Treatment Outcomes for Women Drug Abusers

Annotated Bibliography
April, 1998

Mary E. McCaul, Ph.D
Johns Hopkins University School of Medicine

Author's Note

This annotated bibliography focused on published materials and scientific presentations that resulted from research demonstration initiatives funded by the National Institute on Drug Abuse as well as more recently funded pregnancy and postpartum grants. Journal articles were identified primarily by a Medline search on the names of the Principal Investigators and Co-Investigators of these projects. Additional materials were identified through the reference lists of these published papers. Articles were selected to provide even coverage of the following four areas relevant to the treatment of substance abusing women: identification, assessment characteristics, treatment outcomes, and birth and developmental outcomes of drug-exposed infants.

Identification and Treatment Enrollment of Female Substance Abusers

Assessment Characteristics of Substance-Abusing Women

Treatment Outcomes for Female Substance Abusers

Birth and Developmental Outcomes for Drug-Exposed Infants

Identification and Treatment Enrollment of Female Substance Abusers

Allen, K. (1995). Barriers to treatment for addicted African American women. Journal of the National Medical Association, 87 (10), 751–756.

The Allen Barriers to Treatment Instrument is a 41-item, self-administered rating scale that examines three potential types of treatment barriers, treatment program characteristics, personal beliefs, feelings and thoughts, and socioenvironmental issues. Barriers were conceptualized as external (e.g., lack of insurance coverage, unavailability of child care, lack of treatment slots, lack of transportation) and internal (e.g., failure to recognize the problem, fear of their children being taken away, fear of others' reactions, fear of treatment itself) phenomena that obstruct, restrain, or serve as obstacles to receiving health care. Subjects (N = 97) included substance-abusing women who were residing at home in the community, who had completed detoxification or inpatient programs but declined further care, and who were rapid treatment dropouts from outpatient treatment.

• Subjects were generally single, unemployed African American women in their late 20s to early 30s, with less than a high school education. Eighty-eight percent of the women had at least one child. Almost all women reported cocaine dependence as their primary drug disorder.
• The most frequently reported barriers for substance abuse treatment entry were responsibilities at home as a mother, wife, or partner; inability to pay; lack of insurance; reliance on alcohol and other drugs to deal with stresses of daily life in the community; fear that admission of the drug problem would result in loss of custody of their children; shame as a result of their drug problem; inability to stay alcohol or drug free after previous treatment episodes; and unavailability of an opening because the program is full.
• Findings highlight the importance of both internal and external barriers to access to treatment for African American substance-dependent women.

Christmas, J. T., Knisely, J. S., Dawson, K. S., Dinsmoor, M. J., Weber, S. E., & Schnoll, S.  H. (1992). Comparison of questionnaire screening and urine toxicology for detection of pregnancy complicated by substance use. Obstetrics and Gynecology, 80, 750–754.

This study examined the relative effectiveness of patient interview and drug toxicology for detecting current substance use by pregnant women (N = 302) registered for prenatal care at an urban university hospital.

• At the first prenatal visit, 19% of the patients were identified as current users of alcohol or some illicit substance, with approximately one-third of these identified as users of two or more substances.
• Urine toxicological results were positive for 13.6% of the women for one or more illicit substances; marijuana was most frequently detected. Only 41% of the patients who tested positive on drug toxicology acknowledged recent drug use during the interview.
• Recent substance use was reported by 11.3% of the women during the interview; alcohol was reported most frequently. Of the women who reported recent substance use, half tested positive on urine toxicology.
• Among patients who denied current substance use, approximately 10% acknowledged past use of two or more substances. Approximately one-quarter of these patients tested positive on urine toxicology.
• These findings suggest that a combination of drug toxicology and interview assessment of current and historic drug use may be more effective than either technique alone for detecting substance use during pregnancy.

This research was supported in part by a National Institute on Drug Abuse grant (DA06094).

Grossman, J., Schottenfeld, R. S., Viscarello, R., & Pakes, J. (1993). Cocaine abuse during pregnancy. In L. Harris (Ed.), Problems of drug dependence, 1992: Proceedings of the 54th Annual Scientific Meeting. The College on Problems of Drug Dependence, Inc. [Research Monograph 132] (p. 302). Rockville, MD: National Institute on Drug Abuse.

All women who registered for prenatal care at Yale–New Haven Hospital were screened for cocaine use during pregnancy.

• Thirteen percent of clinic registrants reported cocaine use during pregnancy.
• Nine percent of registrants tested positive for cocaine metabolites
  - of those, 29% denied ever using cocaine;
  - and 49% denied use during their pregnancy.
• There were significant differences in substance use, demographic, and personal characteristics between cocaine users and the overall clinic population.

This research was supported by a National Institute on Drug Abuse grant (DA06915).

Haller, D. L., Dawson, K. S., & Ingersoll, K. S. (forthcoming). Treatment acceptors vs. rejectors: Psychological characteristics of female substance abusers. Manuscript submitted for publication.

This paper examines predictors of successful treatment enrollment among pregnant women seeking substance abuse services in comprehensive day treatment services.

• Over 90% of women who were referred for substance abuse services to the Center for Perinatal Addiction (CPA) refused enrollment.
• Study acceptors (N = 109) were women who completed the initial assessment and were active in treatment for a minimum of 1 month. Study rejectors (N = 26) agreed to be followed in a nontreatment comparison group but refused CPA services.
• Acceptors were five times more likely to report legal involvement than rejectors.
• Acceptors were more likely to report cocaine as their primary drug problem, whereas rejectors were more likely to be primary heroin abusers. Acceptors also had higher Addiction Severity Index (ASI) composite scores for drug severity than rejectors.
• Overall, acceptors reported greater emotional distress and evidenced more severe character pathology than rejectors. Specifically, acceptors had higher ASI composite scores for psychiatric severity than rejectors. Similarly, acceptors were more likely to have elevated validity and clinical scale scores as well as personality disorder scale scores (i.e., Antisocial, Paranoid, and Dependent Personality) on the Minnesota Multiphasic Personality Inventory–2. Acceptors also scored higher on two of the three global severity indices and on six subscales of the Symptom Checklist–90 Revised.
• Findings suggest that treatment rejectors are less likely to have any legal involvement motivating participation, have less severe addictive disorders, and report less emotional distress than treatment acceptors. These factors may lead to their being less motivated for behavior change.

Knisely, J. S., Spear, E. R., Green, D. J., Christmas, J. T., & Schnoll, S. H. (1990). Substance abuse patterns in pregnant women. In L. S. Harris (Ed.), Problems of drug dependence, 1990: Proceedings of the 52nd Annual Scientific Meeting. The Committee on Problems of Drug Dependence, Inc. [Research Monograph 105] (pp. 280–281). Rockville, MD: National Institute on Drug Abuse.

This report compared substance use detection rates by interview versus urine toxicology for women (n = 305) reporting for their first prenatal visit in an urban obstetric clinic.

• Overall, 11% of obstetric (OB) patients reported current drug use, and 23% reported a history of drug use. Most current users reported use of two or more substances.
• Urine toxicology screening identified an additional 10% of the OB patients as current users. Twice as many cocaine users and three times as many marijuana users were identified with urine toxicology than with questionnaire.
• The most accurate detection of substance use patterns of pregnant women can be obtained by use of both interview and toxicology screens.

