Journal Issue: Drug-Exposed Infants Volume 1 Number 1 Spring 1991
Introduction to this Issue
We believe that policy development regarding many of the important issues affecting children today can benefit from comprehensive and multidisciplinary discussion. Toward this end, The Future of Children will focus on selected topics through a series of articles representing different perspectives.
The problem of drug-exposed children is appropriate for this inaugural issue. Public concern about this problem is very high, while public debate is heated and divided. Research and analysis can be helpful in sorting out many of the issues critical to resolving this problem. Furthermore, the varying viewpoints from child welfare, law, economics, medicine, ethics, and developmental psychology are both relevant and necessary in formulating policy responses. It is our hope that the articles presented in this issue will provide useful information and perspective in each of these areas.
Our contributors for this issue include an epidemiologist, psychologists, a pediatrician and researcher, an educator experienced in setting up and evaluating drug treatment programs, a child protective services professional, attorneys representing reproductive rights advocacy and a county attorney's office, a juvenile court judge from one of our largest cities, a medical ethicist, and a health economist. The approaches of the articles range from essaylike perspectives, to review and analysis of the research literature, to descriptive overviews. The Center staff has provided a synthesis and analysis of our current state of knowledge as a basis for a series of policy recommendations.
The primary focus of this issue is illegal drug use during pregnancy, with most frequent reference to use of cocaine. However, in a number of the articles, information about other illegal drugs as well as alcohol and tobacco is presented for comparison purposes. When these drugs are included, the authors refer to "substance exposure" rather than drug exposure.
The issue begins with an analysis of the various studies of the prevalence of drugexposed infants in the United States. Deanna S. Gomby, Ph.D., and Patricia H. Shiono, Ph.D., members of the Center staff, compare the results of hospital-based and population-based studies in their analysis of the research to date. They use the 1990 NIDA Household Survey results along with other data to estimate the number of drugexposed infants born in the U.S. each year.
The article by Barry Zuckerman, M.D., chief of the Division of Developmental and Behavioral Pediatrics at Boston City Hospital and professor of pediatrics at Boston University School of Medicine, presents an overview of the known medical and pharmacologic effects of prenatal exposure to legal and illegal substances, including cigarettes, alcohol, heroin, narcotics, marijuana, and cocaine. Zuckerman points out the complicating factors of biologic variability in infant and maternal response to drug exposure, the differing short- and long-term pharmacologic actions of the individual drugs, and the unknown interactive effects of polydrug exposure. After discussing the numerous unanswered questions and research issues relevant to this problem, he concludes with reference to the many studies that show that outcomes from physiological impairments can be improved or worsened by social factors, such as the quality of caretaking for the child.
In her discussion of developmental issues related to prenatal drug exposure, Diana Kronstadt, Ed.D., draws on past research into the array of behavioral characteristics of drug-exposed newborns. She points out the multiplicity of factors involved in assessing developmental outcomes for drug-exposed infants, including the reality of today's polydrug use and the variations in purity, dosage, and timing in pregnancy when drugs are taken. While Kronstadt recognizes the difficulty in determining the developmental impact of any specific substance, she recommends intensive early intervention efforts for drug-exposed children, based on existing strategies developed primarily for other vulnerable children.
Next, Karol Kumpfer, Ph.D., associate professor of Health Education at the University of Utah, discusses the availability and effectiveness of drug treatment programs. She reviews available treatment effectiveness research and discusses the lack of both research and programs directed toward pregnant women. She describes these and other barriers that impede women from seeking treatment and urges that treatment programs must serve the special needs of women. Finally, she summarizes some of the current federal research and demonstration projects, state initiatives, and model programs.
Focusing on the child welfare and child protective services systems, Charlotte McCullough, M.Ed., program director with Child Welfare League of America, Inc., describes how these systems are being overly stressed by the dramatic increase in demand for services due to increased numbers of children either exposed to drugs prenatally or otherwise endangered by parental drug use. She refers to established approaches toward family preservation and describes the continuum of services and interventions necessary for drug-exposed children and their families, including in-home and out-of-home services, foster care, kinship care, orphanages, adoption, and residential care. The need for comprehensive, innovative treatment programs, including long-term residential drug treatment that includes mothers with their children, is presented in the context of a call for a coordinated response to these families by multiple agencies and systems.
The next set of papers sets forth the legal issues involved in formulating a response to drug-exposed children. Carol Larson, J.D., on the Center staff, presents an overview of the various state legislative and judicial responses to the problem. She discusses current case and statutory law relating to interventions directed either at women during pregnancy and/or the mother and drug-exposed infant after the birth. Larson also discusses the legal framework for these interventions, including criminal laws and civil abuse and neglect laws.
The Larson article serves as an introduction to the three essays that follow, which present perspectives of a reproductive rights attorney, two assistant county attorneys, and a juvenile court judge. Lynn Paltrow, a senior staff attorney with the ACLU's Reproductive Freedom Project, offers her perspective that prosecuting women accused of using drugs while pregnant is both unconstitutional and bad policy. Sonya Steven and Ann Stiehm Ahlstrom, attorneys with the Hennepin County District Attorney's Office in Minnesota, describe what they see as the advantages of that state's law, which includes mandatory reporting to a welfare agency of pregnant women who use drugs and of drug-exposed infants, the provision of services to these women through an interdisciplinary approach, and the possibility of civil commitment if a pregnant woman refuses these services. Finally, as a juvenile court judge in a county burdened by a serious case overload due to the drug problem, Judge Paul Boland of the Los Angeles Juvenile Court offers his perspective about what courts can do to better handle cases involving drug-exposed infants. This includes providing training for judges, legal representation for children, increased clarity in expectations of child welfare, and system-wide resource planning.
Following these perspectives from the legal community, Thomas Murray, Ph.D., director of the Center for Biomedical Ethics at Case Western Reserve University School of Medicine, analyzes the problem of drug-exposed children from the standpoint of an ethicist. He elucidates the complex set of ethical considerations involved in assessing parental and societal responsibilities for the health and welfare of born and unborn children. He emphasizes that any policy response to this problem must be evaluated according to the criteria that it be effective, proportionate, and efficient.
Our issue ends with an article by Ciaran Phibbs, Ph.D., of the Institute for Health Policy Studies at the University of California, San Francisco, discussing the economic implications of maternal substance abuse. Although there is currently a lack of accurate estimates of the total cost in terms of medical, social, and educational expenditures for prenatal substance exposure, Phibbs develops an estimate of both short-term and long-term costs by extrapolating from data on costs related to maternal smoking and alcohol and cocaine use. Stressing a preventive approach, Phibbs emphasizes the need for and cost-effectiveness of programs to reduce the number of women who use drugs during pregnancy.