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Journal Issue: Preventing Child Maltreatment Volume 19 Number 2 Fall 2009

Prevention and Drug Treatment
Authors: Mark F. Testa Brenda Smith

Might Other Interventions Better Address the Risk of Child Maltreatment?

In the spring of 2008, the Chicago Tribune ran a story about a recent graduate of Morehouse College under the headline: “Proof Positive of Flawed Data.” It told the story of a Rhodes Scholarship finalist who was born substance-exposed at the start of the SEI epidemic in Chicago in 1986, “among a wave of inner-city babies exposed to crack in their mother’s womb, children written off by much of society as a lost generation doomed to failure.”59 The article asserted that the drug panic was fueled by flawed data that warned of neurologically damaged and socially handicapped children that would soon flood the nation’s schools and, later on, its prisons.

More recent opinion has backed away from such dire predictions. Much of the earlier work failed to consider the myriad of adverse social, environmental, and other factors that confound the association between parental substance use and impaired childhood growth and development. Barry Lester was among the first researchers to note that early studies of substance-exposed infants over-estimated the effects of cocaine exposure by attributing to cocaine adverse effects that were probably related to other influences such as multiple-drug use, poverty, or cigarette smoking.60 The challenges associated with identifying specific effects of prenatal cocaine exposure, along with the wide-ranging findings of research on the topic, led a group of leading researchers, including Lester, to argue publicly that no particular set of symptoms supports the popular notion of a “crack baby” syndrome.61 They asked the media to stop using the stigmatizing term.62

Recently, however, Lester has noted that some well-designed studies that control for a range of influences are identifying some apparent effects of prenatal cocaine exposure that may even increase over time.63 The studies suggest that prenatal cocaine exposure may have neurological effects that become visible only when “higher level demands are placed on the child’s cognitive abilities.”64 Lester argues that just as it was initially a mistake to overstate the effects of prenatal cocaine exposure, it would also be a mistake to overlook potential effects that are still largely unknown and warrant further research.

A recent study in Atlanta, Georgia, helps to isolate the effects of prenatal cocaine exposure from the effects of the caregiving environment.65 The researchers compared cocaine-exposed infants who remained with their mothers and cocaine-exposed infants placed with alternative caregivers. At two years old, despite having more risk factors at birth, the toddlers with non-parental caregivers had more positive cognitive-language and social-emotional outcomes than did the toddlers living with their parents. Outcomes for the cocaine-exposed toddlers with non-parental caregivers were even slightly more positive than for other toddlers in the study who had not been exposed to cocaine and remained with their mothers. The results underscore the importance of a nurturing caregiving environment for children’s well-being and illustrate that efforts to identify and isolate effects of prenatal cocaine exposure must account for the caregiving context.

In the absence of a definitive link between intrauterine substance exposure and developmental harm, it is difficult to justify categorizing such exposure as a form of child abuse and neglect in its own right. At the same time, it would be imprudent to back off entirely from drug screening at birth. Although some of the higher association of intrauterine substance exposure with subsequent maltreatment is clearly self-referential—that is, drug addicts are more likely to be indicated for future child maltreatment than non-addicts simply because ingestion of illicit substances during pregnancy is itself a reportable allegation—an indicated SEI report is still a useful marker of future risk.66 SEI reports are correlated with mental illness, domestic violence, poverty, homelessness, and other disadvantages that may be more directly associated with child maltreatment. The major inadequacy with existing hospital surveillance practices is that screening is done selectively in such a way that puts African American infants at disproportionate risk of CPS detection and involvement.

Universal screening of all births for substance exposure may be one way to address the inequities in the current process, but targeting illicit substances for special attention may serve only to reify the belief that drug treatment, recovery, and abstinence mark out the best route for ensuring child safety and justifying family reunification. Attending to this one visible manifestation of an underlying complex of family and personal problems can give the false impression that complying with treatment regimes and demonstrating prolonged abstinence are sufficient for deciding when to move forward with reunification plans. But the best evidence to date suggests that successful completion of drug treatment is no better a predictor of future maltreatment risk than non-completion.67 Caseworkers and judges seem to have learned this lesson from their own experience because only one-quarter of participants who successfully completed drug treatment in the Illinois AODA demonstration were eventually reunified with their children.

