Intrauterine Cocaine Exposure Research Articles

Policies Affecting Pregnant Women with Substance Use Disorder

Policies Affecting Pregnant Women with Substance Use Disorder

Infants of Mothers with Cocaine Use: Review of Clinical and Medico-Legal Aspects.

Illicit drug use is a global problem that also affects pregnant women. Substance use and alcohol abuse during pregnancy may have various harmful consequences for both mothers and foetuses. Intrauterine exposure to illicit substances can be investigated through maternal reports and toxicological tests on mothers’ and/or newborns’ samples. While the negative effects of alcohol and opioid use on pregnancy, the foetus, and/or newborn are well established, the effects of cocaine use remain controversial. We performed a review of the literature to evaluate the current state of knowledge of the effects of intrauterine cocaine exposure on newborns’ and children’s long-term development and to highlight possible implications for health professionals dealing with women who use cocaine during pregnancy. Although intrauterine cocaine exposure has been associated with reduced infant measurements, no specific amount of cocaine use exerting such effects has been determined, and no long-term effects have been confirmed. The evidence of cocaine use during pregnancy justifies a clinical and social takeover of the mother and newborn without assuming that there will certainly be long-term damage related to intrauterine cocaine exposure, but also considering other possible associated factors.

Effects of intrauterine substance and postnatal violence exposure on aggression in children

During the cocaine epidemic of the 1980s and early 1990s, many expressed fears that children with intrauterine cocaine exposure (IUCE) would grow up to be unusually violent. The present study examines the relationship of caregiver reports of school-age children's aggressive behavior with IUCE and postnatal exposure to violence. Respondents were 140 low-income, primarily African American children, ages 8-11, and each child's current primary caregiver from a longitudinal study evaluating potential long term sequelae of IUCE. Multiple regression analyses were used to investigate the independent and interactive effects of level of IUCE (None (n = 69), Lighter (n = 47), Heavier (n = 24)) and exposure to violence (Violence Exposure Scale for Children-Revised) on aggressive behavior (Child Behavior Checklist), while also controlling for other intrauterine substance exposures and additional contextual factors. Children's self-reported exposure to violence was significantly positively associated with caregivers' reports of aggressive behavior (β = 2.17, P = .05), as was concurrent caregiver's psychiatric distress (β = .15, P = .003). However, neither IUCE nor its interaction with exposure to violence showed a significant association with aggressive behavior. Findings suggest the importance of postnatal social environment rather than IUCE in predicting aggressive behavior in childhood.

Psychological Distress Among School-Aged Children with and Without Intrauterine Cocaine Exposure: Perinatal Versus Contextual Effects.

Whether intrauterine cocaine exposure (IUCE) explains unique variance in psychiatric functioning among school age children, even after controlling for other biological and social risk factors, has not been fully delineated. As part of a longitudinal birth cohort study of children with and without IUCE, we conducted and analyzed data based on structured clinical interviews with 105 children (57% male) and their caregivers when the child was approximately 8.5 years old; 47% of the children had experienced IUCE. Interviews included past and current major psychological disorders and sub-threshold mental health symptoms. Potential covariates were ascertained by interviews of birth mothers and other caregivers from shortly after the child's birth until the 8.5-year visit. More than one-third of children met DSM-IV criteria for one or more mood, anxiety, attention deficit, or disruptive behavior disorders. IUCE was not significantly associated with children's history of psychological distress, in either bivariate or multiple logistic regressions. In contrast, birth mothers' acknowledgement of greater psychiatric distress at baseline and higher levels of alcohol consumption during pregnancy, and at 8.5 years caregivers' reports of their own psychological distress, and children's lower IQ were predictors of higher rates of psychological morbidity. Findings are consistent with prior reports suggesting that, regardless of IUCE status, children from low-income, urban backgrounds are at heightened risk for psychological distress. Results underscore the need for closer monitoring of the mental health of children living in low-income households, with or without intrauterine substance exposures, to facilitate access to appropriate services.

Prenatal substance exposure: What predicts behavioral resilience by early adolescence?

