• Prenatal exposure to alcohol or other drugs may contribute to a risk of other adverse perinatal outcomes and developmental delays. The extent of this contribution and the duration of these delays remain uncertain.
• Prenatal exposure to alcohol or other drugs can contribute to preterm and small-for-gestational-age (SGA) birth. Other factors that elevate the risk of preterm and SGA birth tend to concentrate in those sociodemographic groups that also have an elevated risk of prenatal drug and alcohol exposure.
• Preterm and SGA birth associated with, or independent of, prenatal drug or alcohol exposure can have developmental consequences. Socioeconomic factors, and especially the extent of prenatal care, predict the extent of these consequences far better than biologic birth status.

The risks to infant development do not end with the neonatal period. As Chasnoff et al. (1992) wrote:

The long-term effects which will be found within the general population of drug-exposed children will not be explained by drug exposure alone. Before we can predict the developmental outcomes for these high-risk children we need further research into the additive and interactive effects of the multiple risk factors to which they are exposed, including in many cases the global effects of poverty, multigenerational substance abuse, and the impact of growing up in a drug-seeking environment.

The next chapter of this monograph will explore these multiple risk factors and their effects on child development.

CHAPTER 2:

ENVIRONMENTAL RISKS AND IMPLICATIONS FOR DEVELOPMENT

As seen in the previous chapter, research evidence on the developmental effects of prenatal drug exposure is sparse, but recent evidence indicates that drug-exposed children are generally not as impaired as early reports had predicted. Drug exposure is only one of many factors that may negatively affect a child's development.

Researchers and scholars have been steadily moving toward an ecological approach to understanding the complex factors that contribute to child development (Belsky 1980; Bronfenbrenner 1979; Gabarino 1990; Kaltenbach & Finnegan 1984; Sameroff & Chandler 1975; Sameroff & Fiese 1990). The complex interaction of individual, family, environment, and community is most evident when one attempts to understand the dynamics of alcohol and other drug abuse, particularly as they affect children.

Researchers widely recognize that, as Dr. Barry Zuckerman states, "The outcome of children of heavy drug-using parents is due to the dynamic interaction of the child and the social environment" (Zuckerman 1991a). Practitioners, too, are keenly aware of the environment and its influence on children's development. "Parents in prison, inadequate health care and parenting skills, abuse and neglect, and multiple foster placements are among the many environmental factors that children encounter. How can we possibly say that these children's behaviors are a direct result of the prenatal drug exposure?" asks Carol Cole, former teacher in the PED (Children Prenatally Exposed to Drugs) Program in Los Angeles.

To fully understand the effects of exposure to drugs on children, it is essential to examine the environmental factors present in at-risk communities. Below is a review of literature that addresses the nature of the caregiving environment in families in which alcohol and other drugs are abused, the effects of foster care, and the known developmental consequences of child abuse and neglect.

CHILDREN, POVERTY, AND VIOLENCE

More children live in poverty than ever before. Between 1979 and 1989, the number of poor children under age six increased by 46 percent, even though the total population of six year olds remained relatively stable. The picture is even bleaker for children of color. Half of all black children under six and 40 percent of all Hispanic children under six are poor. Thirty percent of children in central cities are poor. Of these, 61 percent live in areas of concentrated poverty (National Center for Children in Poverty 1991).

It is in the poor, inner-city communities that much of the client base exists for the programs that currently report new and troubling behaviors among their children. But even more disruptive are two interrelated environmental stresses to which children growing up in at-risk neighborhoods are exposed: drug trafficking and violence.

The relationship between violence and poverty has been thoroughly documented (Williams 1984; Centerwall 1984; Loftin & Hill 1974; Parker & Smith 1979; Wilson 1987). Urban areas, especially inner cities, tend to have much higher rates of interpersonal violence than do rural and suburban communities (American Psychological Association 1993). Areas that are both poor and urban are thus in double jeopardy.

Alcohol and other drugs play a major role in the levels of violence that exist in these communities. At least half of all the perpetrators and victims of homicides in America have been drinking, and a large percentage of violence occurs in places where alcohol is consumed (University of California/Centers for Disease Control 1985).

One consequence of drug use and drug traffic is the high rate of associated neighborhood crime (Gropper 1985). The National Institute on Drug Abuse estimates conservatively that at least 10 percent of homicides and assaults in the United States are drug related (Harwood et al. 1984). Other studies have demonstrated that violent crime and drug abuse tend to occur in the same neighborhoods; also, users of certain types of illicit drugs tend to be arrested for serious crimes against persons at a far greater rate than do persons who do not use those drugs (McBride et al. 1986). Sixty percent of those arrested in Washington D.C. in 1988 tested positive for cocaine and 40 percent for PCP (Molotsky 1988).

Because drugs such as heroin and cocaine are both illegal and valuable, their marketing involves considerable violence: violence among drug dealers over turf, violence between dealers and their customers over price and quality, violence between dealers and those who see them as robbery targets, and violence among drug users over drugs.

Effects of Violence on Children's Development

From an early age, children in at-risk neighborhoods witness violence and crime close to home. Living with the fear of violence in school, in neighborhoods, and at home takes its toll on the development of children, even if they have not been physically injured.

Dr. Barry Zuckerman describes the symptoms that may emerge in children who witness violence: "a diminished ability to concentrate in school because of intrusive thoughts and images; persistent sleep disturbances; disordered attachment behaviors with significant caretakers; nihilistic, fatalistic orientation to the future which leads to increased risk-taking behaviors" (Zuckerman 1991a).

While not enough research has been done on the extent to which preschool-aged children in inner-city neighborhoods are aware of this violence, anecdotal evidence and some studies have shown that it does not go unnoticed by older children. A study of fourth through sixth graders from low-income neighborhood schools in Washington D.C. revealed that almost 30 percent had witnessed at least one incidence of community violence. Almost 16 percent had witnessed shootings and over a quarter had witnessed gang violence. Forty percent of the parents said that their children had witnessed at least one violent episode (Hill 1991).

Twenty-four percent of 168 Baltimore adolescents visiting an inner-city clinic for routine medical care had witnessed a murder, 72 percent knew someone who had been shot, and all had been victims of violence (Zinmeister 1990). Ninety percent of children using the psychiatric clinic at the King/Drew Medical Clinic in South-Central Los Angeles have witnessed violence (Timnick 1989).

The available evidence indicates that such violence can take a toll upon the development, behavior, and emotional well-being of children who are exposed to it. Children in violence-infected neighborhoods have begun to display the symptoms of post-traumatic stress disorder, including depression, violent outbursts, difficulty concentrating, and reduced involvement in the outside world (Pynoos & Eth 1985; Kristal 1982; Landers 1990). Research has begun to document the effects of witnessing violence on child development, which include impaired cognition, memory and learning disorders, and poor school performance (Garbarino, Kostelny, & Dubrow 1991). These effects bear a striking resemblance to those often attributed to prenatal drug exposure.

