Methamphetamine exposure during pregnancy: A meta-analysis of child developmental outcomes

This paper examines developmental outcomes for children prenatally exposed to methamphetamine through maternal use. PSYCHINFO, Scopus, PubMed and ERIC databases were systematically searched for studies up to December 2020. The search identified 38 articles examining cognitive, language, motor and neuroanatomical outcomes in children from birth to 16 years. Study quality was appraised using the Newcastle Ottawa Quality Assessment Scale. Findings from neuroanatomical studies suggested that prenatal methamphetamine exposure may alter whole brain microstructure and reduce subcortical volumes across multiple brain regions. Meta-analysis of 14 studies using a random-effects model revealed associations between exposure and poorer intellectual functioning (Cohen's d = 0.89, 95 % CI: 0.47-1.30), problem solving skills (Cohen's d = 0.82, 95 % CI: 0.07 -1.56), short-term memory (Cohen's d = 0.91, 95 % CI: 0.38-1.43), and language development (Cohen's d = 0.74, 95 % CI: 0.30-1.18). These results emphasise the significant impact of intrauterine methamphetamine exposure across multiple areas of child development, noting that limited total sample size, heterogeneity between studies and control for confounds suggested further studies are required. There is a need for further intervention studies to identify effective prevention and harm minimisation approaches.

Long-Term Developmental Outcomes of Prenatal Cocaine Exposure

The developmental outcomes of prenatal cocaine/polydrug exposure were evaluated using a multivariate research design that controlled for the possible confounding variables of age, sex, socioeconomic status, ethnicity, and caregiver status (i.e., biological parent, relative, foster care, and adoptive parent) using an exposed (n = 41) and nonexposed (n = 35) cohort of preschool children (mean age = 4.25). Results indicated that in utero drug exposure had no effect on cognitive, social, language, and behavioral developmental outcomes as measured by the Stanford-Binet Intelligence Scale: 4th ed., the Social Skills Rating System, the Preschool Language Scale: 3rd ed., the Child Behavior Checklist, and the Vineland Adaptive Behavior Scale-Survey Form.

Profiles of Reactivity in Cocaine-Exposed Children

This study explored the possibility that specific, theoretically consistent profiles of reactivity could be identified in a sample of cocaine-exposed infants and whether these profiles were associated with a range of infant and/or maternal characteristics. Cluster analysis was used to identify distinct groups of infants based on physiological, behavioral and maternal reported measures of reactivity. Five replicable clusters were identified which corresponded to 1) Dysregulated/High Maternal Report Reactors, 2) Low Behavioral Reactors, 3) High Reactors, 4) Optimal Reactors and 5) Dysregulated/Low Maternal Report Reactors. These clusters were associated with differences in prenatal cocaine exposure status, birthweight, maternal depressive symptoms, and maternal negative affect during mother-infant interactions. These results support the presence of distinct reactivity profiles among high risk infants recruited on the basis of prenatal cocaine exposure and demographically similar control group infants not exposed to cocaine.

The development of motor asymmetries in 1-month-old infants who were prenatally exposed to cocaine

The development of motor asymmetries was assessed in 20 infants who were prenatally exposed to cocaine and 23 comparison infants. Asymmetries in stepping, grasping, and head orientation were assessed at 1 month of age. As expected based on the findings of previous research with high-risk infants, infants who were prenatally exposed to cocaine performed a grasping task with their right hand for significantly shorter durations than comparison infants and were less likely to show a dominant hand preference than comparison infants. Comparison infants were also more likely to display a side bias for head orientation and stepping than infants who were prenatally exposed to cocaine. These findings suggest that prenatal exposure to cocaine may alter the typical developmental trajectory of functional asymmetries and may have important implications for long-term developmental outcomes.

Impact of maternal substance use during pregnancy on childhood outcome

The impact of maternal substance abuse is reflected in the 2002-2003 National Survey on Drug Use and Health. Among pregnant women in the 15-44 age group, 4.3%, 18% and 9.8% used illicit drugs, tobacco and alcohol, respectively. Maternal pregnancy complications following substance use include increases in sexually transmitted disorders, placental abruption and HIV-positive status. Effects on the neonate include a decrease in growth parameters and increases in central nervous system and autonomic nervous system signs and in referrals to child protective agencies. In childhood, behavioral and cognitive effects are seen after prenatal cocaine exposure; tobacco and alcohol have separate and specific effects. The ongoing use of alcohol and tobacco by the caretaker affects childhood behavior. Therefore, efforts should be made to prevent and treat behavioral problems as well as to limit the onset of drug use by adolescent children born to women who use drugs during pregnancy.