Understanding behavioral resilience among at-risk adolescents may guide public policy decisions and future programs. We examined factors predicting behavioral resilience following intrauterine substance exposure in a prospective longitudinal birth-cohort study of 136 early adolescents (ages 12.4-15.9 years) at risk for poor behavioral outcomes. We defined behavioral resilience as a composite measure of lack of early substance use initiation (before age 14), lack of risky sexual behavior, or lack of delinquency. Intrauterine substance exposures included in this analysis were cocaine, tobacco, alcohol, and marijuana. We recruited participants from Boston Medical Center as mother-infant dyads between 1990 and 1993. The majority of the sample was African American/Caribbean (88%) and 49% female. In bivariate analyses, none and lower intrauterine cocaine exposure level predicted resilience compared with higher cocaine exposure, but this effect was not found in an adjusted model. Instead, strict caregiver supervision (adjusted odds ratio [AOR] = 6.02, 95% confidence interval (CI) [1.90, 19.00], p = .002), lower violence exposure (AOR = 4.07, 95% CI [1.77, 9.38], p < .001), and absence of intrauterine tobacco exposure (AOR = 3.71, 95% CI [1.28, 10.74], p = .02) predicted behavioral resilience. In conclusion, caregiver supervision in early adolescence, lower violence exposure in childhood, and lack of intrauterine tobacco exposure predicted behavioral resilience among a cohort of early adolescents with significant social and environmental risk. Future interventions should work to enhance parental supervision as a way to mitigate the effects of adversity on high-risk groups of adolescents. (PsycINFO Database Record

Level of intrauterine cocaine exposure and neuropsychological test scores in preadolescence: subtle effects on auditory attention and narrative memory

Neuropsychological processes such as attention and memory contribute to children's higher-level cognitive and language functioning and predict academic achievement. The goal of this analysis was to evaluate whether level of intrauterine cocaine exposure (IUCE) alters multiple aspects of preadolescents' neuropsychological functioning assessed using a single age-referenced instrument, the NEPSY: A Developmental Neuropsychological Assessment (NEPSY) (Korkman et al., 1998), after controlling for relevant covariates. Participants included 137 term 9.5-year-old children from low-income urban backgrounds (51% male, 90% African American/Caribbean) from an ongoing prospective longitudinal study. Level of IUCE was assessed in the newborn period using infant meconium and maternal report. 52% of the children had IUCE (65% with lighter IUCE, and 35% with heavier IUCE), and 48% were unexposed. Infants with Fetal Alcohol Syndrome, HIV seropositivity, or intrauterine exposure to illicit substances other than cocaine and marijuana were excluded. At the 9.5-year follow-up visit, trained examiners masked to IUCE and background variables evaluated children's neuropsychological functioning using the NEPSY. The association between level of IUCE and NEPSY outcomes was evaluated in a series of linear regressions controlling for intrauterine exposure to other substances and relevant child, caregiver, and demographic variables. Results indicated that level of IUCE was associated with lower scores on the Auditory Attention and Narrative Memory tasks, both of which require auditory information processing and sustained attention for successful performance. However, results did not follow the expected ordinal, dose-dependent pattern. Children's neuropsychological test scores were also altered by a variety of other biological and psychosocial factors.

Problematic substance use in urban adolescents: Role of intrauterine exposures to cocaine and marijuana and post-natal environment

BackgroundLinkages between intrauterine exposures to cocaine and marijuana and adolescents’ problematic substance use have not been fully delineated. MethodsProspective longitudinal study with assessors unaware of intrauterine exposure history followed 157 urban participants from birth until late adolescence. Level of intrauterine exposures was identified by mother's report and infant's meconium. Problematic substance use, identified by the Voice Diagnostic Interview Schedule for Children (V-DISC) or the Audio Computer Assisted Self-Interview (ACASI) and urine assay, was a composite encompassing DSM-IV indication of tolerance, abuse, and dependence on alcohol, marijuana, and tobacco and any use of cocaine, glue, or opiates. ResultsTwenty percent (32/157) of the sample experienced problematic substance use by age 18 years, of whom the majority (22/157) acknowledged abuse, tolerance or dependence on marijuana with or without other substances. Structural equation models examining direct and indirect pathways linking a Cox survival model for early substance initiation to a logistic regression models found effects of post-natal factors including childhood exposure to violence and household substance use, early youth substance initiation, and ongoing youth violence exposure contributing to adolescent problematic substance use. ConclusionWe did not identify direct relationships between intrauterine cocaine or marijuana exposure and problematic substance use, but did find potentially modifiable post-natal risk factors also noted to be associated with problematic substance use in the general population including earlier substance initiation, exposure to violence and to household substance use.