FAMILIES IN WHICH ALCOHOL AND OTHER DRUGS ARE ABUSED: THE CAREGIVING ENVIRONMENT

Whether or not they live in at-risk communities, children who live in families abusing alcohol and other drugs are exposed to more immediate risks. The quality of the caregiving environment, reflected in family discord, stability, and status, has been related to children's development in study after study (Sameroff, Barocas, & Seiffer 1984; Goldstein & Tuma 1987). Emerging research on resiliency suggests that neither prenatal exposure to drugs nor poverty can, in itself, predict the developmental outcomes (Werner 1990; Johnson et al. 1990; Leif 1985). However, without support and intervention, the prospects for children from families in which alcohol and other drugs are abused are not promising.

Substance Abuse and the Ability to Fulfill Parental Roles

Many factors detract from the capacity of women abusing alcohol and other drugs to be the kind of mothers they want to be. Howard (1989) found that many women who abuse drugs and/or alcohol were themselves victims of physical, sexual, and emotional abuse as children. Among the 58 women Howard studied, 72 percent had been physically and/or sexually abused, 66 percent came from households where one or both parents used drugs, 55 percent had multiple caretakers while growing up, and over 74 percent experienced violent episodes during their lifetimes.

Substance abuse results in behaviors that are in conflict with secure and nurturing caregiving: social isolation; poor coping skills; and difficulty in managing finances, accessing community resources, making child-care arrangements, or pursuing vocational and educational activities (Leif 1985; Zuckerman 1991a; Pearlman et al. 1982; West & Dalton 1982). Some research has tied alcohol and drug abuse directly to an increased risk of child abuse and neglect (Wright et al 1991; Rose 1991).

Child-Rearing Challenges and Parents' Behaviors

The challenges begin even before the hospital stay is over. Faced with a "difficult baby" at birth, mothers may be upset by the child's high-pitched cries, restlessness, irritability, spitting up, and need for frequent feedings. Once home, children "often experience inconsistent parenting, with their mother behaving one way when she is high and another when she is straight" (Leif 1985). Parents may ignore an infant's signals for stimulation and nutrition, as they lack an understanding of children's needs for routines in daily life. As researchers from the Family Center at Jefferson Medical College note, "If a woman is using additional drugs [other than methadone] which have a soporific effect, she may neglect to feed her child on time, keep an infant dry and clean, and if, at the time, she is withdrawing, she may also be irritable and abusive" (Regan, Ehrlich, & Finnegan 1987).

Parents who abuse alcohol and other drugs may also lack practical skills such as reading a thermometer, administering medication, and preparing nutritious meals (Howard 1989; Leif 1985; Zuckerman 1991a, 1991b; Howard & Kropenske 1990; Fiks, Johnson, & Rosen 1985). They often have difficulty learning the importance of interacting with their child and are often unaware of the child's psychological needs. Their lack of understanding of child development can lead to unrealistic expectations. For example, they may interpret a toddler's eager exploration of the world as "misbehaving." These unrealistic expectations can generate rigid rules and a negative style of interrelating with their children (Bauman & Levine 1986).

The effects of poor childrearing skills can produce and/or amplify the types of developmental consequences associated with prenatal drug exposure (Sher et al. 1991; Kronstadt 1991; Johnson, Boney, & Brown 1990-1991; Burns & Clark 1991; Johnson & Rosen 1990; Howard 1989; Howard et al. 1989; Griffith 1988; Jeremy & Bernstein 1984; Bauman 1980; Leif 1985).

It is a mistake, however, to conclude that all mothers who use alcohol and other drugs uniformly provide inadequate care. As Leif reports, "The stereotyped image of the inadequate addict parent is not necessarily the true picture." With support, many mothers can retain custody, prove themselves capable of learning about developmental issues, and respond to the needs of the growing infant. Unfortunately, without the intensive support needed, many are unable to care for their own children.

FOSTER CARE

Many infants who are prenatally exposed to drugs never go home with their parents and are placed in the foster care system at birth. In a study of 10 hospitals, an estimated 1,200 of the 4,000 drug-exposed infants born in 1989 were placed in foster care (GAO 1990). Even if drug-exposed infants remain in the care of their families after birth, many enter the social services system later, because of the chaotic and often dangerous environment associated with parental drug abuse (GAO 1990).

There has been a dramatic rise in the number of foster care placements coinciding with the rise of crack cocaine use in the mid- and late-1980s. The estimated demand for foster care nationwide increased 29 percent between 1986 and 1989; however, the demand for placement for children under age 6 rose approximately 40 percent (GAO 1990). There have been regional reports that indicate increases in foster care placements by 80 to 235 percent since 1985 (State Interagency Task Force on Perinatal Substance Abuse 1991; Norris 1991).

Infants living with caretakers who abuse substances face a special set of vulnerabilities and risks. According to the U.S. House of Representatives Select Committee on Children, Youth and Families, "Increasing numbers of infants are being born drug-exposed, placing them at particular risk of the multiple problems that lead to out-of-home care" (Report of the Select Committee 1989). Families abusing alcohol and other drugs, whose children are placed in foster homes, are more likely than other families with children in foster care to include mothers with less education, to be poorly housed, and to receive Aid to Families with Dependent Children (AFDC) prior to placement (Walker, Zangrillo, & Smith 1991). Additionally, children from families in which alcohol and other drugs are abused are more likely to enter the foster-care system at a younger age than those placed from the general population. The median age of children placed in foster care because of parental drug abuse is 4.7 years, as compared to 7.5 years for other children (Walker, Zangrillo, & Smith 1991).

Children from homes in which substance abuse occurs may be at higher risk for multiple foster-care placements. These children often exhibit difficult and frustrating behaviors, requiring greater skills and caretaking on the part of foster parents. Long-term, single placements are uncommon for most children in foster care. However, children who have the constellation of behavioral problems frequently associated with families in which substance abuse occurs seem to be harder to place and at higher risk for multiple placements. Pamela Osnes, director of the Carousel Preschool Program in Tampa, Florida, described a child, two and a half years old, who had already been in 15 placements at the time of entry into an early intervention program. While this specific case may be extreme, another practitioner, Carol Cole, reported that children in the PED Program in Los Angeles average five or six foster care placements before they are school age.

Consequently, infants from families in which alcohol or other drugs are abused can represent a special challenge to the foster-care system. According to a recent report by the National Black Child Development Institute (Walker, Zangrillo, & Smith 1991), our nation's child welfare system is inadequate and is not effectively "coping with the problems and magnitude of maternal drug-related cases coming into the system. This is illustrated by low discharge rates, low rates of reunification with biological parents, low rates of adoption, infrequent parent-child and parent-caseworker visiting, and inadequate services essential for reunification." It is interesting to note, however, that one study comparing adoption outcomes found that parents adopting drug-exposed children were just as satisfied with their children as were parents adopting children who had not been exposed in utero (Barth 1991b). This suggests that parent characteristics may have a greater effect upon parent-child relations and child behavior than drug exposure.