This research was supported by a National Institute on Drug Abuse grant (DA06094).

Largo, J. A., Schottenfeld, R. S., Pakes, J., & Forsyth, B. (1994). Primary care-based interventions for pregnant cocaine-abusing women: Comparison of treatment enrollees and refusers. In L. S. Harris (Ed.), Problems of drug dependence, 1993: Proceedings of the 55rd Annual Scientific Meeting. The College on Problems of Drug Dependence, Inc. [Research Monograph 141] (p. 352). Rockville, MD: National Institute on Drug Abuse.

This report examined characteristics of pregnant substance-abusing women who enrolled versus declined participation in a randomized clinical trial of comprehensive day treatment services.

• Routine drug screening consisting of a structured interview and urine toxicology testing identified cocaine use during pregnancy in 16.5% of women enrolled in a hospital-based prenatal care clinic.
• Approximately 60% of substance-abusing women who were eligible for enrollment in the clinical trial agreed to participate.
• Treatment acceptors as compared with rejectors were more likely to identify cocaine as their primary drug problem and seek prenatal care during their last trimester. Acceptors were less likely to report having a confidant and having wanted the pregnancy. No other demographic or drug use differences were observed between treatment acceptors versus rejectors.

Marques, P. R., Tippetts, A. S., & Branch, D. G. (1993). Cocaine in the hair of mother-infant pairs: Quantitative analysis and correlations with urine measures and self-report. American Journal of Drug and Alcohol Abuse 19 (2), 159–175.

Research on the analysis of hair for estimation of drug use has increased, partially in response to the need for a valid index of exposure over the course of pregnancy to examine possible teratological and neurobehavioral associations in drug-exposed infants. This study examines the concordance between mother-infant pairs (N = 62) for the results of hair analyses of drug exposure and studies the relationship of hair analyses to other biological and self-report measures.

• There was a modest correlation between the overall results of maternal and infant hair cocaine values.
• Over half of the samples (N = 32) were determined to be damaged; this loss of samples is a major source of concern with usefulness of hair analyses. When damaged samples were eliminated from the analyses, there was a substantial improvement in the correlation between maternal and infant hair cocaine values. In contrast, when just the damaged samples were considered, there was virtually no relationship between maternal and infant results. Thus, hair analyses of maternal and/or infant hair can provide a quantitative measure of drug exposure, when hair is not damaged.
• A relationship was observed between the results of maternal urinalysis for benzoylecgonine and hair analysis, suggesting that subjects who are regular cocaine users over extended periods of time also are most likely to evidence recent use as measured by the longer acting cocaine metabolite.
• Correlations between maternal hair cocaine values and maternal self-report were weak.

This work was supported by a National Institute on Drug Abuse grant (R18 DA06379).

Palinkas, L. A., Atkins, C. J., Noel, P., & Miller, C. (1996). Recruitment and retention of adolescent women in drug treatment research. In E. R. Rahdert (Ed.), Treatment for drug-exposed women and their children: Advances in research methodology [Research Monograph 166] (pp. 87–109). Rockville, MD: National Institute on Drug Abuse.

This chapter reviews issues of recruitment and retention of adolescents in drug treatment studies and provides a description of the Positive Adolescent Life Skills (PALS) project, a social skills development, social network restructuring, and case management project for high-risk adolescents.

• Three factors have been observed to affect subject recruitment for substance abuse treatment research: (1) the motivation and willingness of substance-abusing individuals to participate in research; (2) the selection criteria of the research project; and (3) institutional constraints in selecting and recruiting potential participants (e.g., reluctance of referral network agencies to refer clients to random assignment protocols).
• Recruitment problems are compounded for adolescents because of the frequent need for parent approval for research participation and the lack of services specifically tailored to this age group.
• Almost three-quarters of the adolescent women evaluated for participation in PALS have not enrolled in the project. Two-thirds of nonparticipants were disqualified from participation-based study eligibility criteria. The remaining third did not enroll for personal reasons, including a lack of interest, failure to meet the recruitment deadline, or a schedule conflict.
• Adolescents who did enroll in the project were more likely to be Latinas from more stable and secure living environments, adolescents who already had been identified by the system as having an existing drug problem, adolescents or their parents who recognized the need for program participation, and adolescents who were part of the social networks of current or former PALS participants.
• Family cohesion, number of social supports, peer acceptance, firm maternal control, and general delinquency were positively associated with program attendance. In contrast, age, pregnancy or parenting status, school dropout status, internal locus of control, POSIT (Problem Oriented Screening Instrument for Teenagers) substance use/abuse, and sexual activity were inversely associated with attendance. Many of these subject characteristics have been found in earlier research to predict onset of drug use in adolescents.
• Adolescent retention in the treatment program was inversely associated with drug use severity.

This research was supported by a National Institute on Drug Abuse grant (R18-DA06911).

Assessment Characteristics of Substance-Abusing Women

Beckwith, L., Espinosa, M., & Howard, J. (1994). Psychological profile of pregnant women  who abuse cocaine, alcohol, and other drugs. In L. S. Harris (Ed.), Problems of drug dependence, 1993: Proceedings of the 55rd Annual Scientific Meeting. The College on Problems of Drug Dependence, Inc. [Research Monograph 141] (p. 116). Rockville, MD: National Institute on Drug Abuse.

This report examined psychological characteristics of pregnant women (N = 145) referred by child protective services for outpatient substance abuse treatment.

• Polysubstance use was extremely common in these pregnant patients, with all women reporting alcohol use, 96% reporting cocaine use, 74% marijuana use, 23% opiate use, and 78% tobacco use.
• Seventy percent of women reported histories of physical and/or sexual abuse, and seventy-eight percent reported having been beaten and/or raped.
• Forty-two percent reported alcohol and/or other drug problems in their family of origin.
• On the Millon Clinical Multiaxial Inventory, all women evidenced symptoms of significant psychopathology, including paranoid ideation, thought disorder, depression, and anxiety. There was a positive association between years of drug use and severity of psychiatric problems.
• Women with greater psychiatric severity had more children.
• These findings highlight the need for psychiatric services as part of a comprehensive system of care for pregnant and postpartum women.

This project was supported by a National Institute on Drug Abuse grant (R18-DA6380).

Brown, E. R. (1992). Program and staff characteristics in successful treatment. In M. M. Kilbey & A. Kursheed (Eds.), Methodological issues in epidemiology, prevention, and treatment research on drug-exposed women and their children [Research Monograph 117] (pp. 305–313). Rockville, MD: National Institute on Drug Abuse.

This paper provides an overview of the complex treatment needs of pregnant substance-abusing women and describes therapeutic components of the MOM's Project in Boston, Massachusetts.

• Treatment programs designed to meet the needs of drug-abusing, pregnant women must address not only drug use but also prenatal care, medical, social, and psychiatric needs.
• Women (N = 157) recruited into the MOM's Project were generally in their 20s, African American, and had less than a high school education. Twenty percent were homeless and another 20% were housed with friends or relatives in unstable living environments. One-third had children living with them, although only half of those with children were receiving public assistance.
• Crack was the most frequently reported drug of abuse.
• About half of the women had been previously treated for substance abuse/dependence.
• Fifty-seven percent had a history of sexually transmitted diseases; 2.6% were diagnosed with AIDS.
• Therapeutic services in the MOM's Project include day treatment for substance abuse, prenatal care and classes, postpartum obstetric care, pediatric primary care, parenting education (including child development, nutrition, and parenting skills development), early intervention programs for young children, on-site child care, and advocacy services to assist with accessing needed social services.