Conversely, parental failures to comply with treatment plans and to demonstrate abstinence may be imperfect indicators of their capacity to parent their children at a minimally adequate level. The best evidence to date suggests that parents of substance-exposed infants pose no greater risk to the safety of their children than parents of other children taken into child protective custody.68 Caseworkers and judges may thus want to consider implementing reunification plans some time after parents engage successfully in treatment but before they demonstrate total abstinence from future drug use. Perhaps the best course of action is to take the spotlight off of parental drug abuse and treatment completion and shine it instead on other co-factors, such as mental illness, domestic violence, and homelessness, that may be more directly implicated in causing harm to a child. A shift of attention from substance abuse to other risk factors could have the additional benefit of reducing stigma and the conflict parents may face if they fear that admitting substance abuse or asking for help with an addiction will lead to loss of child custody.

Although clearly more can be done to improve the integration of services to address the myriad of family and personal problems, such as mental illness, domestic violence, and homelessness, that, along with substance abuse, impair parenting, at some point in the intervention process attention needs to turn to the permanency needs and well-being of the child. Even though the young man profiled in the Chicago Tribune story was one of the 50 percent of substance-exposed infants who were never taken into foster care, by his own account life was not easy for him: “Mom would get drunk and hit me. I had to call the cops and send her to the drunk tank a couple of times.”69 Things finally turned around when his aunt, a Chicago Public Schools administrator, took him into her home at age fourteen: “My aunt’s house was a place of peace. She gave me a place that allowed me to grow. She had books everywhere, even in the bathroom.”70

Both personal accounts and the best research evidence indicate that finding a safe and lasting home for children born substance-exposed is critical to their healthy development and well-being. As of December 2007, however, only 39 percent of children assigned to the treatment group under the Illinois AODA demonstration had exited from foster care, compared with 36 percent in the comparison group. Not only does this small, albeit statistically significant, difference raise concerns about the advisability of heavily investing in recovery coach services, it raises additional questions about the permanency needs of the remaining 61 to 64 percent of drug-involved children who are still in foster care. Because the average age of children born substance-exposed who are removed from parental custody is less than three, it should not be too challenging to find them permanent homes with relatives either as guardians or as adoptive parents or with foster parents who are willing to become their adoptive parents. Although it is unwise to set too firm guidelines, it strikes us as sensible to set a six-month timetable for parents to engage in treatment and twelve to eighteen months to show sufficient progress in all identified problem areas (presuming that both engagement and progress are determined with fair and valid measures). Thereafter, permanency plans should be expedited to place the child under the permanent guardianship of a relative caregiver or in the adoptive home of a relative, foster parent, or other suitable family. As regards the birth of another substance-exposed infant, it seems reasonable, assuming the availability of services, to initiate alternative permanency plans for all of the children unless the parent demonstrates sufficient progress in all problem areas within six months of the latest child’s birth.

In light of the difficulty of isolating the direct effects of prenatal substance abuse and the most recent evidence that some detrimental effects of intrauterine substance exposure on child development may increase over time, the newest empirical findings on the efficacy of Illinois’ recovery coach model in decreasing births of substance-exposed infants helps to bolster the case for improved treatment and service coordination regardless of whether intrauterine substance exposure is considered a form of child maltreatment in its own right. Preventing another potential risk to future child well-being, even if parental substance abuse and intrauterine substance exposure prove not to be determinative of child maltreatment directly, seems well worth the cost of investing in parental recovery from substance abuse and dependence. Such efforts, however, should not substitute for a comprehensive approach that addresses the myriad of social and economic risks to child well-being beyond the harms associated with parental substance abuse.