Maternal cocaine use and caregiving status: group differences in caregiver and infant risk variables

This study examined differences between cocaine and non-cocaine-using mothers, and between parental and non-parental caregivers of cocaine-exposed infants on caregiver childhood trauma, psychiatric symptoms, demographic, and perinatal risks. Participants included 115 cocaine and 105 non-cocaine mother-infant dyads recruited at delivery. Approximately 19% of cocaine mothers lost custody of their infants by 1 month of infant age compared to 0.02% of non-cocaine mothers. Mothers who used cocaine during pregnancy had higher demographic and obstetric risks. Their infants had higher perinatal risks. Birth mothers who retained custody of their infants had higher demographic risks and perinatal risks, higher childhood trauma, and higher psychiatric symptoms compared to birth mothers who did not use cocaine and non-parental caregivers of cocaine-exposed infants. Results highlight the importance of addressing childhood trauma issues and current psychiatric symptoms in substance abuse treatment with women who engaged in substance use during pregnancy.

The elusive romance of motherhood:drugs, gender, and reproduction in inner-city distressed households

This paper explores the social contexts of reproductive decision making among poor African-American women in inner-city distressed households by focusing on women's narratives of their reproductive and maternal experiences. We explore the hidden agendas and motivations that underpin women's reproductive decisions and perceived choices within the turmoil of poverty, domestic instability, economic uncertainty, and addiction. The political economy of reproduction, within which birthing and motherhood in distressed inner-city households take place, generates the conditions for absent fathers, brittle unions, and a highly skewed gendered division of parenting. Locally constituted notions of gender, agency and autonomy are key dimensions in the cultural constructions of motherhood in these female headed households. Woven into the local maternal experiences is also the desire to 'give and receive love'. By focusing on women's own formulations of responsibility and agency in their reproductive decisions, we can see how they make sense of their reproductive histories and maternal experiences amidst the constraints of poverty, class, race, and substance abuse.

Prenatal drug exposure effects on subsequent vulnerability to drug abuse

Research has shown that both prenatal alcohol and tobacco exposure are associated with increased risk of significant adverse medical, developmental, and behavioral outcomes including substance abuse. Research on the outcomes of prenatal exposure to illicit drugs (PNDE) has also found increased physical and behavioral problems for gestationally drug-exposed children. However, a clear picture has not emerged on whether the consequences of PNDE are independent from those associated with having a substance abusing parent and whether PNDE increases vulnerability to drug abuse. Because of its typical co-occurrence with factors inherent in having a drug-abusing parent, PNDE is at least a marker of significant increased risk for a range of negative outcomes including greater vulnerability to substance abuse. Although a review of the relevant research literatures indicates that the direct consequences of PNDE appear to be generally both subtle and nonglobal, PNDE does appear to have negative developmental and behavioral outcomes, and there is evidence that it is a modest direct contributor to increased substance abuse vulnerability.

The association between maternal cocaine use during pregnancy and physiological regulation in 4- to 8-week-old infants: an examination of possible mediators and moderators

OBJECTIVE

To examine the association between maternal cocaine use during pregnancy and physiological measures of regulation, which included heart rate (HR) and respiratory sinus arrhythmia (RSA).

METHODS

Potential mediators and moderators of this association were explored. Participants were 141 mother-infant dyads (77 cocaine exposed and 64 nonexposed) recruited at birth. Average infant HR and RSA was assessed at 4-8 weeks of age during a 15 minute period of sleep.

RESULTS

Results indicated a dose-dependent effect of prenatal exposure to cocaine on RSA. There was no evidence that fetal growth or other prenatal exposure to substances mediated this association or that fetal growth or maternal age moderated this association. Regression analyses also indicated that birth weight (BW), but not birthlength (BL), head circumference (HC) or other substance use, mediated the association between prenatal exposure to cocaine and heart rate.

CONCLUSIONS

These results suggest that cocaine exposure is associated with physiological regulation at 4-8 weeks of age and highlight the importance of considering level of exposure when assessing infant outcomes.

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 Maternal Lifestyle Study (MLS): effects of prenatal cocaine and/or opiate exposure on auditory brain response at one month

OBJECTIVE

To study absolute and interpeak latencies of the auditory brain response in infants exposed to cocaine and/or opiates in utero.Study design The sample included 477 exposed and 554 comparison infants matched for race, sex, and gestational age. Mothers were recruited at 4 urban university-based centers; most were black, receiving public assistance, and had received adequate prenatal care. Exposure was determined by meconium assay and self-report with alcohol, marijuana, and tobacco present in both groups. At 1 month, infants were tested by masked examiners with the auditory brain response.