Intrauterine substance exposures and Wechsler Individual Achievement Test-II scores at 11 years of age

The goal of this study was to evaluate whether intrauterine exposure to cocaine, alcohol, tobacco, or marijuana was associated with unique variance in children's academic achievement test scores after controlling for other substance exposures and contextual variables. Academic achievement scores (Wechsler Individual Achievement Test-Second Edition (WIAT-II)) were collected from 119, low-income, urban 11-year-olds enrolled in a prospective longitudinal study of intrauterine cocaine exposure (IUCE). Newborn recruitment eligibility included >36 weeks gestational age, no neonatal intensive care, no intrauterine exposure to illicit drugs except cocaine or marijuana, and no evidence of fetal alcohol syndrome (FAS). Intrauterine substance exposures (cocaine, marijuana, alcohol, tobacco) were documented in the newborn period using biological assays and maternal self-report. Multivariate analyses evaluated the relationship of each intrauterine exposure and each WIAT-II score controlling for contextual variables and the other substance exposures. In secondary analyses, the Child Depression Inventory (CDI) was added to final models. Results indicate that neither IUCE nor intrauterine exposure to marijuana or tobacco was associated with lower WIAT-II scores in multivariable analyses. Intrauterine alcohol exposure predicted significant variance in Math Reasoning and Spelling scores, but inclusion of children's depressive symptoms attenuated the relationship. Lower maternal education and maternal US birth were also associated with lower WIAT-II scores. Our analyses indicate that among low-income, urban 11-year-olds without a diagnosis of FAS, intrauterine alcohol exposure was negatively associated with math and spelling achievement scores after controlling for other intrauterine substance exposures and contextual factors. That relationship in this sample was partially mediated by children's depressive symptoms, but we cannot establish whether these lower achievement scores precede or follow depressive symptoms. Our findings highlight that neurobehavioral studies evaluating a primary potential neuroteratogen should evaluate other associated intrauterine exposures and contextual factors.

Are There Effects of Intrauterine Cocaine Exposure on Delinquency During Early Adolescence? A Preliminary Report

To ascertain whether level of intrauterine cocaine exposure (IUCE) is associated with early adolescent delinquent behavior, after accounting for prenatal exposures to other psychoactive substances and relevant psychosocial factors. Ninety-three early adolescents (12.5-14.5 years old) participating since birth in a longitudinal study of IUCE reported delinquent acts via an audio computer-assisted self-interview. Level of IUCE and exposure to cigarettes, alcohol, and marijuana were determined by maternal report, maternal and infant urine assays, and infant meconium assays at birth. Participants reported their exposure to violence on the Violence Exposure Scale for Children-Revised at ages 8.5, 9.5, and 11 years and during early adolescence, and the strictness of supervision by their caregivers during early adolescence. Of the 93 participants, 24 (26%) reported ≥ 3 delinquent behaviors during early adolescence. In the final multivariate model (including level of IUCE and cigarette exposure, childhood exposure to violence, and caregiver strictness/supervision) ≥ 3 delinquent behaviors were not significantly associated with level of IUCE but were significantly associated with intrauterine exposure to half a pack or more of cigarettes per day and higher levels of childhood exposure to violence, effects substantially unchanged after control for early adolescent violence exposure. In this cohort, prospectively ascertained prenatal exposure to cigarettes and childhood exposure to violence are associated with self-reported delinquent behaviors during early adolescence. Contrary to initial popular predictions, intrauterine cocaine is not a strong predictor of adolescent delinquent behaviors in this cohort.

Synergy of image analysis for animal and human neuroimaging supports translational research on drug abuse.