The need for family services is especially important when one considers that a fairly high proportion of children are returned to foster-care placements after reunification with their biological parent(s); 32 percent of children previously placed in foster care reenter the social services system, as compared to only 2 percent of children who are adopted (Stein 1987). Research has shown that reunification is twice as likely for parents who do not use drugs as compared to parents who do (Walker, Zangrillo, & Smith 1991). The probability of reunification also decreases over time (Goerge 1990; Fanshel & Shinn 1978). "On discharge indicators [discharge from the foster-care system], it was the children of drug-abusing parents who fared worse. These cases showed (1) fewer discharges overall; (2) much less frequent reunification with the biological parent; (3) more adoptions, but so few as to be insignificant; and (4) in New York, earlier returns to care after discharge . . . half returned within four months" (Walker, Zangrillo, & Smith 1991).

Overall, children from families in which alcohol and other drugs are abused are at especially high risk for placement in an alternate care setting (Kelley 1992; Regan, Ehrlich, & Finnegan 1987). The overwhelming proportion of children in foster care are there because the courts have judged them to be abused or neglected. Child abuse and neglect also intersect with the other risk factors described: prenatal exposure to drugs and alcohol, premature birth, inadequate parenting skills, and foster care. And like these other risk factors, abuse and neglect can also play a critical role in how children develop and behave.

CHILD ABUSE AND NEGLECT

Between 1984 and 1989, there was a 3,000 percent increase in the number of drug-related abuse/neglect petitions in the U.S. juvenile courts. Today, 22 states report that chemical dependency is now a dominant factor in child protective custody cases (Longino 1991).

For society as a whole, reports of child abuse and neglect have been rising at an alarming rate for the past five years. In 1989, there were 2.4 million reports of child abuse and neglect throughout the United States (National Committee on the Prevention of Child Abuse 1990). This represents a 30 percent increase over reports made in 1986 (USDHHS 1988). According to the Study of National Incidence and Prevalence of Child Abuse and Neglect, an estimated 1.5 million children were maltreated in 1986. Of these, 63 percent (or about 1,003,600 children) were neglected and 43 percent (or about 675,000 children) were abused (USDHHS 1988). Below, the variety of risk factors that contribute to the maltreatment of children is explored. This is followed by a section summarizing the results of prospective, longitudinal research that has examined the learning and behavioral consequences of abuse and neglect on young children.

Family and Maternal Risk Factors

Researchers' understanding of child maltreatment has moved away from a belief in a single cause toward a conceptual framework that takes into account the ongoing interaction between the individual characteristics of parents and children, the psychosocial environment of the family, and the stresses or support for families within the broader community and society-at-large (Bronfenbrenner 1979; Belsky 1980; Cicchetti & Rizley 1981). The previous section examined some of the powerful stresses that exist in at-risk urban communities and their contributions to psychosocial and later learning problems experienced by children who live in them. Below, additional risk factors for families, mothers, and children that can increase the danger of child abuse and/or neglect are explored.

Publicity concerning the tragic death of Lisa Steinberg in New York in 1987 and the trial of her father, an attorney, have helped to dispel some of the myths held about child abuse. This case and others like it illustrate that abuse does not occur only in families that live in poverty. While anyone is potentially a child abuser, the dynamics of poverty place an enormous strain on families, so that even the healthiest of individuals may be affected. As Zigler and Hall (1989) state, "No longer do we believe that being poor `causes' child abuse. Rather, the scant educational, economic, and social network resources that so often accompany being poor in America are the variables that contribute to an increased likelihood of abuse." The impact of poverty on a family's ability to cope is illustrated by statistics from the National Center for Children in Poverty (NCCP). NCCP reports that abuse is seven times greater in families with incomes below $15,000 than in those with higher incomes (Levine 1990).

Unemployment has long been associated with child abuse and spouse abuse (Galdston 1965; Gelles 1973; Gil 1970; Light 1973; Steinmetz & Straus 1974; Gabarino & Crouter 1978). In addition to the material deprivation that unemployment can cause, some have postulated that it also contributes to feelings of low self-esteem, frustration, and isolation. Bugental, Mantyla, and Lewis (1989) suggest that these effects on the family can be significantly amplified by a lack of social supports.

Moreover, families in which child abuse occurs often have violent or conflict-ridden relationships (Burgess & Conger 1978; Lahey et al. 1984; Lorber, Felton, & Reid 1984; Straus 1980). As discussed earlier in this section, parents who abuse alcohol and other drugs are more apt than others to witness and be involved in violent acts within and outside of the home. Children in homes where substances are abused are likewise at higher risk for witnessing or experiencing violence (Bandura 1973).

The psychosocial functioning of the parent can affect that parent's ability to provide a nurturing and safe environment for children. Mental illness, such as chronic depression, can make it difficult for parents to sustain meaningful interaction with their children. Depressed parents may be emotionally distant and unavailable to their children and unsuccessful in controlling their children's behavior (Orroschel, Weissman, & Kidd 1980; Weissman & Paykel 1974; Regan, Ehrlich, & Finnegan 1987). Such parental attributes are correlated with an elevated risk of child neglect or abuse.

A number of factors render a child at an elevated risk for abuse, especially when parents are subject to other stresses and lack social support. Preterm babies can be difficult to comfort, have a high-pitched cry, and appear unresponsive to parents (Egeland & Brunnquell 1979; Frodi et al. 1978; Parke & Collmer 1975; Vietze, O'Connor, & Altmeier 1982). Parents often must learn to modify the stimulation they provide to help the infants make gains (Field 1983; Als et al. 1986).

Children with disabilities (cognitive and physical) and those with behaviors that are difficult to manage have also been considered to be at elevated risk for child abuse (Terr 1970; Kempe 1971; Morse, Sahler, & Friedman 1970; Baldwin & Oliver 1975; Johnson & Morse 1968; Herrenkohl & Herrenkohl 1979, 1981; Herrenkohl, Herrenkohl, & Egolf 1983).

While there is no question that some children are more difficult to raise than others, reviews of the literature call into question the direct relationship between specific child characteristics and maltreatment (Starr et al. 1984; Brachfield, Goldberg, & Sloman 1980; Sameroff & Chandler 1975). "These reviews and observational studies are in agreement in noting the power of parental responsiveness and the caretaking milieu in overcoming early developmental difficulties as well as the inability to predict that these children will be maltreated simply on the basis of their own characteristics or behavior" (Pianta, Egeland, & Erickson 1989).

Developmental Consequences of Child Maltreatment

Research has clearly documented that the harmful consequences of child maltreatment persist through early childhood into adolescence and adulthood (Erickson, Egeland, & Pianta 1989; Bruner, Cole, & Lloyd). In recent years, investigators have adopted both clearer definitions of abuses and, with a developmental perspective, have begun to examine the specific developmental and learning sequelae of child maltreatment.

Clinical observations and prospective studies shed the most light on the variability of children's responses to maltreatment. Among these is the Minnesota Mother-Child Interaction Project. Instituted at the University of Minnesota in 1975, the project was specifically designed to develop an integrative model for examining the antecedents of child maltreatment (Pianta, Egeland, & Erickson 1989). Minnesota researchers have conducted longitudinal, prospective studies that have begun to isolate the varied effects of different types of maltreatment over the course of a child's development from infancy to early school years. Their findings are highlighted below.

