Caring forChildren Exposed to Drugs During Pregnancy

For further information or copies of this booklet, contact Doug Burnham

Phone: 859 257-4785 email: burnham@uky.edu

Produced by: University of Kentucky College of Social Work

Training Resource Center Grandparents and Other Relatives Raising Children Training Project

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Introduction

There is plenty of reason to hope that children exposed to drugs during pregnancy can have happy and fulfilling lives. Some of these children may experience challenges, such as learning disabilities, physical limitations, and social impediments. However, with appropriate services, enlightened education opportunities and a loving home environment with caregivers who know how to use effective parenting skills these children can flourish.

Because there are so many factors that can effect the growing fetus and the newborn infant, it is sometimes difficult to know if the infant is responding to drug exposure or other conditions such as the mother’s general health, inadequate nutrition, poor living conditions, lack of prenatal care, ineffective parenting, abuse or neglect, or any number of other conditions or circumstances. This is part of the reason that these children need repeated physical and developmental assessments and evaluations. In these cases, as in most situations, it is development over time that is important to understand.

Each child will respond differently to drug exposure. Some children will show immediate responses to exposure. Some children will not exhibit any effects. For other children the effects will not show up until a later age. It should also be noted that most mothers who abuse drugs use more than one substance making it very difficult to identify specific effects of a particular substance.

This booklet is not intended to cover every characteristic of drug exposed babies or every possible strategy for managing their responses. It is, instead, offered as a beginning effort to understand some of the information available about these babies. Every baby is going to respond differently, based not only on the drug exposure but also to a multitude of other factors. It is hoped that you will keep good records of the experiences of the child in your care and find outlets for sharing that information with other caregivers.

Because of the stress and anxiety that often accompanies the care of children exposed to drugs, it is hoped that caregivers will find or build support systems that can fortify and nurture them. Self care is the caregiver’s gift to the child in their care.

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Effects of Alcohol

Fetal Alcohol Spectrum Disorder:

Fetal Alcohol Syndrome (FAS) – Characterized by growth deficiencies, particular facial features and developmental disorders

Alcohol-Related Neurodevelopment Disorders (ARND) – Characterized by significant delays or disorders in a number of developmental domains, but without the accompanying facial features. IQ may be depressed but usually not as much as the FAS child.

Physical characteristics or issues (It is usually these characteristics that are noticed first):

• Low birth weight• Frequent vomiting and diarrhea (making weight gain difficult)• Feeding problems and poor sucking• Disturbed sleep cycles• Cranial and facial features:• Abnormally small head (due to failure of brain growth)

(microcephaly)• Folds in the upper eyelid reaching from the nose to the end of the

eyelids • Small eye openings• Flat nasal bridge• Low set jaw• Receding jaw• Flattened mid-face• Short upturned nose• Flat philtrum (the space above the upper lip)• Thin upper lip• Benign cardiac tumors

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Possible birth defects (all of these do not usually occur in a child):

• Cleft palate• Eye problems• Hearing problems• Heart defects• Kidney changes• Unusual chest shape• Curved fingers• Shortened fingers and toes• Low muscle tone (floppy babies)• Super sensitive to strong odors, loud noises and rough clothing• Increased irritability and fussiness

Neurological or cognitive issues (usually observed a little later):

• Communication disorders• Language delays• Learning problems• Poor fine motor skills• Mental retardation• Difficulty bonding with caregivers• Difficulty understanding and expressing emotions• Frequent temper tantrums – quick mood changes• Interpersonal interaction problems• Memory problems• Attention deficits• Poor problem solving skills• Less socially competent and more aggressive• Antisocial behavior (ex: a lack of consideration of the rights

and feelings of others and responding negatively to limits and requests of authority figures)

• Difficulty understanding cause and effect• Poor judgment• Trouble applying knowledge

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Some suggested management strategies for caring for a child exposed to alcohol:

Infants:• Establish a professional team of medical and developmental

personnel (e.g. pediatricians, physical therapist, developmental specialist, occupational therapist, speech therapist - school systems can usually provide contact information)

• Establish and maintain routines• Provide a calm environment• Observe child’s response to various clothing • Provide gentle physical stimulation (e.g. holding baby next to

you; massaging back, legs, arms; moving joints – knees, elbows, fingers, wrist, ankles, toes, hips, neck; hugs)

• Interact with the baby with repetitive talk and songs• Frequent medical exams• Repeated developmental assessments• As much as the baby will tolerate, caress the face, chin, and neck.