Elk, R., Andres, R., Helfgott, A., Rhoades, H., Mangus, L., Mirza, I., Burroughs, R., & Grabowski, J. (in press). AIDS-related knowledge and high-risk behaviors of pregnant women dependent on cocaine or opiates. American Journal on Addictions.

Forty-one pregnant women who were dependent on cocaine (n = 30) or opiates (n = 11) were interviewed concerning AIDS-related knowledge and engagement in high-risk behaviors at the time of their enrollment in a specialized clinic for substance-abusing pregnant women.

• Generally, participants demonstrated a high rate of knowledge of HIV high-risk behaviors related to drug use and sexual behavior. Knowledge of medical consequences of HIV infection was somewhat lower, with relatively poor knowledge of AIDS symptoms.
• In contrast, recent engagement in high-risk behaviors was relatively common, with 28% reporting multiple sexual partners, 35% reporting sex with an intravenous drug user, 37% reporting that they had exchanged sex for money or drugs, and only 7% of those who had sex in the last month reporting condom use.
• Overall, the findings indicated that increased knowledge was not associated with decreased risk behavior. These results highlight the importance of providing motivational and behavioral skills training in addition to HIV education for substance-abusing women.

This work was supported by National Institute on Drug Abuse grants (DA08438, DA06143).

Hall, J. A., Henggeler, S. W., Felice, M. E., Reynoso, T., Williams, N. M., & Sheets, R. (1993). Adolescent substance use during pregnancy. Journal of Pediatric Psychology, 18, 265–271.

This study reports on substance use behaviors of pregnant adolescents (N = 50) seen at a specialized Teen OB Clinic. Substance use was assessed by self-report at the initial assessment and by urinalysis at assessment and delivery.

• Self-report data indicated significantly decreased rates of substance use during pregnancy as compared with lifetime use for tobacco, alcohol, marijuana, and crystal methamphetamine. Urinalysis findings supported these observations, with only two subjects testing positive at initial assessment and none at delivery.
• Among those adolescents reporting substance use during pregnancy, frequency of use was quite low (i.e., range: 1–3 times for alcohol and 1–4 times for marijuana).
• These findings support earlier observations of considerable decreases in adolescents' substance use during pregnancy.

This research was supported by a National Institute on Drug Abuse grant (R18-DA06911-01).

Haller, D. L., Knisely, J. S., Dawson, K. S., & Schnoll, S. H. (1993). Perinatal substance abusers. Psychological and social characteristics. Journal of Nervous and Mental Disease, 181, 509–513.

Psychological and social characteristics of perinatal substance abusers (N = 40) were determined at the time of admission to specialized women's substance abuse treatment.

• Pregnant and recently postpartum women reported:
• high rates of familial alcoholism and other addiction (53% paternal substance abuse; 32% maternal abuse);
• high rates of other children (87%);
• poor education and low average cognitive functioning;
• very high rates of sexual HIV-risk behaviors (97% failed to use condoms; 45% > 5 sexual partners in last 2 years; 33% active STD);
• high rates of depressive (28%) and anxiety (31%) disorders;
• high rates of personality disorders (75%), particularly antisocial personality disorder (62%).
• Findings of high levels of initial impairment have several treatment implications:
  • intensive case management to address patients' multiple social needs;
  • mismatch with group treatment emphasis for as many as one-third of patients;
  • need for intensive family therapy, given high levels of multigenerational family    dysfunction;
  • importance of long-term treatment with high degree of structure;
  • guidelines for behavior and consequences for rule violations.

This research was supported in part by a National Institute on Drug Abuse grant (DA06094).

Haller, D. L., Knisely, J. S., & Schnoll, S. H. (1991). Consistency in measurement of psychopathology. In L. Harris (Ed.), Problems of drug dependence, 1991: Proceedings of the 53rd Annual Scientific Meeting. The Committee on Problems of Drug Dependence, Inc. [Research Monograph 119] (p. 229). Rockville, MD: National Institute on Drug Abuse.

This study compared diagnostic rates using a variety of standardized psychological tests in drug-dependent pregnant women (N = 30) newly admitted to a comprehensive perinatal addictions program.

• The Addiction Severity Index (ASI), Structured Clinical Interview for DSM-III-R (SCID) and program clinicians provided comparable rates of identification of women with addictive disorders. The Millon Clinical Multiaxial Inventory (MCMI) failed to detect approximately half of the alcohol and drug disorders, while the Minnesota Multiphasic Personality Inventory (MMPI) detected alcohol abusers but only half of the known drug abusers.
• Rates of depression were highly variable; 58% of subjects received elevated scores on the Beck Depression Inventory, whereas only 10% met diagnostic criteria on the SCID. When agreement on multiple measures was examined, approximately 80% of subjects exhibiting depressive symptoms were identified.
• Reliable measurement of Axis II personality disorders was even more problematic. Every subject was diagnosed with at least one personality disorder on at least one instrument, but there was little consistency across instruments. Antisocial personality disorder was the most frequently diagnosed disorder.

Knisely, J. S., Haller, D. L., & Schnoll, S. H. (1992). Psychiatric disorders in addicted women. In L. Harris (Ed.), Problems of drug dependence, 1991: Proceedings of the 53rd Annual Scientific Meeting. The Committee on Problems of Drug Dependence, Inc. [Research Monograph 119] (p. 445). Rockville, MD: National Institute on Drug Abuse.

Pregnant women seeking substance abuse treatment were administered multiple measures for diagnosis of psychiatric and addictive disorders prior to beginning treatment for substance abuse.

• Clinicians generally were highly accurate in detecting Axis I substance use disorders in project admissions, although there was some tendency to minimize the role of marijuana.
• In contrast, clinicians underreported Axis I (excluding addictive disorders) and Axis II disorders. Based on test findings, 64% of patients had at least one Axis I diagnosis and 100% at least one Axis II diagnosis. Clinicians detected nonaddiction Axis I disorders in 23% and Axis II disorders in 20% of patients.

This work was supported by a National Institute on Drug Abuse grant (DA06094).

Pivnick, A., Jacobson, A., Eric, K., Doll, L., & Drucker, E. (1994). AIDS, HIV infection, and illicit drug use within inner-city families and social networks. American Journal of Public Health, 84, 271–274.

This descriptive study examines the extent of drug use, human immunodeficiency virus infection, and acquired immunodeficiency syndrome among family and social networks of women enrolled in methadone maintenance treatment  (N = 126).