Physically Abused Children

Pianta, Egeland, and Erickson's (1989) longitudinal study indicated no significant differences between children who were physically abused and non-abused children until the age of 18 months. At this time infants who were abused began to display signs of insecure attachment that were higher than normal. By two years of age, abused children were angry and frustrated and could be described as noncompliant. Their overall scores on the Bayley Scales of Infant Development were lower than those of their non-maltreated peers. Over the preschool years, researchers noted increasing negative affect among the abused children, finding also that these children lacked control and exhibited little creativity in problem solving.

By kindergarten, they scored lower on the Wechsler Preschool and Primary Scale of Intelligence (WPPSI) (vocabulary, comprehension, and block design) and were more impulsive, creating classroom disturbances. Their teachers described them as extremely inattentive, unpopular, and aggressive. It is interesting to note that the Minnesota longitudinal study found many of the same results for children who experienced hostile verbal abuse as for those who were physically abused.

Crittenden (1989) hypothesizes that abusive parents have high achievement expectations for their children and tend to view relationships in terms of control and coercion. Children can react differently to high and often unrealistic parental demands, with the abuse resulting from "non-compliance." Some children anticipate parental demands and become high achievers to avoid abuse. Others become defiant, taking no responsibility for their own or their parents' behavior. Children who become the focus of concern are usually those who respond by being non-compliant and hypervigilant about their relationships with other adults such as preschool and primary school teachers.

Sexually Abused Children

Sexual abuse—whether one incident or repeated incidents over time—requires children to make social, psychological, and cognitive adjustments in order to survive. How these adjustments are made has a lasting effect on development (Hartman & Burgess 1989). Sexually abused children may manifest symptoms of the abuse in several different ways. Physical responses to sexual abuse in children may include headaches, stomachaches, changes in appetite, and urinary tract infections. Psychologically, sexually abused children may be unable to concentrate and appear preoccupied, depressed, and less involved or less interested in activities. They may also be anxious around strangers and more anxious or angry in general. Behaviorally, children may respond to sexual abuse by acting out sexually, becoming clingy or withdrawn, or being hyperactive. The emergence of phobias or fears may be especially notable (Tufts-New England Medical Center 1984).

Sexual abuse also has implications for children's behavior in the classroom. Research has indicated that sexually abused children often have a poorer comprehension of daily school tasks, cause more classroom disturbances, and are generally less involved in classroom activities. Sexually abused children are also more likely to make irrelevant responses in class, be less attentive, and appear more nervous and anxious.

Teachers have rated these children as having a strong need for approval, engaging in more help-seeking behaviors, and having poor overall social-emotional adjustment. Teachers have also described sexually abused children as impulsive and dependent, with behavior ranging from withdrawn to aggressive. In general, they are not well-liked by their peers (Erickson, Egeland, & Pianta 1989).

Neglected Children

Children who were neglected generally proceeded down a somewhat different path. By the age of nine months, they received significantly lower scores on the Bayley Scales of Infant Development and by one year of age, they showed signs of being anxiously attached to their mothers. At two these neglected children had poor coping strategies, lacked enthusiasm, were frustrated when presented with problem-solving tasks, and displayed anger and resistance. At three and one-half years of age, these children were characterized by researchers as having very poor impulse control and being inflexible in their approach to solving problems. When presented with a task, neglected children were very distractable and withdrew. Perhaps most striking is the report by observers that more than all other groups of maltreated children, neglected children appeared the "most unhappy." In preschool settings, neglected children between the ages of four and one-half and five were highly dependent on teachers and exhibited adjustment problems.

In kindergarten, they had difficulty understanding the day-to-day demands placed on them, and they had poor work habits. Teachers characterized them as anxious, withdrawn, unpopular, and inattentive. On the WPPSI, neglected children scored much lower on vocabulary and comprehension, and within the daily routine they had difficulty in acquiring reading skills.

Crittenden (1989) hypothesizes that the early lack of exposure to stimulus and response in the caretaking environment leads to a basic lack of understanding of cause and effect. Once neglected children can move about on their own, they are overactive in their exploration of the world. However, without adult supervision or facilitation, their explorations are disorganized, uncontrolled, and often dangerous. Later, as they enter school, neglected children can appear reckless, inattentive, and lacking in social competence. A disturbing characteristic ascribed to neglected children is that they treat others as objects—"pushing them out of the way as if they are chairs or grabbing toys from them as if they are shelves" (Crittenden 1989).

Erickson et al. (1989) report a teacher's description of a six-year-old victim of maltreatment:

Her school performance is extremely erratic. One day she does fine and the next day she can't seem to do anything. Then she usually becomes frustrated and ends up tearing up the work she did the day before. Her behavior is an enormous problem for everyone in the school. One minute she is sweet and loving, holding my hand, and the next minute she is screaming and throwing things. I have never seen such anger! She's a bomb ready to explode!

This behavioral description is a particularly striking example of the similarities between the behavior often ascribed to children who have been prenatally exposed to drugs and the behavioral characteristics of maltreated children.

CONCLUSION

There are many environmental risks that pose threats to healthy child development. These risks can act in combination with one another, as well as in combination with the perinatal risks described in the first chapter of this monograph, to produce a number of developmental deficits and other behavioral and cognitive problems that can threaten a child's development and educational success, as well as pose challenges to parents, other caregivers, and educators. Children with such attributes have begun appearing at increased rates in our nation's schools and preschools. At the same time, a number of programs designed specifically for drug-exposed children are making great strides in acknowledging the multiplicity of risk factors that come into play in the lives of these children. In addition, such programs seek to find strategies to improve the developmental and educational outcomes for at-risk children. These programs and the children they serve are the subject of the next chapter.

CHAPTER 3:

IMPLICATIONS FOR EDUCATION IN PRESCHOOL AND PRIMARY GRADES

The previous chapters of this monograph explored the biological and environmental risks that affect the lives of many children in the United States. The risks begin with the poor health and nutritional status of the mothers. If a mother has poor nutrition, consumes illicit drugs or tobacco, and/or receives inadequate or no prenatal care, her baby is far more likely to be born prematurely, be small for gestational age, and have perinatal complications. While these conditions can pose significant danger to the infant, targeted interventions during early childhood can help avoid adverse outcomes.

Maternal use of alcohol, on the other hand, can lead to permanent and lifelong problems including mental retardation, physical abnormalities, and visual and auditory impairments (Autti-Ramo & Granstrom 1991; USDHHS 1990; Jessup & Green 1987; Streissguth, Clarren, & Jones 1985; Rosett & Weiner 1984; Iosub et al. 1981; Streissguth et al. 1978; Hanson, Jones, & Smith 1976).

While the physiological effects of prenatal exposure to alcohol appear to differ from those of prenatal exposure to illicit drugs, children growing up in families that abuse alcohol or other drugs are often exposed to a number of environmental risks. By the time children enter preschool, the caregiving environment has had ample opportunity to affect their development. For some, the environment poses many hazards, including inadequate caregiving; multiple, short-term foster-care placements; and abuse and neglect. As described in the previous chapter, the consequences of such environmental stress on child development can be devastating.

Both the consequences of maternal substance abuse and the effects of the environment on children's development and learning must be understood in order to marshall effective resources for prevention and intervention. As Costella Tate, social worker for Project D.A.I.S.Y., in Washington D.C. comments, "Some of the identified children (prenatally exposed to drugs) had significant problems at birth due to a lack of oxygen, a byproduct of drug abuse. However, by age three, most of these children are not exhibiting serious problems. This is especially true if the mom and baby had access to formal or informal support systems."