RESULTS

Analyses were conducted for exposed and comparison groups and for level of prenatal cocaine exposure with adjustment for covariates (alcohol, marijuana, tobacco, gestational age at birth, social class, and site). Heavy prenatal cocaine exposure (>/=3 days per week, first trimester) led to an increase in the I-III, I-V, and III-V interpeak latencies and to a shorter latency to peak I. Infants with prenatal opiate exposure showed a longer latency to peak V and a longer III-V interpeak latency.

CONCLUSIONS

Prenatal cocaine and/or opiate exposure affects neural transmission. Detection of these effects requires a large sample with control for gestational age, other drugs, and level of cocaine use.

Prenatal drug exposure and the conceptualization of long-term effects

This paper discusses several factors affecting the development of children prenatally exposed to drugs. In the "first generation" of research in this field a main factor model of disease formed the basis for a belief in the feasibility of detecting the direct pharmacological or teratogenic effects of drug exposure on long-term child development. However, the clustering of confounding variables has constituted a major problem in identifying these effects. In the last few years a "second generation" of research in this field has emerged, and investigators have moved beyond simple main-effect models. The importance of controlling for confounding variables has been underscored. However, prenatal substance exposure is still often studied within a teratology model where the main goal is the search for unique effects of a specific drug or substance. Based on this review it is suggested that an appropriate model for understanding the development of drug-exposed children cannot be based on a main-effect perspective. Rather, such a model must evolve from a contextual perspective, and it is suggested that a transactional model, where both potential risk factors and protective factors are considered, should replace the traditional teratology model in this field.

The Maternal Lifestyle Study: drug use by meconium toxicology and maternal self-report

OBJECTIVE

The objective of this study was to describe drug use by pregnant women participating in the 4-site Maternal Lifestyle Study of in utero cocaine and/or opiate exposure.

METHODS

Meconium specimens of 8527 newborns were analyzed by immunoassay with GC/MS confirmation for metabolites of cocaine, opiates, cannabinoids, amphetamines, and phencyclidine. Maternal self-report of drug use was determined by hospital interview.

RESULTS

The prevalence of cocaine/opiate exposure in the 4 sites was 10.7% with the majority (9.5%) exposed to cocaine based on the combination of meconium analysis and maternal self-report. However, exposure status varied by site and was higher in low birth weight infants (18.6% for very low birth weight and 21.1% for low birth weight). Gas chromatography/mass spectrometry (GC/MS) confirmation of presumptive positive cocaine screens was 75.5%. In the cocaine/opiate-exposed group, 38% were cases in which the mother denied use but the meconium was positive. There was 66% agreement between positive meconium results and positive maternal report. Only 2% of mothers reported that they used only cocaine during pregnancy and mothers were 49 times more likely to use another drug if they used cocaine.

CONCLUSION

Accurate identification of prenatal drug exposure is improved with GC/MS confirmation and when the meconium assay is coupled with a maternal hospital interview. However, the use of GC/MS may have different implications for research than for public policy. We caution against the use of quantitative analysis of drugs in meconium to estimate the degree of exposure. Our study also highlights the polydrug nature of what used to be thought of as a cocaine problem.

Identifying substance abusing delivering women: consequences for child maltreatment reports

OBJECTIVE

The major objective was to determine how and the extent to which SB2669, which requires the identification of substance abusing delivering women, affected the number of children reported for abuse or neglect in several California counties.

METHOD

A monthly time-series model from April 1988 to December 1995 was constructed. The idea underlying the model was that month-to-month changes in the number of child maltreatment reports was a response to the presence of SB2669 in addition to various demographic, social, and economic factors. By separately estimating each county's number of reports, it was assumed that SB2669 did not necessarily affect each county's reports by the same amount, perhaps partially because of different counties' implementation strategies or general policies. Our sampling size consisted of seven high prevalence counties.

RESULTS

The results suggest that the effects of SB2669 on the number of child maltreatment reports are mixed. On an aggregate level, all else constant, and at least for a few years after the passage of SB2669, SB2669 is associated with a decrease in child maltreatment reports in two of the participating counties. This decrease may be due to conscientious implementation of the legislation in these counties. This mixed finding is expected mainly because SB2669, although mandated, was never enforced. Moreover, from the process component of the study we learned that the implementation practices of this legislation vary substantially between and even within counties' hospitals.