• Two-thirds of the subjects reported having been tested for HIV infection. Of these almost half were HIV positive.
• Over 80% of the women lived with family (including sexual partner and children). Slightly more than half lived with at least one of their children.
• Women averaged 2.4 children under the age of 18, approximately half of whom were living with their mother. Among those children still residing with their mothers, two-thirds lived with a mother who reported regular use of illicit drugs, and over 85% lived in a household where at least one adult was a drug user.
• Over half of the women's sexual partners were reported to use illicit drugs regularly. In households where the partner was a current crack user, there was a significant positive association between the woman's use of crack and other forms of cocaine and her partner's use. No such association was observed for heroin use.
• Seventy percent of women reported a history of illicit drug use by at least one sibling.
• Among HIV-positive women, most reported having shared their serostatus with their sexual partner, mother, or at least one sibling. This finding suggests the persistence of a supportive family network for methadone-maintained women.
• Significantly more HIV-positive women reported current use of crack than HIV-negative women. No other differences in drug use patterns were observed as a function of serostatus.
• Forty-five percent of the women's households had at least one HIV-positive member (including the subject herself). Half of these households included at least one child under the age of 18.
• Findings highlight the importance of understanding the social/family context of drug use in developing prevention or intervention programs for substance abuse.

Price, M., Chan, M., Guydish, J., & Werdegar, D. (1994). Special needs of women in drug abuse treatment. In L. S. Harris (Ed.), Problems of drug dependence, 1993: Proceedings of the 55rd Annual Scientific Meeting. The College on Problems of Drug Dependence, Inc. [Research Monograph 141] (p. 351). Rockville, MD: National Institute on Drug Abuse.

This report examined treatment needs of male (n =102) and female (n = 60) participants in a therapeutic community substance abuse day treatment program.

• Women were younger and more likely to live with children, with or without a partner.
• Men were more likely to have been in a controlled environment in the 30 days prior to treatment enrollment, to have a history of incarceration, and to have been incarcerated for longer periods of time than women.
• Gender differences in criminal histories and current living arrangements suggest treatment needs that should be considered in designing therapeutic services.

This project was supported by a National Institute on Drug Abuse grant (R18-DA06979).

Silverman, K., Chutuape, M. A., Svikis, D. S., Bigelow, G. E., & Stitzer, M. L. (1995). Incongruity between occupational interests and academic skills in drug abusing women. Drug and Alcohol Dependence, 40, 115–123.

Fifty pregnant or recently postpartum women were assessed for their occupational interests and academic skills.

• Most women scored at or below the 7th-grade level in reading, spelling, and arithmetic based on the Wide Range Achievement Test, and one-quarter scored at or below the 4th-grade level in these areas.
• Eight of the 10 jobs that were rated as highest in occupational interest were office jobs that required well-established skills in reading, spelling, and arithmetic.
• Academic levels were positively correlated with interest in administrative and skilled clerical positions.
• Generally, there was considerable incongruity between the types of occupations that the women rated as most interesting and their current skills levels, suggesting the need for extensive basic academic training prior to specific vocational preparation.

Treatment Outcomes for Female Substance Abusers

Britt, G. C., Knisely, J. S., Dawson, K. S., & Schnoll, S. H. (1995). Attitude toward recovery and completion of a substance abuse treatment program. Journal of Substance Abuse Treatment, 12, 349–353.

This study examined the utility of the Recovery Attitude and Treatment Evaluator (RAATE) for predicting attrition from specialized substance abuse treatment for pregnant and postpartum women (N = 113).

• Program completers, as compared with dropouts, had significantly better scores on the RAATE subscales measuring resistance to treatment and resistance to continuing care. These differences were largely accounted for by the poorer ratings for those clients who dropped out or were discharged during the first month of treatment.
• There were no differences for clinician ratings on the RAATE for program completers, dropouts, and administrative discharges.
• Findings suggested that the RAATE may be useful in predicting risk for early treatment failure by pregnant and postpartum substance-abusing women.

This work was supported by a National Institute on Drug Abuse grant (DA06094).

Coletti, S. D., Hughes, P. H., Landress, H. J., Neri, R. L., Sicilian, D. M., Williams, K. M., Urmann, C. F., & Anthony, J. C. (1992). PAR Village: Specialized intervention for cocaine abusing women and their children. Journal of the Florida Medical Association, 79 (10), 701–705.

This is a preliminary report of treatment retention outcomes of a prospective randomized clinical trial in which mothers were or were not allowed to bring their young children with them to a long-term therapeutic community program.

• Earlier research has identified lack of child care services in substance abuse treatment facilities as an important treatment barrier for drug-dependent women.
• In 1989, under a NIDA demonstration research grant, PAR Village added specialized on-site child care services that permitted drug-dependent women to bring up to two children under age 10 to live with them at the therapeutic community.
• Demonstration subjects (N = 39) were typically in their late 20s, single, African American, with less than a high school education. Almost all women reported cocaine dependence as their primary drug problem. Over three-quarters had had their first child by age 17, and their average number of children was 3.1.
• Preliminary results suggest that women who are able to keep their children with them in treatment are retained longer in care than women who are not able to bring their children to the therapeutic community. Findings suggest that over 80% of experimental subjects as compared with approximately 50% of controls were still active in treatment 3 months after intake.

This project was supported in part by a National Institute on Drug Abuse grant (R18 DA06369).

Coletti, S. D., Schinka, J. A., Hughes, P. H., Hamilton, N. L., Renard, C. G., Sicilian, D. M., Urmann, C. F., & Neri, R. L. (1995).PAR Village for chemically dependent women: Philosophy and program elements. Journal of Substance Abuse Treatment, 12 (4), 289–296.

This paper provides a description of the treatment philosophy and program operation of specialized women's services incorporated into the PAR Village therapeutic community.

• In the 1980s, successful discharge rates for drug-dependent women were approximately half those for drug-dependent men treated in therapeutic communities. A major barrier to successful completion of care was perceived to be the lack of child care resources for women in long-term treatment.
• PAR Village uses a social learning based model of care, in which the program attempts to create and strengthen skills and abilities within a supportive and nurturing atmosphere.
• Successful completion of residential treatment requires on average 18 months to progress through six progressively less restrictive levels of care. In levels 3–6, treatment focus is expanded to include life and family skills, including parenting and child care skills (e.g., meal preparation, education on normal development issues); health care counseling (e.g., prenatal care, nutritional counseling, health education for child care); psychosocial interventions for coping skills enhancement; and vocational or on-the-job training.
• Young children residing with their mothers at PAR Village receive day care and targeted health and developmental interventions at a specialized on-site therapeutic nursery. Specialized services include a pediatric exam and comprehensive psychological and developmental assessment; consultative evaluations for special problems (e.g., speech, language, hearing tests); age-appropriate developmental stimulation; and refusal skills and assertiveness training for older children.

This project was supported by a National Institute on Drug Abuse (R18 DA06369).

El-Bassel, N., & Schilling, R. F. (1992). 15-month followup of women methadone patients taught skills to reduce heterosexual HIV transmission. Public Health Reports, 107 (5), 500–504.

This paper reports 15-month follow-up results from a prospective, randomized study of a skills-building intervention to reduce HIV sexual risk behaviors versus an information-only comparison condition in methadone-maintained women (N = 91). Two-thirds of subjects were relocated for follow-up; generally there were few differences on demographic and drug use characteristics between subjects who were relocated versus lost to follow-up.