Given the many and varied influences on children who are prenatally exposed to drugs, it is no wonder that such children exhibit a range of characteristics. The patterns of maternal drug abuse, a family's stability, the caretaking skills of the parents, access to quality health care and education, and the availability of social support all vary enormously. So then do the developmental profiles of children.

DIVERSE CHARACTERISTICS OF CHILDREN

The fact that there is no typical profile of drug-exposed children is unanimously confirmed by leading practitioners. Their collective experiences underscore the individual needs and strengths of the children they serve.

In an effort to obtain firsthand accounts of specific behaviors exhibited by children prenatally exposed to drugs, our investigators included interviews with program administrators and practitioners from:

• PED (Children Prenatally Exposed to Drugs) Program in Los Angeles, California
• Operation PAR (Parental Awareness and Responsibility) in Largo, Florida
• Project D.A.I.S.Y. (Developing Appropriate Intervention Strategies for the Young Child) in Washington, D.C.
• Carousel Preschool Program in Tampa, Florida
• Parent-Child Intervention Program in East Palo Alto, California
• Hillsborough County Training Program in Tampa, Florida

They confirmed that the infants and young children in their programs display a range and variety of behaviors. Their clinical impressions are based on observations. While these reports are of children who have been (or are suspected of being) prenatally exposed to drugs, these experts stressed that the behavioral characteristics they observe are not necessarily the consequence of prenatal drug exposure. As Vicky Ferrara, a teacher in the PED Program, states, "once we have examined the histories of children, it is difficult to look at their behavior as specifically due to prenatal drug exposure."

Because practitioners do not see a specific constellation of behaviors and learning problems associated with drug-exposed children, they were asked to identify behavioral or developmental problems that most concern teachers working with an at-risk population. While their responses varied, three themes emerged.

Disorganization

Some children appear to have no framework by which to organize themselves or their environment. This disorganization is manifested in many ways. Some children move from object to object and place to place having great difficulty in completing age-appropriate tasks. While this affects their ability to manipulate materials and learn in solitary play, it can also affect their ability to participate in group activities. For example, a child participating with the teacher in a small group activity may be easily distracted by other materials or drawings on the wall. Once distracted by other items in the room, the child's attention is lost. This short attention span, coupled with a high level of activity, can create classroom disruptions that make it difficult for other children to play and learn. As a result, other children who are also disorganized are easily distracted and, once interrupted, have difficulty returning to the activity at hand.

Difficulty coping with change or transitions in the environment is viewed by some as another manifestation of the disorganization that some children experience. Children can be very fearful when encountering a new situation. Costella Tate from Project D.A.I.S.Y. illustrated this point by recounting a recent class field trip. Even with preparation, children became afraid of the subway and what might happen to them in this situation. What might have been an enjoyable excursion for many children became a frightening experience for these children at risk.

Changes in the staff of a preschool program present another type of transition. Some children will be very upset and cry if they come into the room and see that they have a substitute teacher for the day. The predictability of the daily schedule and the consistency of staff in the program are critical strategies that limit changes and help children organize their environment. Children who have difficulty coping with change need multiple cues to facilitate their moving from one activity to another.

Practitioners offer a variety of explanations for the levels of disorganization that they observe in some children. Some practitioners attribute the disorganization to a lack of early stimulation at home. Children who attend their programs have little or no exposure to the kinds of materials and equipment available in a typical preschool. Others emphasize the lack of adult-child interaction that helps children explore their environment systematically and develop a basic understanding of cause and effect. Some suspect that the disorganization they observe in some children is a consequence of neurological damage resulting from prenatal exposure to alcohol or other drugs.

Language Delays

Practitioners also report a range of language and speech delays, including language- processing problems, poor articulation, limited vocabulary, and limited expressive language skills. Some children do not understand simple questions such as, "Are you hungry?" Even at five years old, they are unable to follow two-steps commands. Another characteristic of children's language-processing problems is their inability to understand the real meaning of words and to generalize these "symbols of experience" to new but similar situations. Carol Cole offers a typical example, "If you tell a child not to go out into the street, he or she does not understand that you mean all streets."

Many practitioners identified poor articulation as a common problem, which makes children's communication attempts unintelligible to both teachers and peers. Superintendent Dr. Charlie Knight reported that children from the Parent-Child Intervention Program (PCIP) in East Palo Alto could not enunciate the word "potty" well enough to make themselves understood, and as a result had frequent toileting accidents.

Children's lack of vocabulary and limited abilities to express themselves are also related to some of the aggressive and disruptive behaviors reported. Children with limited language find themselves unable to engage in imaginative play. Taking on a role and acting it out are crucial to developing more advanced forms of play. Moreover, the frustration that children can feel when they are unable to make their needs known can lead to a variety of aggressive acts. Anyone who has taught in a preschool knows the importance of a child's being able to say "I was playing with that!" When the child cannot, grabbing is usually the next best strategy. Costella Tate from Project D.A.I.S.Y. provides the following vignette:

One little girl in the program was very distant with the teachers in the classroom. She was aggressive with other children and would strike out and hit them. As we worked with her, especially on her expressive language skills, her behavior started to improve. She was finally able to express her needs and feelings. It is hard to know exactly why she had no communication skills. Perhaps it was related to her exposure to drugs prenatally. Maybe it was the physical abuse she experienced as a baby.

Program staff repeatedly mentioned their concern about the caregiving environment as a factor contributing to children's language problems. "The lack of positive verbal interactions between parents and children along with the amount of TV that many children watch at home, all can affect a child's ability to communicate," said Linda Delapenha, diagnostic supervisor in the Hillsborough County Public Schools.

Insecure Attachments

Practitioners frequently refer to children's history of poor attachment to their caregivers. The PED Program reports that many children have five or six foster care or out-of-home placements by the age of three. Even if there are fewer placements, frequently they are unstable. In describing the foster-care system in California, Carol Cole explained that homes are often licensed for certain age groups only, so that as children mature, their foster placement changes. She states that "many children move for this reason. Others are waiting for decisions about reunification with their biological families. This lack of stability and security does not promote attachment and may affect children cognitively as well as emotionally."

It is not surprising, then, that some children have difficulty forming relationships with adults. Practitioners report that these children are indiscriminate in their attachments and will be too friendly or overly affectionate. Others rarely seek the assistance, comfort, and support of an adult.

It is well documented by researchers that early bonding and attachment can influence the development of future relationships. Many theorize that early bonding experiences provide children with a template that they continue to apply to their interactions, not only with adults but also with their peers. Depending on their early experiences, children may cling to adults, and be reluctant to venture out on their own and explore. When children's confidence and trust are compromised, they have difficulty making decisions and moving toward independence—a critical task in the preschool years.

Disorganization, speech and language problems, and the effects of poor attachment are some of the behaviors that most trouble professionals working with children who have been prenatally exposed to drugs and are exposed to other environmental risks.

These problems can impede learning, social development, and mastery over oneself and the environment.

