Judith Schaffer, M.A., is the former Director of Family Resources: The Perinatal Cocaine Project for Birth, Foster and Adoptive Families in New York City. Ms. Schaffer is an adoptive parent and the author of How to Raise an Adopted Child. She has also written numerous articles on the mental health treatment of adoptive families.
Prospective adoptive parents, as well as parents who have recently adopted infants, need to be aware that when a pregnant woman uses cocaine during her pregnancy, it crosses the placenta and causes considerable damage to the developing fetus. Although cocaine is thought to damage many organ systems, the developing central nervous system of the fetus is especially sensitive to this powerful stimulant. Such damage has been implicated in a variety of developmental problems for the infant and later for the child.
A lack of knowledge about the symptoms associated with damage to the central nervous system can lead parents and others to mistakenly attribute them to psychological problems associated with foster care and adoption. It is therefore important that families who adopt infants, as well as agency workers and others who place them, be familiar with the growing research about the unique characteristics of these infants. It is also important to be familiar with the kinds of evaluations available which may help you to determine whether or not an infant has been cocaine-exposed, the special needs of these infants, and the intensive parenting that they appear to require.
Cocaine use has reached epidemic proportions in the United States. By 1986 it was estimated that nearly 40% of people between the ages of 25 and 30 years had tried cocaine (Gawin and Ellinwood). At various hospitals across the country, pregnant women have been interviewed about their use of drugs. Between 10% and 20% of pregnant women admit to using cocaine sometime during pregnancy.
Several studies also indicate that even when a mother reports she is not using drugs, a urine screen may indicate such use. In one of these studies, 26% of pregnant women who tested positive for cocaine denied using it.
In New York City, the great majority of infants coming into foster care are born to women who abused cocaine or "crack" during pregnancy. Cocaine abuse is thought to be escalating as street prices are dropping. In addition, teenagers are thought to be younger when they first use the drug.
Cocaine and amphetamines are both psychomotor stimulants. In early, low-dose use, cocaine produces an increase in pleasure, alertness, a sense of well-being, self-esteem, energy, and sexuality. It lowers anxiety and social inhibitions. It is not associated with hallucinations; therefore, the euphoria appears to be free of negative consequences.
Users soon discover that if they take more cocaine or "crack" the intensity of euphoria increases. If there is no limit on supply, the user may take more of the drug to increase the duration and intensity of these feelings.
Experiments with laboratory animals indicate that cocaine is unique among narcotics. Animals who are given unlimited access to cocaine will compulsively increase self-administration until death follows in 14 days, usually from cardiopulmonary collapse.
Both easy access to cocaine and the more rapid routes of administration, such as using it in its intravenous form (free basing), and/or smoking it in the form of "crack," produce a euphoria so intense that a pattern of high dose binges often develops.
The binging is characterized by re-administration of the drug up to once every 10 minutes for an average of 12 hours (or for as long as seven days). Abusers will then often abstain temporarily for several days, using other narcotics, marijuana, and alcohol to blunt their craving for cocaine.
During the first trimester of pregnancy, often before a woman knows she is pregnant, the embryo increases more than two and onehalf million times in size. Because of this rapid development, the fetus is especially vulnerable to injurious stimuli. Almost all known abnormalities of the fetus are determined at this time. Even if cocaine is used only at the beginning of pregnancy and mother and infant are found to be free of cocaine at birth, the damage to the fetus has already occurred.
The odds of adopting an infant whose mother used cocaine during her pregnancy are not insignificant. It is therefore important for prospective adoptive parents to know what they may be letting themselves in for, according to the current research. Families who have already adopted infants may also need assistance in identifying certain behaviors which are thought to be characteristic of these infants and children.
