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

1. Substance Exposed Newborns: Time for Policy to Catch up with Research Barry M. Lester, PhD Brown Center for the Study of Children at Risk The Warren Alpert Medical School of Brown University Substance Use Disorders and Pregnancy Indianapolis, April 2007

2. Children at Risk Children in our country are facing a “perfect storm” Problems for children are increasing at the same time that resources for helping children are diminishing

3. Substance Abuse 11% of children (8.3 million) live with at least one parent who is either alcoholic or in need of treatment for the abuse of illicit drugs

4. Substance Abuse 3.8 million live with a parent who is alcoholic2.1 million live with a parent whose primary problem is with illicit drugs2.4 million live with a parent who abuses alcohol and illicit drugs in combination

5. Substance Abuse Substance abuse is a contributing factor in 40% of the 1.2 million cases per year of child abuse and in 40-80% cases of families involved with child welfare system

6. Substance Abuse Presence of substance use disorders in parents results in a threefold increase in risk of child maltreatment These children are 3 times more at risk for early onset drug use

7. Part of a cycle that includes: Domestic Violence Community Violence Can lead to psychopathology, delinquency and substance use in adolescents Violent Friends

8. Maternal Drug Use and Child Outcome GENETIC AND PRENATAL ENVIRONMENT PRENATAL POSTNATAL TERATOGENIC CAREGIVING ENVIRONMENT IMMEDIATE LATENT SPECIFIC GENERAL TRANSIENT LONG LASTING COA RISK PROTECTIVE D E V E L O P M E N T

9. History and Headlines COCAINE HURTS BABIES When drug babies reach school age Mothers Turned Into Monsters Pregnant cocaine user guilty of abuse Crack A Disaster of Historic Dimension, Still Growing Studies: Future bleak for crack babies Cocaine: a vicious assault on a child Crack’s Toll Among Babies: A Joyless View, Even of Toys In the 1980s, the “war on drugs,” the crack/cocaine epidemic focused national attention on the relationship between drug use, and social and economic problems in society

10. History and Headlines COCAINE HURTS BABIES When drug babies reach school age Mothers Turned Into Monsters Pregnant cocaine user guilty of abuse Crack A Disaster of Historic Dimension, Still Growing Studies: Future bleak for crack babies Cocaine: a vicious assault on a child Crack’s Toll Among Babies: A Joyless View, Even of Toys Early reports on prenatal cocaine effects created a public frenzy and the myth about “unfit to parent” women and their damaged “crack babies." This impacted legal activities by states on policy decisions affecting women who use illegal drugs during pregnancy

11. History and Headlines Prenatal cocaine exposure has subtle effects on children’s ability to focus their attention Major Trial Finds Only Subtle Fetal Injury From Cocaine A mother’s cocaine use may not doom her childafter all “Crack Kids”: Not Broken A Rush toJudgment Hope for ‘SnowBabies’ Researchers debunk myth of the ‘crack baby’ But, later studies (including ours) failed to support significant associations between prenatal cocaine exposure and increased prevalence of serious newborn congenital malformations, and medical complications

12. Long Term Development The focus has now turned to the long term developmental outcome of children with prenatal cocaine exposure, especially as they reach adolescence

13. Maternal Lifestyles Study U. Tenn Memphis Wayne State U. Miami Brown U. MLS Brown Data Center Research Triangle Institute MLS is funded under a NIDA cooperative agreement with additional support from NICHD and NIMH

14. Summary of Acute Medical Findings • Medical complications of mothers in exposed group were more common but still rare • Polydrug use: cocaine using mothers 49 times more likely to use other drugs • Previously reported congenital anomalies were not found including ultrasound findings • Some effects on physical growth, CNS/ANS signs • (Bauer et al Am J Obstst Gynecol 2002; Lester et al Ped 2001; Bauer et al., Arch Pediatr Adolesc Med 2005; Bada et al., Ostet Gynecol 2002; Amer Dis Child Fetal Neonatal Ed 2002) Shankaran et al., J Peri 2003; Ped 2004)

