Characteristics of attachment organization and play organization in prenatally drug-exposed toddlers

Maternal pre- and postnatal substance use and attachment in young children: A systematic review and meta-analysis

Maternal substance use has often been associated with insecure and disorganized child attachment. We evaluated this association with a meta-analysis of young children and, further, systematically reviewed mediating and moderating factors between maternal substance use and child attachment. We performed a systematic database search of quantitative English language studies on child attachment that included substance-using mothers and their children below 6 years of age. Eleven studies (N = 1,841) met the inclusion criteria and were included in the meta-analysis of attachment security and seven (N = 1,589) studies were included in the meta-analysis of attachment disorganization. We found that maternal substance use was negatively associated with secure attachment in children, but the effect size was small (r = -.10). The association with disorganized attachment was not significant (r = .15). Related to moderating and mediating factors (k = 6), we found evidence on the role of teratogenic and sociological factors on child attachment. Most importantly, the impact of cumulative risks was vital. However, literature was scarce, and studies varied in risk of bias, leaving many unanswered questions on other potential factors underlying the development of attachment in these high-risk children. We discuss the results considering clinical implications and future directions.

A developmental model of addictions: integrating neurobiological and psychodynamic theories through the lens of attachment

Although substance use and abuse may impact brain and behavior, it is still unclear why some people become addicted while others do not. Neuroscientific theories explain addiction as a series of between- and within-system neuroadaptations that lead to an increasingly dysregulating cycle, affecting reward, motivation, and executive control systems. In contrast, psychoanalysis understands addiction through a relational perspective wherein there is an underlying failure in affect regulation, a capacity shaped early developmentally. Considering recent findings suggesting the neurobiological overlap of addiction and attachment, it may be possible to integrate both perspectives into a developmental model through the lens of attachment. The goal of the present review is to evaluate the value of neurobiological and psychodynamic perspectives to inform our understanding of addiction, particularly substance-use disorders.

Attachment Theory and Maternal Drug Addiction: The Contribution to Parenting Interventions

Children's emotional and relational development can be negatively influenced by maternal substance abuse, particularly through a dysfunctional caregiving environment. Attachment Theory offers a privileged framework to analyze how drug addiction can affect the quality of adult attachment style, parenting attitudes and behaviors toward the child, and how it can have a detrimental effect on the co-construction of the attachment bond by the mother and the infant. Several studies, as a matter of fact, have identified a prevalence of insecure patterns among drug-abusing mothers and their children. Many interventions for mothers with Substance Use Disorders have focused on enhancing parental skills, but they have often overlooked the emotional and relational features of the mother-infant bond. Instead, in recent years, a number of protocols have been developed in order to strengthen the relationship between drug-abusing mothers and their children, drawing lessons from Attachment Theory. The present study reviews the literature on the adult and infant attachment style in the context of drug addiction, describing currently available treatment programs that address parenting and specifically focus on the mother-infant bond, relying on Attachment Theory.

Cocaine-induced neurodevelopmental deficits and underlying mechanisms

Exposure to drugs early in life has complex and long-lasting implications for brain structure and function. This review summarizes work to date on the immediate and long-term effects of prenatal exposure to cocaine. In utero cocaine exposure produces disruptions in brain monoamines, particularly dopamine, during sensitive periods of brain development, and leads to permanent changes in specific brain circuits, molecules, and behavior. Here, we integrate clinical studies and significance with mechanistic preclinical studies, to define our current knowledge base and identify gaps for future investigation. Birth Defects Research (Part C) 108:147-173, 2016. © 2016 Wiley Periodicals, Inc.

Security of attachment and quality of mother-toddler social interaction in a high-risk sample

The quality of children's social interactions and their attachment security with a primary caregiver are two widely studied indices of socioemotional functioning in early childhood. Although both Bowlby and Ainsworth suggested that the parent-child interactions underlying the development of attachment security could be distinguished from other aspects of parent-child interaction (e.g., play), relatively little empirical research has examined this proposition. The aim of the current study was to explore this issue by examining concurrent relations between toddler's attachment security in the Strange Situation Procedure and quality of mother-child social interaction in a high-risk sample of toddlers characterized by prenatal cocaine exposure and low levels of maternal education. Analyses of variance suggested limited relations between attachment security and quality of social interaction. Further research examining the interrelations among various components of the parent-child relationship is needed.