Dr. Ira J. Chasnoff and his colleagues at Northwestern University Medical School have been studying the effects of cocaine use during pregnancy. They have followed a number of women and their babies for several years. Their research and the research of others appears to indicate that cocaine use is uniquely damaging to a fetus, far more damaging than other narcotics. In fact, cocaine is so potent that nearly 60% of the pregnancies of the women in these studies ended in one of the following: spontaneous abortion during the first trimester, fetal death, or stillbirth. If you are not certain whether a mother used cocaine at any time during pregnancy, here are some characteristics associated with its use that have been reported by Dr. Chasnoff and others:
The following are characteristics of cocaine exposed infants:
If you don't want to adopt a baby who has been cocaine exposed, you should insist on the following:
Remember that normal infants seek eye contact with their parents. A normal infant can identify the mother's voice and face by 10 days, and, by 14 days, the father's.
If you have already had an infant placed with you who has the above characteristics, or if you wouid like to adopt such an infant, there are a number of things that you can do to help these infants maintain control and improve their tolerance for stimulation.
These infants need parents to do a great many things for them which other infants don't require. They can be difficult in the hospital and difficult at home, and they require a great deal of individual attention. These are not children for parents whose lifestyles are better suited to "quality" vs. "quantity time" parenting.
For more complete parenting advice, I suggest you read the many articles and books by Dr. Chasnoff and his colleagues, Dan Griffith and Jane Schneider. The following suggestions have been made by them. Remember, this is a new field of research. Don't expect your pediatrician to know a great deal about it.
1. Don't allow the infant to become frantic. Early signs that the infant is becoming overstimulated are yawns, sneezes, motor agitation, color changes, and eye aversions. If this happens, give the infant "time out."
2. The use of both swaddling and pacifiers are highly recommended. If the infant has reached the frantic state, swaddle him/her immediately. Then, when the infant is calmer, follow this with a pacifier. If this doesn't work, hold the infant closely, in a vertical position, and rock gently. Up and down rocking, as opposed to the more usual side to side, appears to be more comforting.
3. When they are calm, infants may be unwrapped so they can learn about controlling their body movements themselves. Reswaddle if the signs of overstimulation appear, i.e., frantic, diffuse activity.
4. Stimulate the infant gently, but please do interact with him/her. Because they are so cranky and unresponsive, parents are often inclined to leave them to themselves. Things that normal babies often enjoy don't work for these newborns. Remember that babies who are fragile must be respected for what it costs them to interact. They are often willing to interact a bit after they have been fed, so take advantage of these times. This will improve their tolerance for stimulation and may improve their self-control. 5. Be especially sensitive to your baby and to his/her abiiity to convey information to you. Your infant's responses will let you know which mode of stimulation he or she likes best (talking, touching, looking, holding). Use one of these modes, and when you get a response, try adding a second stimulus, such as holding first and then talking. If you begin to see the early signs that the infant is becoming overstimulated, you are going too fast and will need to decrease the stimuli.
6. Play with the infant when he/she is ready, not because you want to.
Flexible bodies are hallmarks of healthy babies. When they are lying on their backs, normal infants easily lift their arms and move their hands and fingers together in front of their faces. They can also easily lift their hips and bring their feet up to their heads. They explore themselves to learn what they can do as well as where they end and the world begins. Parents are recognized within the first two weeks and by six weeks can be differentiated from others. These schemata pattern the brain and are thought to form the basis for all future learning.
Cocaine babies with central nervous system damage, on the other hand, are characteristically still and lie in extended postures. They find it difficult or impossible to bring their hands together and to lift their legs up when lying on their backs. The human face is often too complex a stimulus for them to relate to. Eye contact with caregivers can overwhelm them and make them frantic.
There are things that parents will need to do for these babies to help them compensate for their deficits and allow them to have more normal experiences. Again, Dr. Chasnoff and his colleagues have made a number of recommendations which can be helpful for parents and infants.
Because these infants are naturally so stiff, they will need parental help in assuming more flexed positions. The infant should be propped in a side-lying position with arms and legs flexed. Leaving them on their backs appears to encourage a hyperextended position.
The infant should be carried in a flexed position. Standing should be discouraged until they are capable of standing alone, since supported standing encourages further extension of the legs. Jumpers and walkers should not be used, ever.