15. Summary of Early Behavior Findings • Lower arousal, poorer quality of movement and self-regulation, higher excitability, increased tone, poorer reflexes on the NNNS(Lester et al., Peds, 2002)

16. Summary of Early Behavior Findings • Alterations in cry acoustics (Lester et al., Peds, 2002) • Delayed auditory brain response (Lester et al., J. Peds, 2003) • During feeding interaction, cocaine using mothers were less flexible, less engaged and spent less time feeding(LaGasse et al., Arch Dis Child Fetal Neonatal Ed 2003)

17. Summary of Early Behavioral Findings • The mother - infant relationship is impaired in face to face interaction (Tronick et al., Dev. Psych. 2006)and attachment(Seifer et al., Child Dev. 2004) • Trajectory of motor development delayed (Loncar et al., Neurotox & Tera 2005) • Parenting stress impacts maternal behavior (Sheinkopf et al., J Ped Psych 2006)

18. 11 Years: More Conduct Disorders in Cocaine Exposed Children P<.01 Exposed Comparison

19. 11 Years: More Delinquency in Cocaine Exposed Children P<.03 Exposed Comparison

20. 11 Years: More Depression in Cocaine Exposed Children P=.03 Exposed Comparison

21. 70 No Cocaine Mod Cocaine Hi Cocaine 65 60 Predicted CBCL Externalizing Score 55 50 45 40 3 4 5 6 7 8 9 Age (Years) Prenatal Cocaine Exposure and Externalizing Behavior P<.001 Adj. (Bada et al., Peds 2007)

22. Pathways to Psychopathology Family History DSM Diagnosis R2 =.61 .14 depression 0.21 ODD 0.14 CD Prenatal drug exposure 0.63 ADHD 7 yr CBCL Total Problems Parent report 0.14 0.54 Difficult Temperament NNNS Dysregulation 3 yr CBCL Total Problems Parent report 0.12 0.31 CFI = 0.93, TLI = 0.921, RMSEA = 0.054, Chi-square/df ratio = 3.88. All path coefficients are significant, p < .05

23. 11 Years: More Cocaine Exposed Show Attenuated Cortisol Stress Reactivity 60% P=.009 50% 40% 30% 20% 10% 0% Exposed Comparison

24. Cocaine Effects On IQ Increase With Age Mental Functioning Over Time 110 COMP EXP 100 90 80 IQ 7.8 at 15 70 4.4 IQ Pts Mean effect = 1.45 IQ with covariates: site, gender, birthweight, SES, maternal IQ, prenatal opiate, alcohol, marijuana, tobacco 60 50 1 2 3 4 5 6 7 Age (Years) (Lester et al 2004)

25. Increased Referrals For Special Ed. IEP at Age 7 referred not referred COMP n=436 89% 11% 84% EXP n=547 16% (~5% increase) Odds Ratio = 1.56 CI 1.054 – 2.199 (Lester et al., Ped Res 2004)

26. Prevention: Additional Cost Per Year For Special Education Services Due To Prenatal Cocaine Exposure 45,000 cocaine births per year X 12.4/100 (baseline IEP rate) X 1.56 - 1 (excess risk attributable to cocaine) X $8,080 (cost per child) = $25,248,384

27. MRI and fMRI Functional MRI (fMRI) studies brain function MRI studies brain anatomy

28. PokeNoGo (Response Inhibition) Task time Go Go No-Go • Event Related Design • 4 runs of 57 trials (25% “No Go” trials) “Press the button when you see a Pokemon, EXCEPT when you see Meoweth”

29. fMRI Shows Frontal Cortex Activation In Cocaine Exposed Children CE = Cocaine Exposed, n=12; non-CE = not Cocaine Exposed, n=12 (Sheinkopf et al., SPR, 2004)

30. Neurobiological Dysregulation Substance Use Infant Behavioral Dysregulation Child behavior, emotion, and neurocognitive deficits Psychopathology Antisociality Prenatal Cocaine Exposure and Substance Use Onset Prenatal Cocaine Exposure Effects on brain alter normal biological processes Prefrontal cortex and related neural circuitry