The use of structural magnetic resonance imaging (sMRI) and diffusion tensor imaging (DTI) in animal models of neuropathology is of increasing interest to the neuroscience community. In this work, we present our approach to create optimal translational studies that include both animal and human neuroimaging data within the frameworks of a study of post-natal neuro-development in intra-uterine cocaine-exposure. We propose the use of non-invasive neuroimaging to study developmental brain structural and white matter pathway abnormalities via sMRI and DTI, as advanced MR imaging technology is readily available and automated image analysis methodology have recently been transferred from the human to animal imaging setting. For this purpose, we developed a synergistic, parallel approach to imaging and image analysis for the human and the rodent branch of our study. We propose an equivalent design in both the selection of the developmental assessment stage and the neuroimaging setup. This approach brings significant advantages to study neurobiological features of early brain development that are common to animals and humans but also preserve analysis capabilities only possible in animal research. This paper presents the main framework and individual methods for the proposed cross-species study design, as well as preliminary DTI cross-species comparative results in the intra-uterine cocaine-exposure study.

Adolescent initiation of licit and illicit substance use: Impact of intrauterine exposures and post-natal exposure to violence

Whether intrauterine exposures to alcohol, tobacco, marijuana, or cocaine predispose offspring to substance use in adolescence has not been established. We followed a sample of 149 primarily African American/African Caribbean, urban adolescents, recruited at term birth, until age 16 to investigate intrauterine cocaine exposure (IUCE). We found that in Kaplan–Meier analyses higher levels of IUCE were associated with a greater likelihood of initiation of any substance (licit or illicit), as well as marijuana and alcohol specifically. Adolescent initiation of other illicit drugs and cigarettes were analyzed only in the “any” summary variable since they were used too infrequently to analyze as individual outcomes. In Cox proportional hazard models controlling for intrauterine exposure to alcohol, tobacco, and marijuana and demographic and post-natal covariates, those who experienced heavier IUCE had a greater likelihood of initiation of any substance, and those with lighter intrauterine marijuana exposure had a greater likelihood of initiation of any substance as well as of marijuana specifically. Time-dependent higher levels of exposure to violence between ages of 8 and 16 were also robustly associated with initiation of any licit or illicit substance, and of marijuana, and alcohol particularly.

Infant Race Affects Application of Clinical Guidelines When Screening for Drugs of Abuse in Newborns

Screening for illicit drugs in newborns has privacy, social, and legal risks for families of the infants. Established drug-screening criteria may be applied in a manner that considers nonproven risk factors such as race in addition to evidence-based factors. The goal of this study was to determine if race was used as a criterion for screening infants for intrauterine cocaine exposure. We hypothesized that infants of black mothers would be more likely to be screened regardless of whether they met the standard criteria for screening of our institution's NICU. We used the electronic medical records of newborn infants and their mothers to determine which mother-infant pairs had documented evidence of meeting the criteria for screening infants for prenatal exposure to illicit drugs set forth in the guidelines of our NICU. We then assessed the rates of drug screening to determine the strongest predictors of whether an infant would be screened. We assessed 2121 mother-infant pairs. Infants born to black mothers were more likely than those born to white mothers to have screening performed whether they met screening criteria (35.1% vs 12.9%; P < .001) or did not (5.3% vs 1.2%; P < .001). In a logistic regression analysis, black race remained independently associated (odds ratio: 2.17 [95% confidence interval: 1.25-3.79]) with drug screening even when we controlled for our standard screening criteria and income, insurance status, and maternal education. Providers seemed to have used race, in addition to recognized risk criteria, as a factor in deciding whether to screen an infant for maternal illicit drug use.

Intrauterine cocaine exposure and executive functioning in middle childhood

This longitudinal study evaluated whether the level of intrauterine cocaine exposure (IUCE) or the interaction between IUCE and contextual variables was related during middle childhood to executive functioning, as assessed with the Stroop Color-Word and Rey Osterrieth Complex Figure tests. The Stroop Interference score measures verbal inhibitory control while the Rey Osterrieth Organizational score evaluates skills such as planning, organization and perception. Masked examiners assessed 143 children at 9.5 and 11 years of age (74 with IUCE and 69 demographically similar children without IUCE). Level of IUCE (Unexposed; Lighter, and Heavier) was documented by positive postpartum maternal reports and infant meconium assays. In covariate-controlled regressions, level of IUCE was not significantly associated with Stroop Interference or Rey Osterrieth Organization scores. However, in covariate controlled post-hoc tests comparing the Heavier exposed group to the combined Lighter/Unexposed group, children in the Heavier group had significantly poorer Stroop Interference scores, but there was no significant group difference for Rey Osterrieth Organizational scores. Children's average Organization scores in Unexposed, Lighter, and Heavier exposed groups were well below the test norm means. Results of this study indicate that heavier IUCE may be associated with mild compromise on school-aged children's ability to inhibit prepotent verbal responses.