Infants should be held upright in a seated position with their arms in front of them. In this position, they have an opportunity to explore their hands and fingers and learn about what they can do. Since it is difficult or impossible for these infants to lift up their legs and play with them or kick reciprocally, parents should help them by holding up their hips and allowing them to play with their feet and legs and to kick.
The infant should spend some time on his/her belly, and colorful toys can be placed beside him/her to encourage movement. These infants may also benefit from montNy physical therapy sessions during which parents can be given training in ways of further encouraging appropriate activities. Rough play should be discouraged.
At the present time, it is not clear whether the prompt identification of the special needs of these newborns, and immediate interventions designed to counteract the reported deficits, will ameliorate the problems caused by prenatal cocaine exposure. It is clear that the lack of such immediate care can only result in further damage to these very needy babies.
Evidence from other well-controlled studies of infants with central nervous system damage makes equally clear that children in infant stimulation programs do better than children who are not given this advantage. We also know such programs must be started early and continued sometimes for years.
Dr. Chasnoff and his associates have found that adoptive parents are especially well-suited to provide the interventions that these babies are thought to need. It is not yet clear, however, whether loving competent care can make these babies all better. The infants who have been studied so far grow up to be children who are described as having short spans of attention, difficulties with impulse control, intellectual deficits, learning difficulties, and hyperactivity.
Despite these outcomes, adoptive parents who are well-motivated, empathetic, able to delay gratification, and able to focus their attention on the infant's needs rather than their own are best prepared to provide the support their child needs to realize his or her full potential. Certainly, a permanent commitment by well-prepared adoptive parents can be the best intervention the child receives.
Chasnoff, I.J., Chisum, G.M., Kaplan, W.E. "Maternal Cocaine Use and Genitourinary Tract Malformations." Teratology 1988. 37:201-204.
Chasnoff, I.J., Burns, K.A., Burns, W.J., Schnoll, S.H. "Prenatal Drug Exposure: Effects on Neonatal and Infant Growth and Development." Neurobehavioral Toxicology and Teratology 1986. 8:357-362.
Chasnoff, l.J., Bussey, M.E., Savich, R., Stack, C.M. "Prenatal Cerebral Infarction and Maternal Cocaine Use." Journal of Pediatrics 1986. 108(3):456-459.
Chasnoff, I.J., Schnoll, S.H., Burns,W.J., Burns, K.A. "Cocaine Use in Pregnancy." New England Journal of Medicine 1985. 313:666-669.
Gawin, EII., Ellinwood, E.II. "Cocaine and Other Stimulants: Actions, Abuse and Treatment." New England Journal of Medicine 1988. 318(18):1173-1182.
MacGregor, S.N., Keith, L.G., Chasnoff, l.J., Rosner, M.A., Chisum,G.M., Shaw, P., Minogue, J.P. "Cocaine Use During Pregnancy: Adverse Perinatal Outcome." American Journal of Obstetrics and Gynecology 1987. 157(3):686-690.
Schneider, J.W., Chasnoff, I.J. "Cocaine Abuse During Pregnancy: Its Effects on Infant Motor Development - A Clinical Perspective." Topics in Acute Care and Trauma Rehabilitation, 1987. 2(1):59-69.
Ira J.Chasnoff, M.D.
Associate Professor of Pediatrics and Psychiatry
Northwestern University Medical School
Director, Perinatal Center of Chemical Dependence
Northwestern Memorial Hospital
Chicago, IL 60611
Janet Chandler, Ph. D (see above)
Dan R. Griffith, Ph.D.,
Developmcntal Psychologist (see above)
Jane Schneider, M.S., P.T.,
Assistant Professor, Programs in Physical Therapy
Northwestern University Medical School
Children's Memorial Hospital
Chicago, IL 60611
National Association for Perinatal
Addiction Research and Education
11 East Hubbard Street, Suite 200
Chicago, IL 60611
(312)329-2512
rev. 8/14/97
For more information, contact:
New York State Citizens' Coalition for Children, Inc.
Judith Ashton, Executive Director
614 West State Street
Ithaca, NY 14850
(607) 272-0034
office@nysccc.org