This may help stimulate the sucking reflex.

Toddlers and preschoolers:• Provide structure and routine• Be predictable – react consistently• Use lots of repetition in teaching• Use multiple communication means• Read aloud• Limit stimuli when trying to teach skill• Break skills into steps• Give lots of positive feedback• Frequently re-teach skills• Expect learning to take longer• Use consistent language

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School age children:• Continue to provide structure and routine• Give positive feedback on small accomplishments (they have to

be real)• Read aloud • Partner with teachers and other school personnel• Advocate for appropriate education plan• Provide reminders• Avoid sarcasm• Plan and provide fun activities• Re-teach skills• Focus on strengths• Provide social opportunities that include one or two other

children• Seek physical and developmental re-evaluations and assessments

Adolescents:• Focus education appropriate to development (this could range

from preparation for higher education to job training)• Increase level of responsibility and foster independence• Provide clear guidance and rules for acceptable behavior• Monitor peer interactions and provide coaching on peer

interactions• Provide direct and clear information about sexual development,

birth control and protection from STDs• Encourage physical activity and recreation• Seek physical and developmental re-evaluations and assessments

Sources:Wake Forest University School of Medicine. (2004). Fetal Alcohol Syndrome: A

Parents Guide to Caring for a Child Diagnosed with FAS. Wake Forest, NC: Wake Forest University.

Hudak, Mark L., Rosemarie C. Tan. (2012). Neonatal Drug Withdrawal. Pediatrics. Elk Grove, ILL: American Academy of Pediatrics (published online January, 30,

2012).

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Effects of Cocaine and Crack Cocaine

Early Possible Characteristics Observed due to Exposure to Cocaine

Infants:• Lower birth-weight and shorter in length• Smaller head circumference (highly correlated with

neurodevelopment problems)• Piercing crying• Irritability and hypersensitivity (newborns may move quickly from

sleeping to screaming inconsolably)• Poor feeding (problems sucking)• High respiratory and heart rates• Poor sleep pattern – unable to sleep, apnea, deep sleep• Increased risk of malformations of the urinary tract• Some babies may exhibit a lack of coordination, early motor

delays, and difficulty tracking visual stimuli• If cocaine is used shortly before birth, the fetus may experience a

stroke• Retinopathy or damage to the iris• Tremulousness• Rigid or stiff body

Some suggested ways of managing the needs of these babies

Intervene before the infant becomes frantic. These babies are easily over stimulated. Some early signs of agitation are yawning, sneezing, exaggerated motor movements, color changes, and eye aversions. Some experts suggest that when a baby becomes frantic, swaddling or holding the baby close, keeping the body vertical and rocking side to side provide some comfort. Bouncing is not recommended. (Remove swaddling when the baby is no longer showing pre-frantic signs.)

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�ese babies usually do not need medication but do need a peaceful environment. If the baby is living in chaos it would be di�cult to provide the quiet tenderness needed. Because these babies are usually sti� with extended posture it is di�cult for them to bring their hands together or li� their legs while lying on their backs. It may be helpful to prop them on their sides, allowing them to grasp toys and play with their feet. Avoid bright lights and abrupt movements.

�ese babies should not be placed in walkers or jumpers.

Later behavioral and cognitive issues observed in cocaine exposed children include:

• Hyperactivity• Lack of organization• Distractibility – difficulty focusing their attention• Unpredictability• Difficulty dealing with transitions or change to routine• A deficit of social and interactional skills• Irritability• Difficulty sorting out relevant versus irrelevant stimuli, making

participation in school more difficult.