• During the active intervention, skills-building participants had high rates of group attendance and treatment retention, suggesting that such interventions are well accepted by methadone patients. Results suggested that skills-building subjects as compared with information-only controls were more likely to initiate discussion of sexual issues, felt more comfortable talking about safer sex with their partners, and reported obtaining, carrying, and using condoms more frequently. Women who received the skills-building intervention also were more likely to perceive themselves as able to reduce their exposure to AIDS, were more interested in learning about AIDS, and were more likely to believe that AIDS can be prevented.
• Follow-up results indicated most of the gains demonstrated immediately following the intervention were still apparent 15 months later. Specifically, skills-building participants continued to report more frequent use of condoms and increased comfort discussing safer sex with their partners. They also were more worried about their children contracting AIDS, saw themselves as more capable of reducing HIV exposure, and were more likely to believe that AIDS can be prevented.
• Although findings are promising in suggesting long-term effects of a multisession skills-building intervention in reducing HIV sexual risk behaviors, the addition of booster sessions may further enhance or help to maintain behavioral changes associated with HIV risk reduction.

This research was supported by National Institute on Drug Abuse grants (DA05356, DA7059).

Elk, R., Schmitz, J., Manfredi, L., Rhoades, H., Andres, R., & Grabowski, J. (1994). Cessation of cocaine use during pregnancy: A preliminary comparison. Addictive Behaviors, 19, 697–702.

This preliminary, retrospective report compared cocaine use and compliance with prenatal care for pregnant substance-abusing women (N = 22) with differing rates of cocaine use (less than or greater than 50% cocaine-positive urines) during their first 4 weeks of treatment in a specialized prenatal substance abuse clinic.

• There were no differences on demographic or drug use characteristics for the two groups.
• Patients who had fewer than 50% cocaine-positive specimens were significantly more likely to be cocaine free at intake than patients who had greater than 50% positive specimens.
• Patients who had fewer than 50% cocaine-positive specimens evidenced greater compliance with drug clinic and prenatal visits than patients who had greater than 50% positive specimens.
• Findings suggest that patients who are drug free at intake are more likely to remain drug free during treatment. Cocaine-free status at intake may reflect a decision to discontinue drug use prior to treatment entry and a high level of motivation to remain drug free.

Elk, R., Schmitz, J., Spiga, R., Rhoades, H., Andres, R., & Grabowski, J. (1995). Behavioral treatment of  cocaine-dependent pregnant women and TB-exposed patients. Addictive Behaviors, 20, 533–542.

This preliminary study examined the efficacy of a contingency management procedure (shaping) on decreasing cocaine use and increasing compliance with health regimens in two health-compromised populations, TB-exposed methadone patients (n = 5) and pregnant substance abusers (n = 7).

• Pregnant substance abusers received monetary incentives for each successive decrease in the level of cocaine metabolite, cocaine-free specimens, or having all three specimens collected each week meet incentive criteria.
• All pregnant patients remained in treatment until delivery; mean treatment duration was 16 weeks.
• Compliance with prenatal care was high, with a mean rate of 72.5% of kept versus scheduled visits.
• There was a tendency for patients to have lower cocaine metabolite levels and more cocaine-free specimens during the incentive as compared with baseline periods.
• Findings are promising for the effectiveness of contingency management interventions to increase prenatal visits and decrease drug use by pregnant substance-abusing women.

This study was supported in part by a National Institute on Drug Abuse grant (DA06143).

Grossman, J., & Schottenfeld, R. (1992). Pregnancy and women's issues. In T. R. Kosten & H. D. Kleber (Eds.), Clinician's guide to cocaine addiction: Theory, research, and treatment (pp. 374–388). New York: Guilford Press.

This book chapter provides an overview of the treatment needs of substance- abusing pregnant women and describes the specialized therapeutic components of the Mothers Project for cocaine-using mothers and their children.

• Across studies, rates of cocaine use during pregnancy are around 10–11%, with considerable variability associated with the site of the prenatal clinic and the detection methods used by the clinic. At the Yale New Haven Hospital, 32% of pregnant women reported lifetime use of cocaine, and 15% reported continued use during pregnancy.
• Cocaine use during pregnancy causes uterine vasoconstriction; this results in oxygen and nutrient deprivation to the fetus and is associated with intrauterine growth retardation.
• In addition to the direct effects of cocaine exposure, birth outcomes for substance-abusing women are affected by a variety of environmental and psychosocial risk factors, including poor maternal health, inadequate housing, single-parent households, and poverty.
• Pregnant substance abusers enter prenatal care later and have higher rates of unregistered deliveries, more emergency room visits, and more missed appointments than do drug-free comparisons.
• It is estimated that 280,000 pregnant women need substance abuse treatment but that less than 11% of women receive services.
• A comprehensive, multidisciplinary, family-centered treatment approach, with an emphasis on the developmental needs of the mother and child and their dyadic relationship, is essential when designing services for substance-abusing pregnant women and mothers.
• Throughout pregnancy and for 6 months postpartum, the Mothers Project offers comprehensive services to cocaine-abusing women. Service elements include prenatal care; individual and group therapy focused on developing coping and problem-solving skills; partners' services; home and outreach services by family support workers; and therapeutic day care services, with early intervention for such developmental problems as expressive language delay, disorganized and aggressive behavior, extreme passivity, and absence of expressed emotions.

Haller, D. L., Knisely, J. S., Dawson, K. S., Elswick, R. K., & Schnoll, S. H. (1994). Retention as a function of psychopathology. In L. S. Harris (Ed.), Problems of drug dependence, 1993: Proceedings of the 55rd Annual Scientific Meeting. The College on Problems of Drug Dependence, Inc. [Research Monograph 141] (p. 349). Rockville, MD: National Institute on Drug Abuse.

This report examines the impact of the type and extent of DSM-III-R Axis II pathology and depression on treatment dropout from comprehensive services for substance-abusing pregnant women (N = 106).

• Subjects were generally single, African American, polydrug users with an average age of 27.  Cocaine was the primary drug of abuse.
• Women with antisocial personality (ASP) disorder were twice as likely to be retained in treatment as women without an ASP diagnosis. Depression and number of Axis II diagnoses were not associated with retention.
• Findings suggest that psychopathology may not be an important determinant of treatment retention among pregnant and postpartum substance abusers.

Howard, J., Beckwith, L., & Espinosa, M. (1994). Participation of mothers in a comprehensive outpatient drug treatment program. In L. S. Harris (Ed.), Problems of drug dependence, 1993: Proceedings of the 55rd Annual Scientific Meeting. The College on Problems of Drug Dependence, Inc. [Research Monograph 141] (p. 355). Rockville, MD: National Institute on Drug Abuse.

This report highlighted the challenge of outpatient treatment attendance in pregnant and postpartum women (N = 62). Services included twice-monthly home visits and center-based activities over an 18-month period.

• The majority of women kept their appointments for home visits.
• Over the course of the project, additional components were implemented to improve outpatient treatment engagement, including community life skills training, personal development program, and enrichment activities (field trips). Patients attended only 17% of center-based activities in the first year, 20% in year 2, and 24% in year 3; however, the percentage of clients who engaged in at least one center-based activity increased from 35% in year 1 to 95% in year 3.
• Women who reported more years of cocaine use and more severe alcohol use were more likely to participate in center-based, outpatient services.

This project was supported by a National Institute on Drug Abuse grant (R18-DA6380).