Longitudinal association between infant disorganized attachment and childhood posttraumatic stress symptoms

AbstractThe purpose of this study was to evaluate whether children with a history of disorganized attachment in infancy were more likely than children without a history of disorganized attachment to exhibit symptoms of posttraumatic stress disorder (PTSD) at school age following trauma exposure. The sample consisted of 78 8.5-year-old children from a larger, ongoing prospective study evaluating the effects of intrauterine cocaine exposure (IUCE) on children's growth and development from birth to adolescence. At the 12-month visit, children's attachment status was scored from videotapes of infant–caregiver dyads in Ainsworth's strange situation. At the 8.5-year visit, children were administered the Violence Exposure Scale—Revised, a child-report trauma exposure inventory, and the Diagnostic Interview for Children and Adolescents by an experienced clinical psychologist masked to children's attachment status and IUCE status. Sixteen of the 78 children (21%) were classified as insecure–disorganized/insecure–other at 12 months. Poisson regressions covarying IUCE, gender, and continuity of maternal care indicated that disorganized attachment status at 12 months, compared with nondisorganized attachment status, significantly predicted both higher avoidance cluster PTSD symptoms and higher reexperiencing cluster PTSD symptoms. These findings suggest that the quality of early dyadic relationships may be linked to differences in children's later development of posttraumatic stress symptoms following a traumatic event.

Longitudinal association between infant disorganized attachment and childhood posttraumatic stress symptoms

The purpose of this study was to evaluate whether children with a history of disorganized attachment in infancy were more likely than children without a history of disorganized attachment to exhibit symptoms of posttraumatic stress disorder (PTSD) at school age following trauma exposure. The sample consisted of 78 8.5-year-old children from a larger, ongoing prospective study evaluating the effects of intrauterine cocaine exposure (IUCE) on children's growth and development from birth to adolescence. At the 12-month visit, children's attachment status was scored from videotapes of infant-caregiver dyads in Ainsworth's strange situation. At the 8.5-year visit, children were administered the Violence Exposure Scale-Revised, a child-report trauma exposure inventory, and the Diagnostic Interview for Children and Adolescents by an experienced clinical psychologist masked to children's attachment status and IUCE status. Sixteen of the 78 children (21%) were classified as insecure-disorganized/insecure-other at 12 months. Poisson regressions covarying IUCE, gender, and continuity of maternal care indicated that disorganized attachment status at 12 months, compared with nondisorganized attachment status, significantly predicted both higher avoidance cluster PTSD symptoms and higher reexperiencing cluster PTSD symptoms. These findings suggest that the quality of early dyadic relationships may be linked to differences in children's later development of posttraumatic stress symptoms following a traumatic event.

Effects of Heavy In Utero Cocaine Exposure on Adolescent Caudate Morphology

We assess the effects of in utero cocaine and polysubstance exposure on the adolescent caudate nucleus through high-resolution magnetic resonance imaging. Cocaine exposure may compromise the developing brain through disruption of neural ontogeny in dopaminergic systems, effects secondary to fetal hypoxemia, or altered cerebrovascular reactivity. Cocaine exposure may also lead to neonatal lesions in the caudate. However, long-term or latent effects of intrauterine cocaine exposure are rarely found. We use T(1)-weighted magnetic resonance imaging to quantify caudate nucleus morphology in matched control and exposed groups. The literature suggests that in utero cocaine exposure consequences in adolescents may be subtle, or masked by other variables. Our comparison focuses on contrasting the control group with high-exposure subjects (mothers who reported 2 median of 117 days of cocaine use during pregnancy; 82% tested positive for cocaine use at term). We use advanced image registration and segmentation tools to quantify left and right caudate morphology. Our results indicate that the caudate is significantly larger in controls versus subjects (P < 0.0025), implying cocaine exposure-related detriments to the dopaminergic system. The right (P < 0.025) and left (P < 0.035) caudate, studied independently, show the same significant trend. Permutation testing and the false discovery rate were used to assess significance.

Socioemotional effects of fathers' incarceration on low-income, urban, school-aged children.

