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Adopting a Child Who Has Been Prenatally Exposed to Drugs: Risks and Realities

By Dan R. Griffith, Ph.D.

Substance abuse by pregnant women, especially crack cocaine abuse, has received a great deal of attention over the past decade by researchers and the media. While it is true that substance abuse has a detrimental affect on the functioning of many women, children, and families in this country, the information presented to the general public to date has been at the very least incomplete and often inaccurate and misleading. Perhaps the most misleading aspect of media coverage concerns the effects of the more prevalent yet legal drugs, alcohol and tobacco. In a 1991 article published in The Future of Children, Gomby and Shiono cited statistics which estimated that approximately 73% of pregnant women in the U.S. use alcohol at some point in their pregnancy, 38% use tobacco, and 2% to 3% use cocaine. Cigarette smoking during pregnancy is firmly linked to low birth weight. Low birth weight in turn places children at risk for developmental problems. Prenatal exposure to alcohol is firmly linked to a range of effects from low birth weight and subtle learning problems to fetal alcohol syndrome. Too little research is available about the effects of prenatal exposure of cocaine. Cocaine, however, has received almost exclusive media coverage and the information presented has leaned towards sensationalism.

The images presented most often by the media have been those of the worst case outcomes: tiny, premature infants thrashing and screaming from the ravages of cocaine and hyperactive and hyperaggressive, out-of-control preschool and school-aged "crack kids." The problem with these images lie not with whether or not some of those prenatally exposed to cocaine might have similar outcomes, but with the messages implied by the sensationalistic media coverage. The first implication is that all exposed children will have the same worst case outcomes and will suffer life long debilitating effects. The second is that all of the problems suffered by these worst case outcomes are caused solely and directly by the prenatal exposure to cocaine.

Contrary to these implications the limited research available to date concerning the short and long term effects of prenatal exposure to cocaine and the present author's clinical experience with hundred's of children exposed prenatally to cocaine and other drugs have found that the effects of prenatal exposure to drugs including cocaine vary widely from child to child, and that the children displaying the worst case outcomes are most often those which have been exposed to numerous prenatal and post-natal risk factors in addition to drugs.

Because the developmental outcomes of children are affected by numerous biological and environmental factors, it is impossible to state that any specific outcome, with the exception of fetal alcohol syndrome, is caused by prenatal exposure to any particular drug. Most researchers and clinicians agree, however, that prenatal exposure to cocaine and other drugs constitute a biological vulnerability in some of the exposed children. Whether or not such vulnerabilities result in negative outcomes depends on the number of other biological risk factors the child has been exposed to (e.g. prematurity, low birth weight, lead, inadequate prenatal and post-natal nutrition and/or medical care) and the quality of the child's post-natal environment.

Research to date has indicated that the majority of children exposed to biological risks including prematurity, low birth weight, and prenatal exposure to alcohol and other drugs do not have serious or debilitating developmental problems. As prospective parents make the decision, however, whether to adopt a child who has been exposed to one or more biological and/or environmental risk factors, it is important to keep in mind that any general statement such as the ones just made concerning outcomes are based on "group statistics." Group statistics represent the average scores or outcomes for a group of children and do not apply directly to any specific child. In other words, no one can predict the developmental outcomes for any particular child simply by knowing which risk factors the child was exposed to. The only way to discover the unique strengths and problems for a specific child is by looking directly at the child over time. Gathering information about biological and/or environmental risks to which that specific child ahs been exposed can inform prospective parents about the odds of different outcomes, but will not provide any guarantees.

Fortunately, most of the potential problems for biologically at risk children are responsive to interventions once they are identified. Periodic screening for such problems can assist parents in optimizing the developmental outcomes of their children. There has been a great deal of research indicating that early screening, diagnosis, and intervention for developmental problems can significantly improve the outcomes for the majority of those children who are affected by these risk factors.

Difficulty regulating behavior, for example, is one of the more common problems displayed by those at-risk children who develop problems. There are numerous strategies to guide parents as they assist their children in developing strategies for controlling their behavior. Once such strategy is to train parents to observe and carefully record the problem behaviors of their children. Through observation parents are able to learn the behavioral cues which their children display before they misbehave, and arrive at an objective understanding of why their children are displaying such behaviors. Once parents learn to read the cues which precede their children's problem behaviors, they will often be able to avoid them altogether by redirecting their children's attention and behavior before the problems occur. By understanding their children's behavior, parents are better able to avoid becoming locked into power struggles by responding with understanding and supportive interventions rather than frustration and anger. Power struggles defeat adult and child alike and most often intensify the behavioral problems of the child.

The benefits gained through approaching a child's behavior with objectivity and understanding are illustrated by the following example. A four year old was referred to the present author because he was "out of control" in his preschool classroom and was becoming increasing aggressive towards his teacher.

When this little boy arrived for testing, my first impression was that he was nothing like what the teacher had described. He was friendly, polite, and during the early phases of testing extremely cooperative. However, after about five minutes of testing had been completed, the child announced that he was done. I tried to persuade him otherwise by redirecting his attention to different items, pushing the table a little close to him, and asking him to try a few more things. This attempt to make him continue when he wanted to quit was met with a behavioral outburst, including screaming, kicking, and shoving at the table. I immediately pulled the table away, at which time the child ran out of the room.

I assumed that the testing phase of the evaluation was over and started writing notes on the child's behavior. A few minutes later, however, the little boy returned to the room and said that he was ready to continue. After another ten minutes or so of testing, the child again said, "I'm done now," to which I replied, "That's fine." He calmly got out of his chair, walked around the room, and then sat down to resume testing. This pattern was repeated several times until all testing was completed and the child scored in the superior range for intellectual reasoning.

It was easy to see in a one-to-one testing situation that this child recognized the limits of his concentration and coped with increasing frustration by briefly removing himself from the frustrating situation. It is equally easy to see, however, how this behavior created problems in the classroom. By wandering around, he would be disrupting the learning of other children.

When the teacher tried to make him sit back down, she was increasing his frustration by removing from him the one method he had developed for coping. The result was that the teacher and child became locked in a power struggle. Each repeatedly frustrated the other to the point that the teacher was exasperated and angry with the child and the child lost control and would hit or kick the teacher. As soon as the teacher understood why this child needed to get out of his seat, her attitude towards him and consequently his reactions to her became more positive. With the emotional elements removed from this situation it became a relatively easy task to teach this child new coping strategies which were not disruptive to the classroom.

In conclusion, prenatal exposure to alcohol and other drugs is associated with numerous biological and environmental risk factors which may lead to emotional, behavioral, and/or learning problems in children. The research to date, however, is a testimony to the eternal resilience of children. Not all of the children exposed to multiple risk factors develop problems and the majority of those who do develop problems are very responsive to the benefits of consistent, predictable, nurturing care givers combined with early screening, diagnosis and intervention for their problems.

Dan R. Griffith is a clinical associate in the Department of Psychiatry and Behavioral Sciences, Northwestern University Medical School, Evanston, Ill. He was formally a developmental psychologist with the National Association for Perinatal Addiction, Chicago. He does independent consulting from his office:

Dan R. Griffith
Clinical Psychologist
1433 S. Brophy Street
Park Ridge, Illinois 60068
(847)692-744