Hughes, P. H., Coletti, S. D., Neri, R. L., Urmann, C. F., Stahl, S., Sicilian, D. M., & Anthony, J. C. (1995). Retaining cocaine-abusing women in a therapeutic community: The effect of a child live-in program. American Journal of Public Health, 85, 1149–1152.

This clinical trial randomized cocaine-abusing women to the standard therapeutic community (TC) program (n = 22) or an enhanced TC program that allowed one or two children to reside with their mothers (n = 31).

• In the year preceding the clinical trial, women had significantly poorer retention in treatment than men.
• Mean length of stay was significantly longer for women in the enhanced TC program (mean = 300.4 days) than for women in standard care (mean = 101.9 days).
• After 3 months, more than three-quarters of the women (77%) in the enhanced program remained in treatment versus less than half of the standard care women (45%). After 6 months, retention was 65% versus 18% of enhanced as compared with standard program participants.
• Findings suggest that allowing women to live with their children during residential drug treatment enhances their retention in care, potentially improving the mother-child relationship and post-discharge treatment outcomes.

This project was supported in part by a National Institute on Drug Abuse grant (R18 DA06369).

Kim, R. I., Sees, K. L., & Delucchi, K. L. (1994). Couples in substance abuse treatment. In L. S. Harris (Ed.), Problems of drug dependence, 1993: Proceedings of the 55rd Annual Scientific Meeting. The College on Problems of Drug Dependence, Inc. [Research Monograph 141] (p. 357). Rockville, MD: National Institute on Drug Abuse.

This preliminary report examined the outcomes for long-term methadone detoxification patients of engaging in a psychosocial treatment intervention with (n = 17) versus without (n =91) their partner.

• Within the 17 couples engaged in treatment, there was a strong correlation in treatment attrition. Significant positive correlations also were found for opioid urinalysis results and withdrawal symptoms.
• Generally, patients in treatment with their partners had fewer positive urinalysis results and reported decreased withdrawal symptoms and craving.
• Overall, treatment attrition did not differ for patients with versus without partners. However, there was a trend for female patients in treatment with their partners to stay longer than female patients without partners.

This research is supported by a National Institute on Drug Abuse grant (R18-DA06097).

Knisely, J. S., Haller, D. L., Dawson, K. S., Elswick, R. K., & Schnoll, S. H. (1994). Factors associated with retention in two intensive outpatient substance abuse programs. In L. S. Harris (Ed.), Problems of drug dependence, 1993: Proceedings of the 55rd Annual Scientific Meeting. The College on Problems of Drug Dependence, Inc. [Research Monograph 141] (p. 348). Rockville, MD: National Institute on Drug Abuse.

This report examined predictors of retention in time-limited versus self-paced intensive outpatient treatment for pregnant and postpartum substance-abusing women (N = 52).

• Subjects were generally single, African American, polydrug users with an average age of 27. Cocaine was the primary drug of abuse.
• Women in the self-paced treatment program were twice as likely to drop out as compared with those in the time-limited program. Residence in the program's dormitory and the presence of legal problems at the time of treatment entry decreased the likelihood of dropout from the self-paced program.
• Women who were older and had participated in earlier substance abuse treatment programs also were more likely to be retained in treatment.
• These findings highlight the importance of environmental factors as determinants of treatment retention for pregnant and postpartum women.

This study was supported in part by a National Institute on Drug Abuse grant (DA06094).

Nelson-Zlupko, L., Dore, M. M., Kauffman, E., & Kaltenbach, K. (1996). Women in recovery: Their perception of treatment effectiveness. Journal of Substance Abuse Treatment, 13, 51–59.

Twenty-four women enrolled in specialized treatment for female substance abusers were interviewed to determine utilization and perceived helpfulness of services in specialized and nonspecialized drug treatment programs.

• On average, women had had four drug treatment episodes.
• Based on the women's rank ordering of service availability, the most widely available services were individual counseling, therapeutic medication, health care monitoring, psychological evaluation, and addiction education. Reproductive health and sexuality education, parenting education, help obtaining child care, and on-site child care were seen as the least available services.
• Services rated as most helpful included transportation assistance; help obtaining such basic needs as food, clothing, and housing; recreational activities; on-site health care; and 12-step meetings.
• Patients stated that respect and genuine concern by their individual counselor was the single most important factor affecting their decision to remain in treatment.
• Women indicated that when child care services were accessible, they were among the most helpful services for improving attendance at drug treatment. Relatedly, parenting skills training was the most frequently identified need by study participants.
• Women consistently reported that their needs differed from men, and that these needs were either silenced or minimized in co-ed treatment groups. Indeed, over a quarter of respondents perceived co-ed groups as unhelpful or very unhelpful to their recovery.

Seiden, A. M., Chandler, J. M., & Davis, G. (1994). Countering countertransference issues in chemical dependency treatment of multiproblem pregnant women-Dramatic improvement in outcome. In L. S. Harris (Ed.), Problems of drug dependence, 1993: Proceedings of the 55rd Annual Scientific Meeting. The College on Problems of Drug Dependence, Inc. [Research Monograph 141] (p. 353). Rockville, MD: National Institute on Drug Abuse.

This report examines the importance of addressing the expectations of recovery held by program staff and associated problems with patient goal development and limit setting when working with multiply disadvantaged pregnant women.

• A number of staff barriers for the provision of effective treatment services for pregnant, medically and often psychiatrically impaired, substance- abusing women were identified, including (a) staff attitudes that condoned continued drug use ("Who wouldn't use under these circumstances?"); (b) attempts to "rescue" the patient in intended helpfulness; and (c) therapeutic overambition, underambition, or unclear goals.
• In response to these staff barriers, an intervention was conducted with employees that addressed staff countertransference issues and expectancies.
• Prior to the staff intervention, only 5 of 38 (13%) patients completed the entry phase of treatment and attained regular drug-free urinalysis results and consistent program attendance. In contrast, 9 of 15 (60%) patients admitted following the staff intervention have graduated from the entry phase and 8 have maintained gains through continued care.

This project was supported by a National Institute on Drug Abuse grant (DA06387).

Stevens, S. J., & Arbiter, N. (1995). A therapeutic community for substance-abusing pregnant women and women with children: Process and outcome. Journal of Psychoactive Drugs, 27, 49–56.

This retrospective study (N = 161) examines characteristics and treatment outcomes for pregnant women and women with children enrolled in a therapeutic community.

• The primary substance abuse problem was cocaine, followed by alcohol, heroin, amphetamines, opioids, marijuana, and other drugs.
• On average, women were 28 years old and had 11.5 years of education. The majority of women were unmarried (never married, divorced, or separated), were unemployed, and had at least one legal conviction. Half of the women were court referred, and a third were involved with child protective services at time of treatment admission.
• Results of a "Violence Questionnaire" administered to a subsample of patients indicated that 90% of the women had been physically assaulted, over 50% had been the aggressor in a violent episode, and 95% reported having been raped.
• Six-month follow-up outcomes for program completers (N = 13) versus dropouts (N = 44) indicated that completers were less likely to have used alcohol or drugs or to have been rearrested and were more likely to be employed on a full- or part-time basis, to be participating in support groups, and to have at least one child living with them for the majority of the followup period.

This research was supported in part by a National Institute on Drug Abuse grant (1 R18 DA06918).

