In This Chapter
- The impact of substance use on prenatal development
- The impact of substance use on childhood development
The lives of millions of children are touched by substance use disorders (SUDs). The 2007 National Survey on Drug Use and Health reports that 8.3 million children live with at least one parent who abused or was dependent on alcohol or an illicit drug during the past year. This includes 13.9 percent of children aged 2 years or younger, 13.6 percent of children aged 3 to 5 years, 12.0 percent of children aged 6 to 11 years, and 9.9 percent of youths aged 12 to 17 years.48 These children are at increased risk for abuse or neglect, as well as physical, academic, social, and emotional problems.49
A predictable, consistent environment, coupled with positive caregiver relationships, is critical for normal emotional development of children. Parental substance abuse and dependence have a negative impact on the physical and emotional well-being of children and can cause home environments to become chaotic and unpredictable, leading to child maltreatment. The children's physical and emotional needs often take a back seat to their parents' activities related to obtaining, using, or recovering from the use of drugs and alcohol.50
This chapter discusses how prenatal and postnatal substance use by parents affects fetal and early childhood development. It is intended to help child protective services (CPS) caseworkers understand the behaviors and problems that some children in the child welfare system may exhibit and that hold implications for their potential need for services.
A Definition of Child Maltreatment
The Child Abuse Prevention and Treatment Act, reauthorized in the Keeping Children and Families Safe Act of 2003 (P.L. 108-36), provides the minimum standards for defining child physical abuse, neglect, and sexual abuse that States must incorporate into their statutory definitions in order to receive Federal funds. Under this Act, child maltreatment is defined as:
"Any recent act or failure to act on the part of a parent or caregiver, which results in death, serious physical or emotional harm, sexual abuse or exploitation, or an act or failure to act which presents an imminent risk of serious harm."51
A "child" under this definition generally means a person younger than age 18 or who is not an emancipated minor. In cases of child sexual abuse, a "child" is one who has not attained the age of 18 or the age specified by the child protection law of the State in which the child resides, whichever is younger.52
The Impact on Prenatal Development
In 2006 and 2007, an average of 5.2 percent of pregnant women aged 15 to 44 years used an illicit drug during the month prior to being surveyed, and 11.6 percent had consumed alcohol.53 Nationwide, between 550,000 and 750,000 children are born each year after prenatal exposure to drugs or alcohol.54 These children often are medically fragile or born with a low birth weight. Some are born prematurely and require intensive care.
Identifying the effects of drugs and alcohol on fetuses has posed challenges for researchers. While there has been some success researching the effects of alcohol on fetal development, securing accurate information regarding the use of illicit drugs from pregnant women or women who have given birth has proven to be very difficult. In addition, women who abuse substances often have other risk factors in their lives (e.g., a lack of prenatal care, poor nutrition, stress, violence, poor social support) that can contribute significantly to problematic pregnancies and births.
The sections that follow summarize some of what is known about the effects of substance use on prenatal development.
Pregnancy and SUDs
Women who use alcohol or illicit drugs may find it difficult or seemingly impossible to stop, even when they are pregnant. Moreover, pregnancy can be stressful and uncomfortable. For someone who commonly uses drugs and alcohol to minimize pain or stress, this practice may not only continue, but also become worse. Pregnant women can face significant stigma and prejudice when their SUDs are discovered. For these reasons, some women avoid seeking treatment or adequate prenatal care. Other pregnant women, however, do seek treatment. According to the Substance Abuse and Mental Health Services Administration, 3.9 percent of the women admitted to State licensed or certified SUD treatment programs were pregnant at the time of admission.55 In another study, pregnant women aged 15 to 44 years were more likely than nonpregnant women of the same age group to enter treatment for cocaine abuse.56
Screening Newborns at Birth
Opinions differ about how best to respond to prenatal substance exposure. Some hospitals are reconsidering whether they should test newborns for drugs, and some courts are treating prenatal substance exposure as a public health matter, turning to CPS only if they determine the child was harmed. Decisions regarding whether and when to screen newborns for prenatal substance exposure are beyond the purview of CPS.
Child welfare legislation has provided some guidance regarding how such cases should be handled. The Keeping Children and Families Safe Act of 2003 requires that health care providers notify CPS, as appropriate, to address the needs of infants born exposed to drugs, and requires the development of a plan of safe care for any affected infants. In 2006, statutes in 15 States and the District of Columbia specified reporting procedures when there is evidence at birth that an infant was exposed prenatally to drugs, alcohol, or other controlled substances. Additionally, 13 States and the District of Columbia included prenatal substance exposure in their definitions of child abuse or neglect.57
The Effects of Prenatal Exposure to Alcohol
Drinking alcohol during pregnancy can have serious effects on fetal development. Alcohol consumed by a pregnant woman is absorbed by the placenta and directly affects the fetus.58 A variety of birth defects to the major organs and the central nervous system, which are permanent, can occur due to alcohol use during pregnancy, though the risk of harm decreases if the pregnant woman stops drinking completely.59 Collectively, these defects are called Fetal Alcohol Syndrome (FAS). FAS is one of the most commonly known birth defects related to prenatal drug exposure. Children with FAS may exhibit:
- Growth deficiencies, both prenatally and after birth
- Problems with central nervous system functioning
- IQs in the mild to severely retarded range
- Small eye openings and poor development of the optic nerve
- A small head and brain
- Joint, limb, ear, and heart malformations.