Prenatal exposure to methadone and buprenorphine: a review of the potential effects on cognitive development

The amount of opioid users receiving opioid maintenance therapy has increased significantly over the last few years. As a result, an increasing number of children are prenatally exposed to long-lasting opioids such as methadone and buprenorphine. This article reviews the literature on the cognitive development of children born to mothers in opioid maintenance therapy. Topics discussed are the effects of prenatal exposure on prematurity, somatic growth, brain volume, myelination, and the endocrine and neurotransmitter system. Social-environmental factors, including parental functioning, as well as genetic factors are also described. Areas requiring further research are identified.

Quality of attachment and home environments in children prenatally exposed to PCP and cocaine

Quality of attachment, disorganization in attachment, and the contribution of caregiver interactions in the home were investigated for infants prenatally exposed to PCP and cocaine and their caregivers. The drug-exposed infants were compared with infants of similar ethnicity, socioeconomic status (SES), and living in the same geographical area of the city with non-substance-abusing mothers. The majority of drug-exposed infants were insecurely attached to their caregivers and did not differ in the percentage of security in the three caregiving environments in which the infants were growing up: biologic mother care, kinship care, or foster mother care. The majority of drug-exposed children were disorganized. Change in caregivers during the first year was not found to be related to the rate of insecurity in any of the caregiving environments. The majority of the non-drug-exposed comparison infants were securely attached, and only a small percentage were disorganized. The high incidence of insecurity in the drug-exposed group is discussed in relation to maternal and environmental circumstances that can alter the assumption of security in attachment for the majority of children and caregivers toward insecurity in attachment.

GREATER RIGHT FRONTAL EEG ASYMMETRY AND NONEMPHATHIC BEHAVIOR ARE OBSERVED IN CHILDREN PRENATALLY EXPOSED TO COCAINE

Responses to emotion-inducing stimuli were examined in 27, 3- to 6-year-old children, who were prenatally exposed to cocaine, and 27 unexposed controls. Children were monitored for EEG activity and their affect during an infant crying, simulated maternal distress, and a mildly frustrating task. Multivariate analyses indicated that the cocaine-exposed children had greater right frontal EEG asymmetry, showed fewer empathic reactions to a crying infant as well as to their own mothers, and they were less proficient in completing a cooperative task. These findings highlight the need for continued longitudinal research on the effects of early drug exposure for later socioemotional development.

The neuropsychology of conduct disorder

This article reviews evidence from neuropsychological tests that brain dysfunction is a correlate of conduct disorder. Most studies report consistent findings of differential neuropsychological deficits for antisocial samples in verbal and “executive” functions. Neuropsychological measures are related to some of the best indicators of poor outcome for children with conduct symptoms, such as early onset, stability across time, hyperactive symptoms, and aggressiveness. Neuropsychological tests statistically predict variance in antisocial behavior independently of appropriate control variables. This article argues that neuropsychological variables warrant further study as possible causal factors for conduct disorder and presents one developmental perspective on how neuropsychological problems might contribute risk for conduct disorder.

Child maltreatment and foster care: unpacking the effects of prenatal and postnatal parental substance use

Parental substance use is a well-documented risk for children. However, little is known about specific effects of prenatal and postnatal substance use on child maltreatment and foster care placement transitions. In this study, the authors unpacked unique effects of (a) prenatal and postnatal parental alcohol and drug use and (b) maternal and paternal substance use as predictors of child maltreatment and foster care placement transitions in a sample of 117 maltreated foster care children. Models were tested with structural equation path modeling. Results indicated that prenatal maternal alcohol use predicted child maltreatment and that combined prenatal maternal alcohol and drug use predicted foster care placement transitions. Prenatal maternal alcohol and drug use also predicted postnatal paternal alcohol and drug use, which in turn predicted foster care placement transitions. Findings highlight the potential integrative role that maternal and paternal substance use has on the risk for child maltreatment and foster care placement transitions.

Cocaine Exposure Is Associated With Subtle Compromises of Infants' and Mothers' Social-Emotional Behavior and Dyadic Features of Their Interaction in the Face-to-Face Still-Face Paradigm

Prenatal cocaine and opiate exposure are thought to subtly compromise social and emotional development. The authors observed a large sample of 236 cocaine-exposed and 459 nonexposed infants (49 were opiate exposed and 646 nonexposed) with their mothers in the face-to-face still-face paradigm. Infant and maternal behaviors were microanalytically coded. No opiate-exposure effects were detected. However, mothers of cocaine-exposed infants showed more negative engagement than other mothers. The cocaine-exposed dyads also showed higher overall levels of mismatched engagement states than other dyads, including more negative engagement when the infants were in states of neutral engagement. Infants exposed to heavier levels of cocaine showed more passive-withdrawn negative engagement and engaged in more negative affective matching with their mothers than other infants. Although effect sizes were small, cocaine exposure, especially heavy cocaine exposure, was associated with subtly negative interchanges, which may have a cumulative impact on infants' later development and their relationships with their mothers.