33. METH

34. Here we ago again…. Media hype re methamphetamines The Meth Epidemic: Hype vs Reality New drug wave delivers 'crank babies' Earlier alarm over cocaine's effects could limit aid for meth abuse Generation of Meth Babies Children of meth users are filling foster homes Meth Infants Called the New “Crack Babies” Only Future Will Tell Full Damage Speed Wreaks on Kids

35. More…. meth babies” “could make the crack baby look like a walk in the nursery” Crack Then, Meth Now What the press didn’t learn from the last drug panic One Hit of Meth Enough to Cause ‘News Defects’ Commentary, Join Together Online ONE SHOT OF CRYSTAL METH CAUSES BIRTH DEFECTS: U OF T STUDY Oops– mice MA injected into peritoneum

36. Research In This Area Is Just Beginning The National Toxicology Program, U.S. Department of Health and Human Services, Center for the Evaluation of Risks to Human Reproduction (CERHR), Expert Panel Report on meth concluded that “in terms of the potential adverse reproductive and developmental effects of meth exposure, that “studies that focused upon humans were uninterpretable due to such factors as a lack of control of potential confounding factors and the issue of the purity and contaminants of the methamphetamine used by the drug abusers” (p.191). NTP-CERHR, Monograph on the Potential Human Reproductive and Developmental Effects of Amphetamines, NIH Publication No. 05-4474, July 2005

37. Clinical Research Network Infant Development, Environment And Lifestyle Study (IDEAL) Brown Oklahoma California IDEAL Iowa Hawaii Supported by NIDA Grant No. R01DA014948-01 Auckland Mec Tox (NIDA)

38. Prevalence of Alcohol and Other Substance Use During Pregnancy: IDEAL vs. NPHS (Prevalence rate of MA in IDEAL is 6%) Arria, et al, 2005

39. IDEAL Demographic Characteristics Race/Ethnicity Single, no partner 50% Predominantly Medicaid recipients 86% Average age 25 yr Low income < $10,000 MA 34% Comp 21% Gestational Age< 35 wk 9% Grant et al., Ped Research 2004

40. Substance Dependence Disorder Percent Based on SASSI (Substance Abuse Subtle Screening Inventory) OR (95% CI) = 12.08 (4.06-35.94) (Derauf et al in press)

41. Prenatal Care

42. Child Protective Services

43. Effects of MA on Infants Born Small for Gestational Age (SGA) 10 MA Exposed Incidence of SGA (%) 3.5X more likely to be SGA 5 Not MA Exposed P=.001 0 Smith et al., Peds, 2006

44. Arousal EXP COMP State Stress EXP COMP P<.01 Effects of MA on NNNS Summary Scores Physiological Stress P<.05 Adj P<.007 Adj EXP COMP Findings: Exposed lower arousal but more stress signs (Smith et al Neurotox, in press)

45. Dose Response: Amphetamine Metabolite in Meconium and NNNS Scores Quality of Movement r = -.51 N = 21 Regulation CNS Stress r = .68 N = 21 r = -.51 N = 21

46. Cry To First Stimulus, % (Reactive) Effects of MA on Acoustical Cry Characteristics P<.05 Adj EXP COMP Changes in Voice Pitch (Unstable) Percent Dysphonation (Noise) P<.05 Adj P<.05 Adj EXP COMP EXP COMP Findings: Exposed more reactive, with noisy, unstable cry (LaGasse et al Ped Res 2004)

47. Policy is dependent on Social Context “We find the defendant guilty as charged by the media”

48. Policy Responses Impacting the Child Rearing Environment 2 parallel policy responses towards drug use by women Sanctions Treatment

49. Sanctions • Drug use by mothers as legal/criminal issue • Criminal justice system - Child welfare system • Harming child by using drugs • Child abuse in its most destructive form • Focus: favors imprisonment, child removal •   Sanctions motivate drug using mothers to treatment

50. Treatment • Drug use by pregnant women/mothers viewed as a health (medical) issue • Harm reduction • Focus: reproductive health care, substance abuse therapy, relationship with child