Practitioners are just now beginning to follow into kindergarten and into the primary grades the cohort of children who were prenatally exposed to drugs and other risks. However, it is clear that if such problems persist, children will be at high risk for school failure.

As Courtney Cazden states, "language is both the curriculum content and the learning environment, both the object of knowledge and the medium through which knowledge is acquired." From first through third grade children are learning to write and to read, to encode symbols and decode symbols. They are asked to work increasingly on their own, remember and follow instructions, and relate concepts to one another. At this age children become intensely interested in their peers and through their positive social interaction develop social competence.

Early intervention provided through such specialized programs as those described below and comprehensive child development programs such as Head Start will assist many children at risk to develop the skills needed to succeed in school.

THE PROMISE OF SPECIALIZED PROGRAMS

While researchers have been studying prenatal drug exposure, administrators and teachers have begun to develop programs to effectively address the troubling behaviors exhibited by children from environments in which substances are abused. Six nationally recognized programs are described below. They illustrate the range of characteristics exhibited by children at risk and detail the key features that make these programs successful.

PED Program

As early as 1984, the Los Angeles Unified School District recognized the need to establish a program to serve preschool children who were prenatally exposed to drugs. Initially, the PED (Children Prenatally Exposed to Drugs) Program was located in the Salvin School, one of 17 schools serving children in the district with special needs.

To be eligible for the PED Program, children must be three years of age and have an IQ within the normal range. In addition, children enrolled must have had a medical history of prenatal drug exposure and display one or more of the following behavioral characteristics: tremors, perceptual disorganization, blanking out, speech and language disorders, minimal developmental delays, disorganized play, difficulty with transitions, poor peer relationships, and poor coping skills (Los Angeles Unified School District 1989).

Early in its history, the sponsors of the PED Program recognized that children prenatally exposed to drugs do not need to be placed in a separate classroom. Maintaining children in separate classrooms allowed PED practitioners to learn more about such children's specific needs and to design appropriate interventions. Over the years, PED Program staff have systematically documented the behavioral characteristics of children enrolled and specific strategies that they found effective. Published as a practical guide, Today's Challenge: Teaching Strategies for Working with Young Children Pre-Natally Exposed to Drugs/Alcohol is now used by many other programs across the country (Los Angeles Unified School District 1989).

The PED Program articulates a clear philosophy based on children's needs for consistent and nurturing relationships. Therefore, an accepting and respectful emotional climate is at the heart of the PED Program's approach to intervention. The context suggested by PED practitioners is one where "children know what's expected of them and know what to expect," explains Carol Cole, a former PED program teacher. The quality of teachers' interactions with children, predictable routines and rituals, careful observations and assessments, transition planning, and a high teacher-to-child ratio are all "protective factors" that PED staff incorporate into their design of preschool classrooms.

PED's guidebook organizes teaching strategies into six major areas: learning, play, social/emotional, communication, motor development, and home/school partnership. Suggested strategies embody developmentally appropriate practice and reflect the understanding that young children must be actively engaged in the learning process.

PED's pioneering work has significantly influenced the field through its clearly articulated approach to working with children prenatally exposed to drugs and environmental risks. The Los Angeles Unified School District, Division of Special Education has recently launched the Infant/Preschool Program, a model demonstration project to test strategies outlined by the PED Team in the district's publicly funded child-care centers. This important project, begun in 1991, will provide critical information on how successful and adaptable the PED Program model is when applied to integrated settings.

Operation PAR

As a therapeutic community in Florida, Operation PAR (Parental Awareness and Responsibility) has provided a comprehensive range of services since 1970. Because of its focus on recovering adults, PAR represents a different approach from PED and other school-based programs. In April 1990, a collaborative research and demonstration project between Operation PAR and the University of Southern Florida Psychiatry Department expanded PAR's treatment program for women. PAR Village is a residential therapeutic community where mothers, living with their children, participate in drug treatment. PAR Village is designed to address the common problem that chemically dependent mothers face—the lack of adequate child care that often forces mother to forgo or interrupt their treatment.

Mothers who enter this residential family program must be 18 or older and have a serious drug abuse or dependency problem. They must have a child under 12 months of age; they may also bring a second child age 10 or younger.

A key feature of PAR Village is a child-care program for drug-exposed infants and children of chemically dependent parents. Children enrolled in the center receive comprehensive evaluations that form the basis of individual education plans. The educational approach is based on the High Scope Curriculum and the curriculum addresses the social, emotional, motor, language, and cognitive development of the children enrolled. In addition to typical child care activities, mothers routinely visit their children at child care to enhance the bonding between parent and child.

PAR Village offers a unique combination of services that addresses the multiple needs of chemically dependent mothers and their children. The program evaluation currently underway will yield important data on whether child care services linked to treatment produce better treatment outcomes for parents in the long term.

Project D.A.I.S.Y

Project D.A.I.S.Y. (Developing Appropriate Intervention Strategies for the Young Child) is one of the initiatives of the Early Childhood Program Branch in the District of Columbia Public Schools. This program is a developmentally appropriate, regular education program that includes in its population children who have been prenatally exposed to drugs.

Project D.A.I.S.Y. currently serves 60 children. Each classroom is comprised of fifteen children in each of the four classroom sites. Of the fifteen children in each classroom, five children are documented from the D.C. General Hospital Birth to Three tracking system as prenatally substance exposed. The other ten children in the classroom are students for whom no risk factors have been identified. The classrooms are multi-aged settings that fully integrate drug-exposed children with their non-exposed peers in regular education early childhood classrooms.

Project D.A.I.S.Y. is supported by a multidisciplinary consultation team comprised of two clinical social workers, three speech and language pathologists, two clinical psychologists, and a nutritionist. Additionally, the program offers parent groups and home-based intervention support to all of the children in the D.A.I.S.Y. classrooms and their families.

The emphasis of Project D.A.I.S.Y. is in the development of strategies that can be generalized to diverse populations of children that exhibit similar concerns. Some key concepts of this project include:

• Caring communities in which children share a common sense of belonging must be developed.
• Consistent routines and rituals that provide predictability in the environment must be established.
• Environments must reflect the range of developmental needs of students.
• Teachers must use and model a common language to create a common set of experiences and understanding for children.
• The curriculum must reflect the diversity of children.
• Parents must be viewed as partners in the educational process.

The dissemination of the effective strategies used in Project D.A.I.S.Y. is currently taking place in 60 schools within the District of Columbia.

Carousel Preschool Program

The Carousel Preschool Program is based at the Florida Mental Health Institute at the University of South Florida. Children are referred from the pediatric department within the College of Medicine at the University and are also self-referred from the community.

Prior to enrollment, children attend a full-day screening. They are observed by staff who use specific protocols for data collection. Standardized intelligence tests are also administered. Children attend the program five days per week, six hours per day. The program is in session for 11 months of the year. Two teachers with special education backgrounds and a part-time supervisor who has a mental health background are assigned to each classroom. In addition, each child is assigned a case manager who works with the entire family, referring the family to support services and evaluating the entire family's progress.