Attachment Status in Children Prenatally Exposed to Cocaine and Other Substances

Attachment status of children exposed in utero to cocaine, opiates, and other substances was examined at 18 months (n=860) and 36 months (n=732) corrected age. Children exposed to cocaine and opiates had slightly lower rates of attachment security (but not disorganization), and their insecurity was skewed toward ambivalent, rather than avoidant, strategies. Continued postnatal alcohol use was associated with higher rates of insecurity and disorganization at 18, but not 36, months of age. Stability of attachment across the 18-month period was barely above chance expectation. Attachment status at 18 months was associated with child temperament and caregiver-child interaction; at 36 months, attachment was associated with child temperament, child behavior problems, and caregivers' parenting self-esteem.

The impact of parental problem drug use on children: what is the problem and what can be done to help?

AIM

To review the literature on the impact of parental problem drug use on children, and indicate the efficacy of key evaluated interventions to reduce the impact of parental drug use on children.

METHODS

Comprehensive narrative review of English language published research and intervention spanning the last three decades identified through searching library databases and citation.

FINDINGS

Problem drug use can impede parenting and the provision of a nurturing environment. Although small-scale, localized and resource-intensive these key evaluated interventions show cautious optimism that problem drug-using parents can reduce drug use and achieve better family management. Children have rarely been directly the focus of intervention.

CONCLUSIONS

Wider application and more rigorous evaluation of interventions in this area are needed. Given the scale of the problem it is important to establish how statutory services can apply the lessons of these more localized interventions.

Level of prenatal cocaine exposure and infant-caregiver attachment behavior

The objective of this longitudinal prospective cohort study was to determine whether level of prenatal cocaine exposure, or the interaction between level of prenatal cocaine exposure and contextual risk variables, was associated with a higher rate of infant-caregiver insecure attachment and disorganized attachment, or with alterations in infant crying or avoidant behavior, after controlling for prenatal exposure to alcohol, tobacco, and marijuana, the quality of the proximal caregiving environment, and other covariates. Subjects were 154 full-term 12-month-old infants (64 unexposed, 61 with lighter cocaine exposure, 29 with heavier cocaine exposure) and their primary caregivers from low-income, urban backgrounds. Exposure status was determined in the maternity ward by biologic assay (infant meconium and/or maternal or infant urine) and maternal self-report. At the 12-month follow-up visit, infants were videotaped with their primary caregiver in Ainsworth's Strange Situation. Reliable coders masked to exposure status scored videotapes for attachment variables, amount of crying, and level of avoidance. Contrary to popular perceptions, level of prenatal cocaine exposure was not significantly related to secure/insecure attachment status, disorganized attachment status, or rated level of felt security. Foster care status also was not associated with attachment status. However, heavier prenatal cocaine exposure, in interaction with maternal contextual variables (public assistance or multiparity) was associated with alterations in infant socio-affective behavior, including a higher level of behavioral disorganization, more avoidance of the caregiver, and less crying.

Do "we just know"? Masked assessors' ability to accurately identify children with prenatal cocaine exposure

This study evaluated perceptions of masked assessors to determine whether there are subtle differences in cocaine-exposed and unexposed children who might be identified by those interacting with children. As part of a longitudinal study, developmental assessors were masked to 163 4-year-old children's actual in utero cocaine exposure status and developmental history. After each battery, assessors documented their guesses of the child's cocaine exposure. Thirty-seven percent of the children who were exposed were misclassified as unexposed, whereas 74% of those unexposed were incorrectly classified as exposed. Although the sample did not differ on assessment scores when results were analyzed by actual cocaine exposure status ( >.3), children who did less well on assessments were more likely to be labeled by assessors as cocaine-exposed ( <.001). Results highlight the potential of stereotyping and negative attributions that might distort observations, both in unmasked studies of prenatal cocaine exposure and in clinical settings.