For children growing up in households where the parent or parents continue to use drugs, attachment is difficult. The parent(s) may be detached and neglectful. These children may:

• Exhibit more distrust of others and be less willing to learn from adults

• Have difficulties understanding the emotions of others• Have difficulties regulating their own emotions• Find it hard to maintain relationships with others• Have a limited ability to feel remorse or empathy• Demonstrate a lack of confidence and social skills, making school,

work, and relationships more difficult• Exhibit depression and anxiety• Score lower on school achievement tests

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Some suggested management ideas for these children as the get older (toddlers, preschoolers, and early school ages):

• Routine• Quiet but interactive environment• Consistency in care givers• Limited availability of play things• Slow and supervised introduction to other children• One on one time with caregiver and other caring adults in

developmentally appropriate play

• If children are to remain with substance abusing parents they will fair better if they have regular interactions with other caring and non-using adults.

• Draw upon the strengths and potentials of the child and support them.

Sources:Brown, Josephine V., Roger Bakeman, Claire D. Coles, Kathleen A. Platzman, Mary Ellen Lynch. (2004). Prenatal cocaine exposure: A comparison of 2-year-0ld children in parental and nonparenetal care. Child Development, 75, 1282-1295

Frank, D.A., M.Augustyn, W.G. Knight, T. Pell, B. Zuckerman. (2001). Growth, development and behavior in early childhood following prenatal cocaine exposure: A systematic review. Journal of the American Medical Association. 285, 613-625.

Frank, D.A., R. R. Jacobs, M. Beeghly, A. Augustyn, D. Bellinger, H. Cabral, et al. (2002). Level of prenatal cocaine exposure and scoreson the Bayley Scales of Infant Development: Modifying effect of caregiver, early intervention, and birth weight. Pediatrics, 110, 1143 – 1152.

Office on Child Abuse and Neglect, Children’s Bureau. (2009). How Parental Substance Use Disorders Affect Children, Protecting Children in Families Affected by Substance Use Disorders. Washington D.C. Administration for Children and Families. (retrieved from http://www.childwelfare.gov/pubs/usermanuals/substanceuse)August 8 2012.

Thompson, Barbara L., Pat Levitt and Gregg Stanwood. (2009). Prenatal exposure to drugs: effects on brain development and implications for policy and education.Nature Reviews Neuroscience (April 2008 10-4 pp 303-312). London, England.

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Effects of Methamphetamine

Early Possible Effects that might be observed:• Growth retardation• Low birth weight• Brain lesions• Difficulty sucking and swallowing • Hypersensitivity to touch• Extreme rigidity or floppiness• Respiratory problems• Lethargic, low arousal • Move quickly from deep sleep to screaming • Quickly become agitated and difficult to console• Poor quality of movement• Poor fine motor skills• May experience withdrawal – which can be traumatic and painful

(and go on for several weeks or months)

Some suggest strategies for caring for these infants:• Develop a strong team of professionals• Insist on periodic medical evaluations• Insist on periodic developmental evaluations• Create and maintain a quiet calm environment• Provide a pacifier• Avoid using swings or jumpers• Maintain a strict feeding schedule• Learn signs of agitation and respond quickly (swaddling, gentle

side to side swaying)• Establish and maintain routines• Allow your behavior as caregiver to become predictable• Remain positive and avoid negative self-fulfilling prophecies• Soft and gentle physical interaction – touch, massage, hugs• Provide soft and repeated verbal interaction – comforting sounds

like cooing and songs.

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• Reading to the baby is also recommended• Prop baby on his/her side so he/she can play with his/her feet• Floor play with baby (You can also play on a bed or other surface

as long as the adult is on the baby’s level)• Avoid over stimulating with too many play things• Develop a support system for caregiver

Effects that may be noticeable later – particularly as child enters a learning environment:

Emotional:• Depression • Feel bad about themselves• Exhibit lots of guilt and self blame• Feel like things will always be bad• Attach to strangers rather quickly but have difficulty trusting

caregivers

Behavioral:• Like to be alone• Eat too much or too little• Have a hard time focusing or paying attention• Signs of ADHD• Impulsive • Transitions are very difficult• Do not get on well with others• Move quickly from being very active to being very tired

Cognitive:• Some difficulties in talking and listening• Trouble reading – moving from left to right• Difficulty remembering a list of things• Difficulty remembering what they were just told• May not easily learn from mistakes or experiences• May not pick up on cues• Difficulty paying attention – may seem like they are in a fog

