NYHOMESTUDY BLOG

January 27, 2009

By SUSAN OKIE
BALTIMORE – One sister is 14; the other is 9. They are a vibrant pair: the
older girl is high-spirited but responsible, a solid student and a devoted
helper at home; her sister loves to read and watch cooking shows, and she
recently scored well above average on citywide standardized tests.

There would be nothing remarkable about these two happy, normal girls if it
were not for their mother’s history. Yvette H., now 38, admits that she used
cocaine (along with heroin and alcohol) while she was pregnant with each
girl. “A drug addict,” she now says ruefully, “isn’t really concerned about
the baby she’s carrying.”

When the use of crack cocaine became a nationwide epidemic in the 1980s and
’90s, there were widespread fears that prenatal exposure to the drug would
produce a generation of severely damaged children. Newspapers carried
headlines like “Cocaine: A Vicious Assault on a Child,” “Crack’s Toll Among
Babies: A Joyless View” and “Studies: Future Bleak for Crack Babies.”

But now researchers are systematically following children who were exposed
to cocaine before birth, and their findings suggest that the encouraging
stories of Ms. H.’s daughters are anything but unusual. So far, these
scientists say, the long-term effects of such exposure on children’s brain
development and behavior appear relatively small.

“Are there differences? Yes,” said Barry M. Lester, a professor of
psychiatry at Brown University who directs the Maternal Lifestyle Study, a
large federally financed study of children exposed to cocaine in the womb.
“Are they reliable and persistent? Yes. Are they big? No.”

Cocaine is undoubtedly bad for the fetus. But experts say its effects are
less severe than those of alcohol and are comparable to those of tobacco -
two legal substances that are used much more often by pregnant women,
despite health warnings.

Surveys by the Department of Health and Human Services in 2006 and 2007
found that 5.2 percent of pregnant women reported using any illicit drug,
compared with 11.6 percent for alcohol and 16.4 percent for tobacco.

“The argument is not that it’s O.K. to use cocaine in pregnancy, any more
than it’s O.K. to smoke cigarettes in pregnancy,” said Dr. Deborah A. Frank,
a pediatrician at Boston University. “Neither drug is good for anybody.”

But cocaine use in pregnancy has been treated as a moral issue rather than a
health problem, Dr. Frank said. Pregnant women who use illegal drugs
commonly lose custody of their children, and during the 1990s many were
prosecuted and jailed.

Cocaine slows fetal growth, and exposed infants tend to be born smaller than
unexposed ones, with smaller heads. But as these children grow, brain and
body size catch up.

At a scientific conference in November, Dr. Lester presented an analysis of
a pool of studies of 14 groups of cocaine-exposed children – 4,419 in all,
ranging in age from 4 to 13. The analysis failed to show a statistically
significant effect on I.Q. or language development. In the largest of the
studies, I.Q. scores of exposed children averaged about 4 points lower at
age 7 than those of unexposed children.

In tests that measure specific brain functions, there is evidence that
cocaine-exposed children are more likely than others to have difficulty with
tasks that require visual attention and “executive function” – the brain’s
ability to set priorities and pay selective attention, enabling the child to
focus on the task at hand.

Cocaine exposure may also increase the frequency of defiant behavior and
poor conduct, according to Dr. Lester’s analysis. There is also some
evidence that boys may be more vulnerable than girls to behavior problems.

But experts say these findings are quite subtle and hard to generalize.
“Just because it is statistically significant doesn’t mean that it is a huge
public health impact,” said Dr. Harolyn M. Belcher, a neurodevelopmental
pediatrician who is director of research at the Kennedy Krieger Institute’s
Family Center in Baltimore.

And Michael Lewis, a professor of pediatrics and psychiatry at the Robert
Wood Johnson Medical School in New Brunswick, N.J., said that in a doctor’s
office or a classroom, “you cannot tell” which children were exposed to
cocaine before birth.

He added that factors like poor parenting, poverty and stresses like
exposure to violence were far more likely to damage a child’s intellectual
and emotional development – and by the same token, growing up in a stable
household, with parents who do not abuse alcohol or drugs, can do much to
ease any harmful effects of prenatal drug exposure.

Possession of crack cocaine, the form of the drug that was widely sold in
inner-city, predominantly black neighborhoods, has long been punished with
tougher sentences than possession of powdered cocaine, although both forms
are identically metabolized by the body and have the same pharmacological
effects.

Dr. Frank, the pediatrician in Boston, says cocaine-exposed children are
often teased or stigmatized if others are aware of their exposure. If they
develop physical symptoms or behavioral problems, doctors or teachers are
sometimes too quick to blame the drug exposure and miss the real cause, like
illness or abuse.

“Society’s expectations of the children,” she said, “and reaction to the
mothers are completely guided not by the toxicity, but by the social
meaning” of the drug.

Research on the health effects of illegal drugs, especially on unborn
children, is politically loaded. Researchers studying children exposed to
cocaine say they struggle to interpret their findings for the public without
exaggerating their significance – or minimizing it, either.

Dr. Lester, the leader of the Maternal Lifestyle Study, noted that the
evidence for behavioral problems strengthened as the children in his study
and others approached adolescence. Researchers in the study are collecting
data on 14-year-olds, he said, adding: “Absolutely, we need to continue to
follow these kids. For the M.L.S., the main thing we’re interested in is
whether or not prenatal cocaine exposure predisposes you to early-onset drug
use in adolescence” or other mental health problems.

Researchers have long theorized that prenatal exposure to a drug may make it
more likely that the child will go on to use it. But so far, such a link has
been scientifically reported only in the case of tobacco exposure.

Teasing out the effects of cocaine exposure is complicated by the fact that
like Yvette H., almost all of the women in the studies who used cocaine
while pregnant were also using other substances.

Moreover, most of the children in the studies are poor, and many have other
risk factors known to affect cognitive development and behavior – inadequate
health care, substandard schools, unstable family situations and exposure to
high levels of lead. Dr. Lester said his group’s study was large enough to
take such factors into account.

Ms. H., who agreed to be interviewed only on the condition that her last
name and her children’s first names not be used, said she entered a drug and
alcohol treatment program about six years ago, after losing custody of her
children.

Another daughter, born after Ms. H. recovered from drug and alcohol abuse,
is thriving now at 3. Her oldest, a 17-year-old boy, is the only one with
developmental problems: he is autistic. But Ms. H. said she did not use
cocaine, alcohol or other substances while pregnant with him.

After 15 months without using drugs or alcohol, Ms. H. regained custody and
moved into Dayspring House, a residential program in Baltimore for women
recovering from drug abuse, and their children.

There she received psychological counseling, parenting classes, job training
and coaching on how to manage her finances. Her youngest attended Head
Start, the older children went to local schools and were assigned household
chores, and the family learned how to talk about their problems.

Now Ms. H. works at a local grocery, has paid off her debts, has her own
house and is actively involved in her children’s schooling and health care.
She said regaining her children’s trust took a long time. “It’s something
you have to constantly keep working on,” she said.

Dr. Belcher, who is president of Dayspring’s board of directors, said such
programs offered evidence-based interventions for the children of drug
abusers that can help minimize the chances of harm from past exposure to
cocaine or other drugs.

“I think we can say this is an at-risk group,” Dr. Belcher said. “But they
have great potential to do well if we can mobilize resources around the
family.”