Mother-infant interaction at 12 months in prenatally cocaine-exposed children

This study examined mother-infant interactions of 12-month-old African-American prenatally cocaine-exposed infants and their mothers. Videotaped observations were made during a free-play dyadic interaction, a brief separation, and a reunion period. Videotapes were coded for maternal and child behaviors during each phase of the procedure. Although there were few differences in interactive behaviors between prenatally cocaine-exposed and nonexposed children and their mothers, children who were prenatally exposed to cocaine ignored their mother's departure (odds ratio [OR] = 3.0, p < .05) during separation significantly more often than nonexposed subjects. In addition, mothers who abused cocaine engaged in significantly more verbal behavior (F(2,104) = 7.00, p < .001) with their children than mothers of nonexposed children. These findings indicate that women who used cocaine during pregnancy may not differ from nonusers in their interactions with their 12-month-old infants.

A prospective comparison of developmental outcome of children with in utero cocaine exposure and controls using the Battelle Developmental Inventory

Children with in utero cocaine exposure may be at risk for adverse neurodevelopmental outcome. To evaluate such outcome in young children, we administered the Battelle Developmental Inventory (BDI) to a group of inner-city children with (COC) and without (CON) in utero cocaine exposure at ages 3 and 5 years. Sixty-five COC and 68 CON, similar at age of testing, were evaluated at both time points by examiners masked to child group status. Both groups scored poorly and worsened over time. Although Total BDI raw scores were lower in the COC group than in the CON group at 3 years, this difference was related to postnatal environmental factors, caregiver (p = .022), and home environment (p = .010), not to in utero cocaine exposure (p = .88). At 5 years, the Total BDI score was related to the home environment (p < .001) but not to the caregiver (p = .36) or in utero cocaine exposure (p = .83). We conclude that inner-city children are at risk for adverse developmental outcome regardless of in utero cocaine exposure.

Teacher-assessed behavior of children prenatally exposed to cocaine

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Intrusive caregiving and quality of attachment in prenatally drug-exposed toddlers and their primary caregivers

The relation between caregiver intrusiveness and the quality of attachment was tested among 51 prenatally drug-exposed toddlers and their primary caregivers. Biological mothers and kinship/foster caregivers neither differed as to caregiver intrusiveness nor as to their toddlers' attachment security and attachment organization. Insecure and disorganized/disoriented attachments were found to be more prevalent in this sample than in normal samples. In keeping with recent findings in non-drug-abusing samples (Isabella & Belsky, 1991; Lyons-Ruth, Repacholi, McLeod, & Silva, 1991), more caregivers of toddlers with avoidant or disorganized/disoriented attachments were found to be intrusive than caregivers of toddlers with secure or resistant attachments.

Attachment behavior and its antecedents in offspring born to methadone-maintained women

Videotaped 35 full-term, African American infants exposed in utero to methadone and 46 comparison infants at 12 months participating in a separation-reunion procedure to assess aspects of the infant's attachment relationship to the mother. Mothers in the two groups were comparable on education, age (18-35 years), socioeconomic status, parity, IQ and marital status. Offspring born to methadone-maintained women did not differ from comparison infants in indexes of proximity-seeking at reunion but did display higher scores on indexes of disorganized and avoidant behavior and lower scores on indexes of contact-maintaining behavior. Mothers' perceptions during pregnancy of their future infants' degree of bothersomeness were also related to higher scores on contact-maintaining behavior and lower scores on avoidant behavior. Finally, antecedents of attachment behavior within the opioid group alone were considered. The implications of using dimensional attachment ratings for uncovering more subtle attachment antecedents are discussed.

Perinatal substance abuse: the impact of reporting infants to child protective services

OBJECTIVE

The purposes of this study were to follow the judicial placement of newborns with positive toxicology screening results and to determine how long such infants remained in foster care, separated from their mothers or other relatives, and the length of court dependency. We also determined the mothers' compliance with court orders, the availability and use of rehabilitative services, factors used by the court to determine the final disposition, and the eventual placement of the infants.

METHODS

The cohort sample consisted of all infants from San Mateo County (CA) born at Stanford University Hospital during a 2-year period whose urine tests in the well-baby nursery were positive for illicit substances. Fifty-three newborns were identified, and their medical records and court documents were matched and reviewed from birth until termination of judicial review (or 5 years). Data were summarized and analyzed by logistic regressions to identify predictors of specific outcomes.