Alcohol-Related Neurodevelopmental Disorder (ARND) and Alcohol-Related Birth Defects (ARBD) are similar to FAS. Once known as Fetal Alcohol Effects, ARND and ARBD are terms adopted in 1996 by the National Academy of Sciences' Institute of Medicine. ARND and ARBD encompass the functional and physiological problems associated with prenatal alcohol exposure, but are less severe than FAS. Children with ARND can experience functional or mental impairments as a result of prenatal alcohol exposure, and children with ARBD can have malformations in the skeletal and major organ systems. Not all children who are exposed prenatally to alcohol develop FAS, ARND, or ARBD, but for those who do, these effects continue throughout their lives and at all the stages of development, although they are likely to present themselves differently at each developmental stage. Exhibit 3-1 compares typical childhood behavior at each developmental stage with behaviors and characteristics associated with FAS, ARND, and ARBD.
Exhibit 3-1
Childhood Behavior and Characteristics Associated with FAS, ARND, and ARBD60
Developmental Stage
Typical Behaviors or Characteristics
FAS/ARND/ARBD Behaviors or Characteristics
Infants
- Develop mental and physical skills
- Bond with caretakers
- Problems with spatial and depth perception, muscle coordination and development, facility with speech, and processing information
- Attention deficit disorder
- Inability to focus
- Possible attachment disorders
Toddlers
- Develop sense of self
- Assert independence by saying "no"
- Difficulty exercising self-control, which leads to self doubt and feelings of inadequacy
5–7 year olds
- Try new things
- Meet or exceed academic standards
- Learn new social skills
- Overwhelmed with new situations and interactions with other children
- Inability to pick up social skills by observation
- Problems meeting academic standards
8–12 year olds
- Increased influence of peers
- Games become important method of bonding and developing interpersonal skills
- Difficulty remembering rules of games
- Lack of remorse in breaking rules
- Become depressed and exhibit other behavior problems
Teenagers
- Continued detachment from parents
- Development of individual identity
- Learn to identify with larger community
- May lack skills to become good community members
- Become socially isolated
- May find their way to peer groups that engage in high risk behaviors
- May withdraw altogether from groups
More information on FAS is available from the National Organization on Fetal Alcohol Syndrome (http://www.nofas.org
) and the National Center on Birth Defects and Developmental Disabilities (http://www.cdc.gov/ncbddd/fas).
The Effects of Prenatal Exposure to Drugs
Similar to alcohol use, use of other substances can have significant effects on the developing fetus. For example, cocaine or marijuana use during pregnancy may result in premature birth, low birth weight, decreased head circumference, or miscarriage.61Prenatal exposure to marijuana has been associated with difficulties in functioning of the brain.62 Even if there are no noticeable effects in the children at birth, the impact of prenatal substance use often can become evident later in their lives. As they get older, children who were exposed to cocaine prenatally can have difficulty focusing their attention, be more irritable, and have more behavioral problems.63 Difficulties surface in sorting out relevant versus irrelevant stimuli, making school participation and achievement more challenging.
The Effects of Prenatal Methamphetamine Use
Prenatal exposure to methamphetamine can cause a wide range of problems, including birth defects, fetal death, growth retardation, premature birth, low birth weight, developmental disorders, and hypersensitivity to touch in newborns. Older children who were exposed prenatally to substances may exhibit cognitive deficits, learning disabilities, and poor social adjustment.64
Caseworkers should note that methamphetamine users might not be knowledgeable about the potential harm to themselves or to the fetus. Like cocaine and heroin users, methamphetamine users tend to avoid prenatal care clinics.65 Caseworkers also should be careful of labeling children who have been exposed prenatally to methamphetamine. For example, labeling a child as a "meth baby" can cause the child or others to have lower expectations for academic and life achievements and to ignore other causes for the physical and social problems the child may encounter.66
Pregnancy as a Motivation for Treatment
Given the dangers associated with substance use during pregnancy, women who abuse substances during pregnancy should receive treatment as early as possible. Research has found that women often are more amenable to entering treatment when they are pregnant.67 CPS caseworkers and other professionals, therefore, should try to use the pregnancy to motivate women to change. CPS caseworkers may not have much opportunity to interact with women who have not yet given birth unless there are other children in the family who have entered the child welfare system.
Once their babies are born, significant changes can occur in the lives of women who abused alcohol or drugs during pregnancy. In the case of babies who test positive for substances at birth, the mothers may experience remorse and sadness over the actual or potential consequences of their substance use, which also can be a motivating factor to seek treatment. If CPS is involved, mothers may admit to enough drug use to explain the positive drug test, but not to an addiction, due to the fear of losing custody of their children. They may comply with treatment requirements in order to compensate for the problems their SUD may have caused their children. Nevertheless, new difficulties may begin when CPS closes the case and the pressure is off the mothers to stay clean. For instance, they may be tempted to use drugs and alcohol again. (For more information on treatment issues, see Chapter 5, Treating Substance Use Disorders.)