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Some suggested strategies in caring for these children:• Maintain routine• Be predictable• Maintain professional team• Insist on periodic physical and developmental evaluations• Advocate for your child – particularly with the school system or

social services• Be realistic and patient• Find a couple of things they are good at and help them achieve in

these areas• Provide lots of verbal support and encouragement• When teaching skills you may need to repeat several times• Respond to their developmental age rather then their

chronological age • If they have established family roles, honor them but slowly

remove burdensome adult responsibility• Assist them in labeling their emotions• Develop a support system for caregiver• You may have to educate teachers, youth leaders, child care

providers and others who have regular contact• Honor birth parents and discuss them positively. This promotes

the child’s feeling of “lovability”• Assist pre teens and teens in learning more about their own

history

Sources:Kronstadt, Diana (Spring, 1991). Complex developmental issues of prenatal drug

exposure. The Future of Children. Vol 1, No1.Princeton, NJ. Woodrow Wilson School of Public and International Affairs, Princeton University.

LaGasse, Linda L., Chris Derauf, Lynne M Smith, Elana Newman, Rizwan Shah, Charles Neal, Amelia Arria, Marilyn Huestis, Sheri DellaGrotta, Hal Lin, Lynn M Dansereau, Barry Lester. (2012). Prenatal methamphetamine exposure and childhood behavior problems at 3 and 5 years of age. Pediatrics. Vol 129, no. 4. Elk Grove, ILL., American Academy of Pediatrics.

National Alliance for Drug Endangered Children (2003). Drug Exposed Children: What Caregivers Should Know. National Alliance for Drug Endangered Children.

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Oregon Post Adoption Resource Center. Parenting Children Who Have Been Exposed to Methamphetamine. Salem, Oregon. Oregon Department of Human Services.

Sheridan, Kathryn, Wendy I Haight, Leah Cleeland. (2011). The role of grandparents in preventing aggressive and other externalizing behavior problems in children from rural, methamphetamine-involved families. Children and Youth Services Review. Vol 33.

Retrieved from www.elservoer/cp,/locate/childyouth March 1, 2013.

Smith, Lynne, Linda L, LaGassee, Chris Derauf, Penny Grant, Rizwan Shah, Amelia Arria, Marilyn Huestis, William Haning, Arthur Strauss, Sheir Dela Grotta, Jing Liu, Barry M. Lester (2006). The infant development, environment, and lifestyle study: effects of prenatal methamphetamine exposure, polydrug exposure, and poverty on intrauterine growth. Pediatrics, vol 118 no 3. Elk Grove, ILL., American Academy of Pediatrics

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Further Reading

Fantastic Antone Succeeds: Experiences in Educating Children with Fetal Alcohol Syndrome by Judith Kleinfeld (1993). University of Alaska, Anchorage

Fantastic Antone Grows Up: Adolescents and Adults with Fetal Alcohol Syndrome by Judith Kleinfeld (2000). University of Alaska, Anchorage

Trying Differently Rather than Harder: Fetal Alcohol Spectrum Disorder by Diane Malbin

Bruised Before Birth: Parenting Children Exposed to Prenatal Substance Abuse by Joan McNamara, Amy Bullock, and Elizabeth Grimes, 1993

Best I Can Be: Living with Fetal Alcohol Effects by Liz Kulp 2013 (4th ed.)

Forfeiting All Sanity: A Mother's Story of Raising a Child with Fetal Alcohol Syndrome by Jennifer Poss Taylor 2010, Tate Publishing and Enterprises, LLC. Mustang, OK

Damaged Angels: An Adoptive Mother Discovers the Tragic Toll of Alcohol in Pregnancy by Bonnie Bixton 2004, Carroll and Graf Publishers. NY, NY

Tool Kit for Children Prenatally Drug Exposed. Macomb Intermediate School District (Michigan). http://www.misd.net/earlyon/PrenatalDrugExposureToolKit.pdf

Parenting Children who have been Exposed to Methamphetamine. Oregon Post Adoption Resource Center. Portland, Oregon. http://www.ohsu.edulmarc/orpostadoptionresourcecenter.pdf

This booklet was produced and printed in whole or part with state or federal funds.

July 2013

Grandparents and Other Relatives Raising Children Training Project