RESULTS

All 53 infants had normal physical examinations and uneventful hospital courses. Their ethnic distribution, with 68% being African-American and 7% being Hispanic, differed from the rest of the nursery population, which was predominantly Hispanic. Twenty-six (46%) of the 53 infants were returned to their mothers within 1 week of birth; 39 (76%) of the infants were reunited with some relative within the first month of life. At 12 months of age, 10 infants (19%) remained in foster care; however, none remained in foster care beyond 18 months. The length of time infants were dependents of the court ranged from 1 month to >5 years; 70% of the cases were "closed" between 6 and 30 months of life. Nine (17%) were dependents of the court for >36 months. Final placement of the infants was 35 (66%) reunited with at least one parent, 9 (17%) in long-term guardianship relationships with other relatives, and 9 (17%) adopted. All of the mothers were ordered to complete a drug rehabilitation program; 24 mothers (44%) fully complied and had repeatedly drug-free urine tests; 2 others (4%) had drug-free urine tests after incomplete participation in drug rehabilitation. Twenty-two (42%) of the mothers never complied with drug rehabilitation. Subsequent drug use was evident in less than half of the mothers during the period of study. Only one mother was reported for child abuse. Characteristics that most strongly predicted failure in family reunification were a history of failed drug rehabilitation, previous involvement of Child Protective Services, or previous removal of a child because of substance abuse.

CONCLUSION

Identifying and reporting newborns exposed to maternal substance abuse during pregnancy can be associated with beneficial changes in the environment of the infants and successful rehabilitation of many mothers. The use of judicial supervision, rehabilitative and supportive services, and long-term involvement of social services without criminal prosecution are key to successful outcome. This study supports the policy and recommendation of the American Academy of Pediatrics and should lessen health professionals' concerns about negative effects of reporting these patients to Child Protective Services.

Effects of Prenatal Drug Exposure on Birth Outcomes and Early Child Development

Public attention has been drawn to the needs of children who have been exposed to drugs, alcohol, and tobacco in utero. Despite initial concerns that prenatal substance exposure could have global and permanent effects, current research suggests that many of these children do not have significant birth outcomes. Developmental outcomes are also mixed. This paper presents a review of the literature on the impact of prenatal drug exposure on infants and young children. In addition, birth outcome and development data are presented on 80 children who were exposed to multiple substances in utero and who were with their mothers in a treatment facility. Both intra-uterine and extra-uterine factors related to children's outcomes are discussed.

Data Base of Studies on Prenatal Cocaine Exposure and Child Outcome

A computerized data base of characteristics and findings of the literature on prenatal exposure and child outcome was developed. The data base can be used to summarize and describe the literature resulting in a more objective understanding of the findings as well as to determine methodological problems that can shape the direction of future studies. Based on a literature search 99 studies were identified, 76 of which met methodological criteria and were included in the final data base. The data base shows that our knowledge base is limited, scattered, and compromised by methodological problems that mitigate any conclusions about whether or not or how prenatal cocaine exposure affects child outcome. Only a few studies have followed children beyond age 3. In addition, the cocaine problem is more complicated than first envisioned. It is a multifactorial problem including the use of other drugs and parenting and environmental lifestyle issues.

Infant development and developmental risk: a review of the past 10 years

OBJECTIVE

To review critically the research on infant developmental risk published in the past 10 years.

METHOD

A brief framework on development in the first 3 years is provided. This is followed by a review of pertinent studies of developmental risk, chosen to illustrate major risk conditions and the protective factors known to affect infant development. Illustrative risk conditions include prematurity and serious medical illness and infant temperament, infant-caregiver attachment, parental psychopathology, marital quality and interactions, poverty and social class, adolescent parenthood, and family violence.

RESULTS

Risk and protective factors interact complexly. There are few examples of specific or linear links between risk conditions and outcomes during or beyond the first 3 years of life. Infant development is best appreciated within the context of caregiving relationships, which mediate the effects of both intrinsic and extrinsic risk conditions.

CONCLUSIONS

Complex and evolving interrelationships among risk factors are beginning to be elucidated. Linear models of cause and effect are of little use in understanding the development of psychopathology. Refining our markers of risk and demonstrating effective preventive interventions are the next important challenges.