Stevens, S., Arbiter, N., & Glider, P. (1989). Women residents: Expanding their role to increase treatment effectiveness in substance abuse programs. International Journal of the Addictions, 24, 425–434.

This retrospective review examined the effects of introducing specialized women's services to a therapeutic community.

• Program enhancements included increasing the female/male client ratio; hiring a women's program director and additional female staff, introducing women's therapy groups and seminars, making more changes in the community regarding communication and job assignment, and permitting women to bring their young children with them to live.
• Average length of stay for women residents increased almost 80% from 89 days prior to versus 158 days following program changes.
• Length of stay for mothers with children was greater than that of the overall population.

Strantz, I. H., & Welch, S. P. (1995). Postpartum women in outpatient drug abuse treatment: Correlates of retention/completion. Journal of Psychoactive Drugs, 27, 357–373.

This randomized field study examined retention of cocaine-dependent, postpartum women (N = 292) in specialized intensive day treatment versus traditional outpatient services.

• Subjects had an average age of 30.5 years; were generally African American, never married, and unemployed; and had at least a high school education. The median number of children was three.
• The completion rate was significantly higher in the intensive day program (45%) as compared with the outpatient program (21%); however, there was no significant difference in average length of stay between the two programs (19.9 versus 17.7 weeks in intensive day and outpatient, respectively).
• For the intensive day treatment program, voluntary clients tended to remain in treatment longer than court-ordered clients.
• Retaining custody of the infant (as opposed to having the infant removed to the custody of a relative or foster home) was a strong predictor of retention in intensive day services, particularly for voluntary clients.
• For mothers who had voluntarily entered treatment, the number of children with the mother in her household was a strong positive predictor of outpatient program retention but was a negative predictor of intensive day treatment retention, where daily participation was required.
• Medical composite scores on the Addiction Severity Index (ASI) were positively related to length of outpatient stay but negatively related to intensive outpatient retention.
• Psychiatric composite scores on the ASI predicted reduced length of stay for voluntary patients enrolled in intensive day treatment.
• Generally, patients reported small but highly satisfying social support systems, composed almost exclusively of family members. Overall, there was little relationship between social support and treatment retention.
• The most frequently cited treatment barriers were related to personal feelings ("did not feel like going at times," "program required too much time") and problem denial ("felt I could manage on my own"). Such practical barriers as obtaining child care or transportation were not predictors of treatment dropout.

This research was supported by a National Institute on Drug Abuse grant (1-R18-DA07311-05).

Wallen, J. (1992). A comparison of male and female clients in substance abuse treatment. Journal of Substance Abuse Treatment, 9, 243-248.

This retrospective study examined characteristics and treatment outcomes of male (N = 181) and female (N = 48) patients receiving inpatient services at two private, nonprofit facilities.

• Women and men had comparable completion rates for inpatient treatment.
• Over half of male and female clients reported paternal alcohol problems, and approximately one-quarter reported maternal alcohol problems.
• Women were significantly more likely than men to report sexual abuse during childhood (33%) and as adults (27%). Interestingly, reported sexual abuse was positively related to treatment completion, suggesting that negative feelings about childhood experiences may be related to involvement in the treatment process.
• Approximately 30% of women and men reported physical abuse during childhood.
• Women reported significantly more difficulty socializing and higher levels of hopelessness than men.

Birth and Developmental Outcomes for Drug-Exposed Infants

Andres, R. L., & Larrabee, K. (1996, March). Prenatal care and patterns of drug use: Relative contributions to perinatal outcome in cocaine-dependent women. Philadelphia, PA: Society for Gynecological Investigation.

Birth outcomes (N = 72) were examined retrospectively on the basis of the frequency of cocaine use and prenatal care during the pregnancy.

• Cocaine-dependent women who did not receive prenatal care were most likely to deliver preterm and to deliver low-birth-weight infants as compared with cocaine-dependent women who received prenatal care in a specialized clinic for pregnant substance-abusing women.
• When women enrolled in the specialized clinic were categorized as to whether they had fewer or greater than 50% cocaine positive urine specimens, this measure of drug use did not correlate with perinatal complications.
• Investigators concluded that regular prenatal care has a greater impact on improving birth outcomes of pregnant substance-abusing women than does the actual frequency of cocaine use.

Andres, R. L., Wilson, P. D., Elk, R., & Grabowski, J. (1992, February). Adjunctive behavioral therapy is associated with a decrease in the incidence of preterm labor and delivery in pregnant drug users. San Francisco, CA: Society for the Perinatal Obstetrics.

Birth outcomes were compared retrospectively for pregnant substance-abusing women who did or did not receive intensive behavioral therapy during the pregnancy.

• Incidence of preterm labor requiring tocolytic medications and preterm delivery was reduced among women who received intensive behavioral therapy during the pregnancy.
• No differences between the two groups were observed in incidence of small-for-gestational-age infants, birth weight, preterm premature rupture of the membranes, or mean prenatal visits.

Azuma, S. D., & Chasnoff, I. J. (1993). Outcome of children prenatally exposed to cocaine and other drugs: A path analysis of three-year data. Pediatrics, 92, 396–402.

This study examined the strength and directionality of the effects of a variety of biological, behavioral, and environmental variables on 3-year developmental outcomes of infants exposed prenatally to cocaine and other drugs.

• Path analysis results revealed that drug exposure, home environment, and level of perseverance had significant direct effects on cognitive function as measured by the Stanford-Binet IQ test at 3 years of age. Head growth and parental report of behavioral functioning on the Child Behavior Checklist did not contribute significant direct effects on outcomes.
• Poor task perseverance measured at 3 years had twice the effect of prenatal drug exposure on IQ. Prenatal drug exposure and current home environment had similar levels of effect on 3-year IQ.
• Smaller head circumference was associated with poorer perseverance scores and appears to be a mediating variable between drug exposure and poor perseverance.
• These findings highlight the variety of factors that influence developmental outcomes of drug-exposed children.

Black, M., Schuler, M., & Nair, P. (1993). Prenatal drug exposure: Neurodevelopmental outcome and parenting  environment. Journal of Pediatric Psychology, 18 (5), 605–620.

This prospective study compared neurodevelopmental outcomes using the Brazelton Neonatal Behavioral Assessment Scale (BNBAS) for drug-exposed (N = 20) and drug-free (N = 20) infants at 2–3 days and 2, 4, and 6 weeks after birth. All women in the drug-exposed group used cocaine; additionally, these participants reported heroin, marijuana, alcohol, and nicotine use.

• Mean birth weight was lower for drug-exposed as compared with drug-free infants.
• Drug-using women began receiving prenatal care later in their pregnancy (4.8 months) than non-drug-using women (3.0 months).
• Shortly after birth, drug-exposed infants obtained poorer scores on three of the six BNBAS subscales and evidenced higher depression cluster scores as compared with drug-free infants.
• Differences on the BNBAS between drug-exposed and drug-free infants decreased over the course of the 6-week testing period, although there continued to be evidence of poorer autonomic regulation for drug-exposed infants at week 6.
• Independent of prenatal drug exposure, infants with lower BNBAS scores were least likely to be living in a child-centered home environment.
• Generally, no group differences were observed in nurturance, child-centered stimulation, or parenting stress between drug-using and non-drug-using mothers. Also, mothers in both groups used social support to cope with parenting stress; however, this relationship was stronger in the non-drug-using women than in the drug-using women.