The Impact on Childhood Development
Exposure to parental SUDs during childhood also can have dire consequences for children. Compared to children of parents who do not abuse alcohol or drugs, children of parents who do, and who also are in the child welfare system, are more likely to experience physical, intellectual, social, and emotional problems. Among the difficulties in providing services to these children is that problems affected or compounded by their parents' SUDs might not emerge until later in their lives.68
This section summarizes some of the consequences of SUDs on childhood development, including a disruption of the bonding process; emotional, academic, and developmental problems; lack of supervision; parentification; social stigma; and adolescent substance use and delinquency.
Disruption of the Bonding Process
When mothers or fathers abuse substances after delivery, their ability to bond with their child—so important during the early stages of life—may be weakened. In order for an attachment to form, it is necessary that caregivers pay attention to and notice their children's attempts to communicate. Parents who use marijuana, for example, may have difficulty picking up their babies' cues because marijuana dulls response time and alters perceptions. When parents repeatedly miss their babies' cues, the babies eventually stop providing them. The result is disengaged parents with disengaged babies. These parents and babies then have difficulty forming a healthy, appropriate relationship.
Neglected children who are unable to form secure attachments with their primary caregivers may:
- Become more mistrustful of others and may be less willing to learn from adults
- Have difficulty understanding the emotions of others, regulating their own emotions, or forming and maintaining relationships with others
- Have a limited ability to feel remorse or empathy, which may mean that they could hurt others without feeling their actions were wrong
- Demonstrate a lack of confidence or social skills that could hinder them from being successful in school, work, and relationships
- Demonstrate impaired social cognition, which is awareness of oneself in relation to others as well as of others' emotions. Impaired social cognition can lead a person to view many social interactions as stressful.69
Emotional, Academic, and Developmental Problems
Children who experience either prenatal or postnatal drug exposure are at risk for a range of emotional, academic, and developmental problems. For example, they are more likely to:
- Experience symptoms of depression and anxiety
- Suffer from psychiatric disorders
- Exhibit behavior problems
- Score lower on school achievement tests
- Demonstrate other difficulties in school.
These children may behave in ways that are challenging for biological or foster parents to manage, which can lead to inconsistent caregiving and multiple alternative care placements.
Positive social and emotional child development generally has been linked to nurturing family settings in which caregivers are predictable, daily routines are respected, and everyone recognizes clear boundaries for acceptable behaviors.70 Such circumstances often are missing in the homes of parents with SUDs. As a result, extra supports and interventions are needed to help children draw upon their strengths and maximize their natural potential despite their home environments. Protective factors, such as the involvement of other supportive adults (e.g., extended family members, mentors, clergy, teachers, neighbors), may help mitigate the impact of parental SUDs.
Lack of Supervision
The search for drugs or alcohol, the use of scarce resources to pay for them, the time spent in illegal activities to raise money for them, or the time spent recovering from hangovers or withdrawal symptoms can leave parents with little time or energy to care properly for their children. These children frequently do not have their basic needs met and often do not receive appropriate supervision. In addition, rules about curfews and potentially dangerous activities may not be enforced or are enforced haphazardly. As a result, SUDs are often a factor in neglect cases.
Parentification
As children grow older, they may become increasingly aware that their parents cannot care for them. To compensate, the children become the caregivers of the family, often extending their caregiving behavior to their parents as well as younger siblings. This process is labeled "parentification."71
Parentified children carry a great deal of anxiety and sometimes go to great lengths to control or to eliminate their parents' use of drugs or alcohol. They feel responsible for running the family. These feelings are reinforced by messages from the parents that the children cause the parents' SUDs or are at fault in some way if the family comes to the attention of authorities. Sometimes these children must contact medical personnel in the case of a parent's overdose, or they may be left supervising and caring for younger children when their parents are absent while obtaining or abusing substances.
Social Stigma
Adults with SUDS may engage in behaviors that embarrass their children and may appear disinterested in their children's activities or school performance. Children may separate themselves from their parents by not wanting to go home after school, by not bringing friends to the house, or by not asking for help with homework. These children may feel a social stigma attached to certain aspects of their parents' lives, such as unemployment, homelessness, an involvement with the criminal justice system, or SUD treatment.
Adolescent Substance Use and Delinquency
Adolescents whose parents have SUDs are more likely to develop SUDs themselves. Some adolescents mimic behaviors they see in their families, including ineffective coping behaviors such as using drugs and alcohol. Many of these children also witness or are victims of violence. It is hypothesized that substance abuse is a coping mechanism for such traumatic events.72 Moreover, adolescents who use substances are more likely to have poor academic performance and to be involved in criminal activities. The longer children are exposed to parental SUD, the more serious the negative consequences may be for their overall development and well-being.
https://www.childwelfare.gov/pubs/usermanuals/substanceuse/chapterthree.cfm
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