Psychopathology in infancy

The first three years of life present unique challenges to the study of psychopathology. We highlight four of the issues in a selective review of the developmental psychopathology of early childhood, including lack of specificity of risk and outcome variables, measurement difficulties, rapid developmental changes and the centrality of the relationship context in early childhood. We also highlight issues relevant to conceptualizations of disorders of infancy, emphasizing especially the need for efforts to validate clinical disorders. We consider two major domains of infant development that we believe are especially relevant to a discussion of psychopathology, namely, regulation of emotion and infant-caregiver attachment. Discussions of these two domains of infant development and their psychopathological extremes allow us to consider conceptualizations of psychopathology from the dual perspectives of developmental psychopathology and clinical disorders. We conclude by suggesting a number of strategies to build upon previous research.

Standardized test performance of children with a history of prenatal exposure to multiple drugs/cocaine

Twenty-four children, age 14 to 50 months, with a history of prenatal exposure to multiple drugs including cocaine, were matched by adjusted birth age and sex to 24 children with no history of drug exposure. All children had been living in stable, drug-free environments from at least the age of 11 months. Tests administered included the Sequenced Inventory of Communicative Development-Revised (SICD), the Bayley Scales of Infant Development, and the Peabody Picture Vocabulary Test-Revised (PPVT-R). Results indicated significant differences between groups and genders on the SICD when age was covaried and between groups on the Bayley. No groups or genders differed on the PPVT-R. Many (45.8%) of the children in the drug-exposed group qualified for intervention services according to Washington state criteria. Subject characteristics, other than age, did not play a significant role in the findings of group differences. It is concluded that, due to the cumulative effects of prenatal history, these children should be considered at risk for language delay.

Characteristics of pregnant substance abusers in two cities in the northeast

This study examined the drug use patterns of pregnant women in two inner city sites, selected to overrepresent cocaine users. Women who used cocaine were much more likely to have used some combination of cigarettes, alcohol, and marijuana in addition to cocaine during pregnancy. There was little difference in the patterns of drug use in the two study sites, Trenton, New Jersey, and northwestern Philadelphia. A number of demographic and lifestyle variables of cocaine users, soft drug users (cigarettes, alcohol, and/or marijuana), and abstainers were compared. The cocaine-using group was significantly older and had more children, had less stable and more isolated living situations, was less likely to be employed and more likely to be receiving public assistance during pregnancy, and was more likely to have a higher drug- and alcohol-using social environment and family history than soft drug users or abstainers. Of significance was that many of the high-risk lifestyle factors exhibited by cocaine users were also seen, albeit to a lesser extent, among the soft drug users. These findings have implications for the timing of intervention strategies that would be most effective.

Prenatal cocaine exposure adversely affects development of the primate cerebral cortex

This study was conducted to determine whether prenatal exposure to cocaine interferes with the development of the primate cerebral cortex. For this purpose, pregnant rhesus monkeys received cocaine orally (20 mg/kg/day in fruit or candy treats), twice a day from the 40th-102nd days of pregnancy (E40-E102), which is a period of corticogenesis in this species. The control group of pregnant animals received fruit or candy treats only. On E64 and E65, all animals received intravenous injections of [3H]thymidine. Monkeys were allowed to deliver at term. The offspring were sacrificed at age 2 months, and their brains were processed for histology and autoradiography. The analysis of cresyl violet-stained sections showed that prenatal treatment with cocaine significantly altered lamination of the primate cerebral cortex, in some cases completely blending distinction between individual layers. In addition, autoradiographic analysis revealed that in the control animals, [3H]thymidine labeling concentrated in cortical layers V and/or IV depending on the cytoarchitectonic area observed. In contrast, drug-treated animals displayed labeled cells in the white matter and cortical layer VI in addition to layers V and IV, suggesting inability of cortical cells to reach proper cortical layers. The number of labeled cells was also much lower in these animals. Finally, immunocytochemical studies with antisera directed toward glial fibrillary acidic protein showed that prenatal exposure to cocaine had dramatic effect on the glial fibers normally observed in the upper cortical layers. In many cortical regions of cocaine-treated animals, we observed practically no such fibers. This study demonstrates that cocaine administered during pregnancy can significantly affect the development of the primate cerebral cortex.

Behavior in cocaine-exposed infants and children: association versus causality

The effects of prenatal cocaine exposure on infant and child development and behavior are uncertain. This ambiguity has been enhanced by the early nature of human research and suboptimal study designs. Methodological difficulty in this research, particularly in the consideration of confounding effects, has made it difficult to ascribe causal relationships. Future research must consider more precise measures of confounding.