Carousel is funded by the Office of Special Education Programs in the U.S. Department of Education to develop a model for working with prenatally exposed children age two and one-half to school age. The program has been operating for six years. Currently they are serving sixteen children—eight typically developing children who have no known history of prenatal drug exposure and eight who have had positive toxicity screens at birth.

Parent-Child Intervention Program

Six years ago the Ravenswood City School District in East Palo Alto, California, began to search actively for support to develop programs for children prenatally exposed to drugs. The impetus came from the superintendent, Dr. Charlie Knight, who began getting calls from teachers expressing concerns about the difficult and different behaviors they were observing in the incoming kindergarten classes. Teachers noticed that many children took far longer to acclimate to the rules and routines of school. Unlike past groups of kindergartners, many of these five and six year olds would have frequent toileting accidents. The most disturbing problems identified were episodes of explosive and unprovoked violence.

Recognizing that drugs played an increasingly destructive role in the community, the district applied for and received funding from the Office of Substance Abuse Prevention (OSAP, HHS) to launch a Parent-Child Intervention Program (PCIP). Working with hospitals, clinics, and child protective service agencies, since 1989 the PCIP has provided child care for infants, toddlers, and preschoolers prenatally exposed to drugs. Now serving 49 children from 20 families, PCIP offers both parent/caregiver education and support services. Through early intervention, the Ravenswood City Schools District is attempting to prevent the troubling behaviors that its teachers have observed in recent kindergarten classes.

Key ingredients for successful programming based on PCIP's experience include the following (Knight 1991):

• Support early development by providing services at or near birth.
• Provide child care that enables mothers and other caregivers to get respite care as well as treatment and other support services.
• Locate all the relevant community resources.
• Offer long-term services that acknowledge the range of supports that parents need to move away from drugs, acquire education, and settle in to employment.
• Require mothers to attend parenting counseling several times per week.
• Coordinate with critical county agencies such as child protective services, health clinics, treatment programs, and housing.
• Provide thorough and ongoing training for staff to equip them to respond to the diverse strengths and needs of the children and families they serve.

Hillsborough County Training Program

Hillsborough County Public Schools in Tampa, Florida, is the twelfth-largest district in the U.S., serving urban, rural, and suburban communities. Three years ago, the district organized a countywide task force called the Drug Exposed Children's Committee (DECC) to plan and coordinate services for drug-exposed children.

Comprised of school administrators, specialists, teachers, Head Start staff, and other community leaders, this committee began its work by conducting a study to identify four to six year olds prenatally exposed to drugs. Using a teacher-developed checklist of behaviors commonly attributed to drug-exposed preschoolers, researchers rated the behaviors of 85 children enrolled in programs serving a high-risk population. In addition, experienced clinical staff conducted interviews with children's parents to determine whether or not these children had been prenatally exposed to alcohol or other drugs. While the findings remain unpublished, DECC Chairperson Linda Delapenha reports that "there was no correlation between at-risk behaviors and parents' self-reports of substance abuse. Children with developmental and behavioral problems had complex histories including child abuse, parental death, prescription drug use by pregnant mothers, and other environmental or health problems sufficient to cause them to be at risk for school failure" (Delapenha n.d., unpublished).

Study results have formed the basis of the current philosophy of DECC and related school services. Linda Delapenha notes:

One child in the study sample seemed to exhibit all the "classic signs" of a child who has been prenatally exposed to drugs: distractible, disorganized play, and somewhat violent and aggressive behavior. I was convinced that, of all the children studied, this child had definitely been exposed to drugs. The caregiver interview revealed something different. The child was being sexually abused. This was a good lesson for all of us (Delapenha 1991, personal communication).

Recent efforts of the DECC and the school district have primarily focused on providing an inservice training program for the district's preschool and primary school teachers to enhance their skills in working with at-risk children. Designed for teachers in mainstream settings, the training program is based on an early childhood education model rather than an instructional approach. It assumes that classrooms are equipped with interest centers, and children are actively engaged with a range of materials.

The training program is organized into six three-hour evening sessions and is designed to be highly interactive and practical. Early on, teachers are involved in make-and-take activities, which give them concrete ideas to integrate into their programs. Teacher recertification credits are offered to all those attending the training programs, providing an additional incentive for teachers to attend. Participating teachers come from a variety of school- and community-based settings, including state-funded preschool, preschool special education, Head Start, day care, and primary grades. The success of the training program has been recognized by the Robert Wood Johnson Foundation, which has awarded the Hillsborough County Public Schools with a two-year grant to develop its training program and disseminate it nationally.

These six programs are examples of ways in which the education and treatment communities are designing services to meet the needs of families and children living in situations in which alcohol and other drugs are abused. The list of communities adapting these approaches continues to grow. In some cases, this takes the form of direct services to preschoolers; in others, the services are focused on enhancing the skills of classroom staff in mainstream settings, such as preschools and primary grade classrooms.

CONCLUSION

Even though practitioners often find it difficult to define clearly the etiology of the problem behaviors they confront in the classroom, they have identified a number of strategies to improve both the classroom environment and educational outcomes. Some of these strategies are grounded in sound early childhood education practices, while others are adapted from strategies used in special education. Practitioners have found that children need:

• environments that are flexible and allow visual stimuli to be regulated according to their abilities to manage these stimuli
• consistent and nurturing staff who form close bonds with the children in their care
• predictable routines so that they are able to anticipate and manage change
• transition procedures that allow them to ease slowly from one activity to another

Other aspects of sound programming include:

• the use of a wide range of assessment techniques that generate information regarding children's skill levels, coping strategies, and learning styles
• sound individual education plans
• learning environments that enable teachers to meet children's individual needs effectively
• strong partnerships between families and schools
• parent services, including parenting education, drug treatment programs, and social services

SUMMARY AND IMPLICATIONS

Many risk factors can compromise infant prospects for healthy development. The use of illicit drugs or alcohol by their mothers during pregnancy is among those risks. However, there are many other pre- and postnatal factors that can affect infant development. Some, such as prenatal care, can help moderate the risk of adverse outcomes associated with drug or alcohol exposure. Others, such as inadequate childrearing skills, can transform perinatal vulnerabilities into psychosocial disabilities with lifelong implications. What follows is a summary of conclusions drawn from the research about the role that prenatal exposure to drugs and other risk factors play in challenging the healthy development of our children as well as some of the ways in which this challenge can be met.

EFFECTS OF PRENATAL EXPOSURE TO ALCOHOL AND OTHER DRUGS

• The use of alcohol during pregnancy can lead to Fetal Alcohol Syndrome (FAS) or Alcohol-Related Birth Defects (ARBD), both of which involve permanent physical and cognitive disabilities.
• Heroin, and possibly other illicit drugs, can result in the neonatal abstinence syndrome. While the long-term effects of this condition remain uncertain, it places substantial stress on both the infant and parents and requires extensive and expensive medical care.
• Prenatal exposure to alcohol and other drugs may contribute to a risk of other adverse perinatal outcomes and developmental delays. The extent of this contribution and the duration of these delays remain uncertain.
• Prenatal exposure to alcohol and other drugs can contribute to preterm and small-for-gestational-age (SGA) birth. Other factors that elevate the risk of preterm and SGA birth tend to concentrate in those sociodemographic groups that also have an elevated risk of prenatal drug and exposure.
• Preterm and SGA birth associated with, or independent of, prenatal drug or exposure can have developmental consequences. Socioeconomic factors, and especially the extent of prenatal care, predict the extent of these consequences far better than biologic birth status.