CONCLUSIONS/FUTURE DIRECTIONS

A decrease in maltreatment reports in the presence of SB2669 is not necessarily the most desirable outcome in the light of what we know about the relationship between substance abuse and child maltreatment. Law makers need to rethink the purpose of the law and provide the necessary language, tools and training to ensure that the goals of identifying substance abusing mothers and their families are met. Provisions also need to be made that somehow enforce this legislation. These provisions could lessen county-level and hospital-level variability in implementing the law.

Growth of infants prenatally exposed to cocaine/crack: comparison of a prenatal care and a no prenatal care sample

OBJECTIVE

It has not been possible to draw firm conclusions about the effects of prenatal cocaine exposure because of methodologic problems involved in the conduct of this research. This study, designed to overcome some of these methodologic problems, is a prospective, longitudinal investigation of the effects of prenatal cocaine/crack exposure on neonatal growth in two samples, one with and one without prenatal care (PC).

METHODS

Women in the PC sample (n = 295) were interviewed at the end of each trimester about their use of cocaine, crack, alcohol, tobacco, marijuana, and other drugs. Women in the no prenatal care (NPC) sample (n = 98) were interviewed at delivery about their drug use during each trimester of pregnancy. In both samples, information was also obtained about sociodemographic, lifestyle, psychologic, and social support characteristics. Both samples consisted of women who were predominantly low income, single, and high school educated. Of the women, 48% in the PC sample were black; 81% in the NPC sample were black. Infants were examined during the postpartum hospital stay by project nurses who were blind to maternal substance use status.

RESULTS

Women in both samples who used cocaine/crack during pregnancy were older, had lower family incomes, and used more alcohol than did women who did not use cocaine/crack during pregnancy. In addition, women in the NPC sample were more likely to be black, less educated, gained less weight during pregnancy, and used more alcohol than did women in the PC sample, regardless of cocaine use. In both samples, cocaine/crack use during early pregnancy predicted reduced gestational age, birth weight, length, and head circumference, after controlling for the significant covariates of cocaine use. In a comparison of the samples, the offspring of the NPC/cocaine group were significantly smaller than were the offspring of the PC/no cocaine group, whereas the offspring of the PC/cocaine and NPC/cocaine groups did not differ.

CONCLUSIONS

These results indicate that exposure to cocaine/crack during early pregnancy decreases the intrauterine growth of exposed offspring in women with and without PC. Each of the growth parameters was affected indicating symmetric growth retardation. The adequacy of PC was not a significant factor in determining the difference between cocaine-exposed and nonexposed infants. These samples are being followed throughout childhood to determine whether there are long-term effects of prenatal cocaine/crack exposure on growth.

The vulnerable preschool child: the impact of biomedical and social risks on neurodevelopmental function

The scope of preschool children with biological risk and social disadvantage is large and includes over 1 million (28%) newborns per year. Currently in 1996, 7% of children are born with low birth weight, 1% are born with very low birth weight, 20% have alcohol exposure, and 10% have other drug exposure. Poverty is dynamic and impacts on 25% of children less than 6 years old with increased frequency in children who are minority, have mothers with less than a high school education, or are unmarried. There has been a markedly increased survival in very low birth weight and extremely low birth weight infants in the past 10 years. Outcomes of these neonatal populations reveals that parenchymal brain injury is the major predictor of cerebral palsy which occurs in 7% to 10% of very low birth weight survivors. However, poverty is the major predictor of low IQ. Fetal alcohol syndrome occurs in 1.9 per 1,000 births and is most often associated with mild mental retardation and educational underachievement. Studies investigating cocaine revealed that it is a multifactorial problem overlapping with polysubstance abuse and other risk factors for social disadvantage. The overwhelming number of children do not have cerebral palsy or severe mental retardation. The long-term impact is more subtle and needs more systematic analysis as well as critical evaluation of cognitive impairments and educational under-achievement. Hypoxic ischemic encephalopathy (HIE) cannot be determined by one biological measure. Though multiple disability occurs in 70% of children with Sarnat stage 3 HIE, 30% of survivors are not disabled. Children with mild to moderate HIE have long-term outcomes that are influenced by 9- to 12-month neurodevelopmental status and social disadvantage. By combining strategies to lessen biological risks and enhance developmentally appropriate environments, long-term outcomes of preschool children can be optimized.