The goal was to evaluate whether children of incarcerated fathers are more likely to report or exhibit behavioral symptoms than their equally disadvantaged peers without an incarcerated father. During an ongoing longitudinal study of intrauterine cocaine exposure involving 102 children (50% male and 89% black) from urban, low-income homes, questions regarding incarceration of the child's father were asked of the child's primary caregiver at each visit during school age. Children were administered the Children's Depression Inventory between the ages of 6 and 11 years, and their primary caregivers completed the Child Behavior Checklist. In addition, the children's teachers completed the Teacher Report Form. Children's Depression Inventory, Child Behavior Checklist, and Teacher Report Form data obtained at the oldest available age after the first report of paternal incarceration were analyzed. In bivariate analyses, children whose fathers were in jail had higher Children's Depression Inventory total scores compared with children without incarcerated fathers, indicating more depressive symptoms. This finding was robust in multivariate analyses after adjustment for children's age, gender, prenatal cocaine and alcohol exposure, and school-age violence exposure. Teachers reported higher Teacher Report Form externalizing scores for children whose fathers were in jail, after adjustment for age, gender, prenatal cocaine and marijuana exposure, and school-age violence exposure. Children of incarcerated fathers reported more depressive symptoms and their teachers noted more externalizing behaviors, after controlling for other biopsychosocial risks. Interventions targeted to ameliorate the distress of children with incarcerated fathers should be considered.

Fibromuscular dysplasia in association with intrauterine cocaine exposure

Fibromuscular dysplasia (FMD) is an idiopathic disease of small- and medium-sized arteries, involving one or more vascular beds. Patients may present with a range of symptoms, which may not readily lead to a diagnosis of FMD. While maternal cocaine abuse during pregnancy has previously been associated with vascular alterations in the fetus, an association specifically with FMD has not previously been described. In this case report, a 21-month-old male presented with a 3-week history of daily vomiting, with temporary improvement of symptoms, then relapse followed by loss of consciousness. His medical history was significant only for maternal cocaine use. Clinical evaluation revealed dilated cardiomyopathy, and a presumptive diagnosis of myocarditis was rendered. Respiratory arrest and death occurred 2 days after admission. Postmortem examination demonstrated intimal-type multivessel FMD, which was determined to be the cause of the clinical presentation. Without a postmortem examination, it is unlikely that a diagnosis of intimal fibroplasia, a rare variant of FMD (5% of cases), would have been made. This case thus illustrates the continuing utility of the classic postmortem examination. More intriguingly, the case suggests a possible relationship between in utero cocaine exposure and the development of fibromuscular dysplasia in the child.

Similar and functionally typical kinematic reaching parameters in 7- and 15-month-old in utero cocaine-exposed and unexposed infants.

This study examined the effects of intrauterine cocaine exposure on the reaches of 19 exposed and 15 unexposed infants at 7 and 15 months using kinematic measures. Infants sat at a table and reached for a rattle, a toy doll, and a chair. Videotaped reaches were digitized using the Peak Performance system. Kinematic movement variables were extracted (e.g., reach duration, peak velocity, movement units, path length) and ratios computed (e.g., path length divided by number of movement units). Regardless of exposure status, reaches of older infants were faster, more direct, had fewer movement units, and covered more distance with the first movement unit. Exposed infants covered more distance per movement unit than unexposed infants, but there were no other significant differences. Reaches of exposed and unexposed infants were essentially similar. Importantly, reach parameters for these high-risk infants were similar to reach parameters for infants at lower social and biological risk.

Child safety: homicide by child abuse: South Carolina upholds conviction under "Crack Mom" law.

In State v. McKnight, the Supreme Court of South Carolina decided 3-2 to affirm McKnight’s conviction for homicide by child abuse based on the finding that her cocaine use during pregnancy caused her daughter to be stillborn. Under South Carolina law, a person is guilty of homicide by child abuse if he or she “causes the death of a child under the age of eleven while committing child abuse or neglect, and the death occurs under circumstances manifesting extreme indifference to human life.” During the trial, the pathologist who conducted the autopsy testified that (1) the only way for the infant to have cocaine byproducts present in her system was ifthe mother had ingested cocaine, and (2) the cause of death was intrauterine fetal demise. Another pathologist testified that there was a reasonable degree of medical certainty that the cause of death was intrauterine cocaine exposure.