EFFECTS OF ENVIRONMENTAL RISKS

• A number of postnatal risk factors can, individually or in combination with other factors including drug or alcohol exposure and/or preterm or SGA birth, contribute to behavioral and cognitive impairments.
• A substantial number of children who have been prenatally exposed to drugs grow up in environments characterized by postnatal risk factors, including poverty, exposure to violence, inadequate caregiving, parents who abuse alcohol and other drugs, child abuse and neglect, and multiple foster care placements.
• The effects of exposure to and anxiety caused by witnessing violence in the home and community can also affect children's emotional life and development.
• Risk factors in households in which the primary caregivers abuse alcohol and other drugs include family discord and violence, inadequate or inappropriate interactions with children, lack of adult supervision, and disorganization and instability.
• Child abuse or neglect can play a critical role in how children develop and behave. Risk factors for child abuse or neglect include a vulnerable perinatal status due to drug or alcohol abuse; preterm or SGA birth; parents who abuse alcohol and other drugs; and a household subject to stresses such as poverty and a lack of social supports.
• Many infants and children who are prenatally exposed to drugs have parents who abuse alcohol and other drugs, have been abused or neglected, and/or are placed in foster homes. Many experience multiple placements before they reach school age. While foster care may be preferable to life in a household in which alcohol and other drugs are abused, the instability and disruptions caused by foster placement, and especially multiple placements, also take a toll on a child's emotional and cognitive development.
• Postnatal risk factors can, individually or in combination, produce effects including behavioral disorganization, language delays, difficulties with attachment and bonding, memory and learning disorders, inadequate social skills that result in difficulty relating to peers and adults, post-traumatic stress disorder, and behavioral problems ranging from withdrawal to unprovoked violence.

EDUCATIONAL IMPLICATIONS

Children entering preschool and elementary classrooms bring with them a wide range of behaviors, dispositions, and learning styles. Some of these pose problems, both for the children's healthy development and educational outcomes, and for classroom management. Many strategies for managing classrooms with children with cognitive and developmental challenges have been developed and used successfully throughout the country. In addition, a number of specialized programs are developing and refining approaches dealing with children whose development and educational success are threatened by prenatal drug and alcohol exposure, as well as the other risk factors outlined in this monograph. Careful assessment techniques, tailored educational interventions, opportunities for individual attention, and small class size can contribute to the healthy development of children and mediate the effects of behavioral, emotional, and cognitive problems, whatever their etiology.

It is dangerous to oversimplify a response to the "problem of drug-exposed children." Stereotyping these children can mislead teachers and other caregivers as to children's abilities and potential. Prenatal drug or alcohol exposure may indicate that a child is at risk, but exposure cannot be taken as a definitive sign that the child will not develop normally. As Richard Barth (1991) wrote, "Children exposed to drugs in utero do not represent a class of children—they may be as varied as children who are not exposed." At the same time, many children who are not prenatally exposed to alcohol face incredible threats to their health and development because of child abuse and maltreatment, parents who abuse alcohol and other drugs, violence, and a host of social ills. Ignoring these children simply because they are not drug exposed seriously underestimates the damage done by these other hazards.

It is up to us whether at-risk children will become members of a "lost generation." The success that dedicated practitioners have in reaching such children proves that growth, healthy development, and educational achievement are real possibilities for all children. With the proper knowledge and resources, practitioners can meet this challenge. Parents, educators, and citizens cannot, and should not, refuse these children the help they deserve in surmounting the barriers to a healthy and fulfilling future.

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APPENDIX A

SOURCES OF INFORMATION

This appendix explains the sources of information used in the three major sections of the monograph.

EFFECTS OF PRENATAL EXPOSURE TO ALCOHOL AND OTHER DRUGS

Five databases were searched for citations to research reports since 1980 on the effects of prenatal exposure to alcohol and other drugs. These databases included MEDLINE, ERIC, ECER, PsycINFO, and Drug Information-Alcohol Use/Abuse. Selected articles were read to inform our work, focusing on:

• the primary research on the effects of prenatal drug exposure and its long-term developmental outcomes
• the most important historical and contemporary research on prenatal alcohol exposure, as well as several comprehensive reviews of the literature on this subject
• reports, descriptions, and materials emanating from programs whose goals include improving the developmental and educational outcomes of children prenatally exposed to drugs and alcohol

Published research was augmented with interviews with six researchers currently engaged in studies of prenatal drug or alcohol exposure. These studies were identified by reviewing:

• research reports cited in the literature searches described above
• grant and contract awards and other resource materials provided by the Office of the Assistant Secretary for Planning and Evaluation, the Department of Education, the National Institute on Drug Abuse, and the Administration on Children and Families
• testimony at congressional hearings provided by the project sponsors and identified through a search of the Government Printing Office Monthly Catalog Database and obtained from congressional committees and subcommittees
• the Federal Research in Progress database

The researchers generously shared their time and thoughts concerning prenatal exposure to alcohol and other drugs. None commented in detail on current unpublished research. The standards of medical research and the requirements of many peer-reviewed medical journals recognize the danger of premature release of research data or conclusions, which may be misinterpreted by the lay community, divorced from the methodological context and the author's full text. However, the researchers provided citations to or copies of recent and forthcoming publications, ensuring access to the most recent available information. Appendix B includes a list of those interviewed.

Research and information on the effects of preterm and small-for-gestational-age births were identified as well as prevalence and sociodemographic considerations, by:

• searching MEDLINE
• consulting resources on early child development
• reviewing the reference lists of relevant articles identified during the primary literature search
• reviewing HOLLIS, the catalog of the library collections of Harvard University

ENVIRONMENTAL RISKS AND IMPLICATIONS FOR DEVELOPMENT

Much of the base material for this section was gathered using:

• standard sources on the relevant issues
• targeted literature searches in MEDLINE, ERIC, ECER, Family Resources, Child Abuse and Neglect Database, and PsycINFO
• reference lists of the articles on prenatal drug and alcohol exposure, many of which cite research relevant to confounding and intervening variables

Also utilized were inhouse expertise and resources on child development; substance abuse; child abuse and neglect; domestic, peer, and community violence; and the effects of poverty on family systems.

IMPLICATIONS FOR EDUCATION IN PRESCHOOL AND PRIMARY GRADES

Comprehensive studies describing the behavioral, psychological, and demographic characteristics of the current population of at-risk children seen in preschools and

programs for drug-exposed children do not exist. A few programs have published clientele descriptions, but these lack methodological rigor. Thus most of our information on these children was obtained from practitioners and practitioner reports. Practitioners with programs for drug-exposed children were identified by reviewing:

• program descriptions and reports identified through the literature review
• testimony before congressional hearings
• articles in the popular press provided by the project sponsors and identified through searches of the PAPERS, UPI, and AP databases
• program descriptions and materials provided by the project sponsors

Using semistructured protocols, representatives from 12 programs were interviewed. Appendix B identifies these individuals and their programs.