Chasnoff, I. J. (1987). Cocaine- and methadone-exposed infants: A comparison. In L. Harris (Ed.), Problems of drug dependence, 1986: Proceedings of the 48th Annual Scientific Meeting. The Committee on Problems of Drug Dependence, Inc. [Research Monograph 76] (p. 278). Rockville, MD: National Institute on Drug Abuse.

This study compared pregnancy complications and birth outcomes for cocaine-exposed (N = 52) and methadone-exposed infants (N = 73). Mothers in both groups were comparable for social and demographic backgrounds as well as alcohol, marijuana, and cigarette use during pregnancy.

• There was an increased rate of labor and delivery complications (premature labor, precipitous labor, abruptio placentae, and fetal distress) in cocaine-using as compared with methadone-maintained women.
• There was no difference in fetal growth parameters between the two groups.

This project was supported by a National Institute on Drug Abuse grant (1R01-DA04103-01).

Chasnoff, I. J., Burns, W. J., & Schnoll, S. H. (1983). Perinatal addiction: The effects of maternal narcotic and nonnarcotic substance abuse on the fetus and neonate. In L. Harris (Ed.), Problems of drug dependence, 1983: Proceedings of the 45th Annual Scientific Meeting. The Committee on Problems of Drug Dependence, Inc. [Research Monograph 49] (pp. 220–226). Rockville, MD: National Institute on Drug Abuse.

This retrospective medical record examined obstetric complications and birth outcomes as a function of type of primary maternal addiction. Infants were divided into primary heroin/methadone (N = 51), mixed sedative/stimulant (N = 22), pentazocine/tripelennamine (N = 13), phencyclidine (N = 9), and drug-free controls (N = 27). Women with a history of heavy alcohol use were excluded from enrollment.

• Demographic characteristics and cigarette smoking rates were similar across the five subject groups.
• Maternal weight gain, APGAR scores, and frequency of perinatal complications were similar across all groups.
• Approximately one-quarter of the heroin/methadone-exposed infants required therapy for drug withdrawal based on clinical criteria of marked irritability, poor feeding, and/or excessive weight loss. No infant in the other groups required withdrawal therapy.
• Heroin/methadone- and pentazocine/tripelennamine-exposed infants had significantly lower weight, length, and head circumference than control infants.
• As compared with control infants, infants in all four drug-exposed groups showed deficits in state control with an abnormal predominant state, increased lability of state, and poor consolability as measured on the Brazelton Neonatal Behavioral Assessment Scale administered at 2 days of age. Additionally, methadone-exposed infants demonstrated poor visual and auditory orientation responses and poor motor control.
• Overall, findings suggest that neurobehavioral deficits are apparent in infants exposed to nonnarcotic as well as narcotic drugs, although somatic growth deficits are apparent primarily in narcotic-exposed infants.

Chasnoff, I. J., Griffith, D. R., Freier, C., & Murray, J. (1992). Cocaine/polydrug use in pregnancy: Two-year follow-up. Pediatrics, 89, 284–289.

Developmental outcomes at 3, 6, 12, 18, and 24 months were compared for infants exposed to cocaine, typically in combination with marijuana and alcohol (n = 106), infants exposed to marijuana and/or alcohol (n = 45), and infants of alcohol- and drug-free controls (n = 81).

• There were no significant differences in weight or length between the drug-exposed and drug-free infants at each developmental assessment period.
• Head circumference was significantly smaller for infants in both drug-exposed groups as compared with drug-free controls. Prenatal cocaine exposure was a significant predictor of head circumference at 3, 6, and 12 months of age.
• Overall, there were few significant differences on mean scores on the Bayley Scales of Infant Development across the three infant groups from 3 months to 2 years of age. Where differences did exist, mean scores were within half a standard deviation of standardized norms.
• However, a higher proportion of alcohol/marijuana-exposed infants as compared with drug-free controls showed impairment on the Mental Development Index of the Bayley Scales of Infant Development at 6, 12, 18, and 24 months of age.
• Similarly, a greater proportion of infants in both drug-exposure groups as compared with drug-free controls demonstrated impairment on the Psychomotor Development Index of the Bayley Scales of Infant Development at several of the developmental assessments.
• The failure of head circumference of drug-exposed infants to catch up with that of drug-free controls may have important developmental implications, as earlier research has suggested that poor head growth is a better predictor of developmental outcomes than head circumference at birth.

This work was supported by a National Institute on Drug Abuse grant (DA04103).

Chasnoff, I. J., Griffith, D. R., MacGregor, S., Dirkes, K., & Burns, K. A. (1989). Temporal patterns of cocaine use in pregnancy: Perinatal outcomes. Journal of the American Medical Association, 261 (12), 1741–1744.

Obstetric and neonatal outcomes were obtained prospectively for pregnant women with primary cocaine abuse (N = 109) as compared with non-drug-abusing women (N = 40). Cocaine-abusing women were enrolled by the 12th week of pregnancy in a comprehensive program for substance-abusing women.

• None of the obstetric outcomes were significantly affected by amount, frequency, or route of cocaine use.
• Infants of women who used cocaine throughout their pregnancy had significantly lower mean gestational age, lower mean birth weight, smaller mean head circumference, a higher rate of premature delivery, and an increased risk of being small for gestational age as compared with non-drug-exposed infants.
• There was a risk for seizures in infants exposed to cocaine throughout pregnancy and who tested positive for cocaine and its active metabolites at birth.
• Genitourinary tract abnormalities were observed for both infants exposed to cocaine throughout pregnancy and infants exposed only during the first trimester.
• Results on the Neonatal Behavioral Assessment Scale (NBAS) showed significant impairment of orientation, motor ability, state regulation, and number of abnormal reflexes for both infants exposed to cocaine only during the first trimester and infants exposed throughout pregnancy as compared with non-drug-exposed infants.
• Clearly, cocaine exposure only during the first trimester of pregnancy places the neonate at increased risk for delivery complications, genitourinary tract abnormalities, and neurobehavioral deficits relative to non-drug-exposed neonates. These findings highlight the importance of prevention programs to alert women to the dangers of cocaine use before they become pregnant.

Chasnoff, I., MacGregor, S., & Chisum, G. (1988). Cocaine use during pregnancy: Adverse perinatal outcome. In L. Harris (Ed.), Problems of drug dependence, 1987: Proceedings of the 49th Annual Scientific Meeting. The Committee on Problems of Drug Dependence, Inc. [Research Monograph 81] (p. 265). Rockville, MD: National Institute on Drug Abuse.

This study compared neonatal outcomes for cocaine-exposed, polydrug-exposed, and drug-free infants, matched for maternal age, parity, tobacco use, and medical complications.

• Incidence of intrauterine growth retardation (IUGR) was 19% in the cocaine group, 4% in the polydrug group, and 3% in controls.
• Abruptio placentae occurred in 17% of cocaine versus 1.4% of polydrug and control infants.
• Other serious adverse outcomes (perinatal cerebral infarctions and seizures) were observed in 5 cocaine-exposed infants, with no control or polydrug-exposed infants experiencing these complications.

Christmas, J. T., Knisely, J. S., Schnoll, S. H., & Ruddy, S. (1992). Fetal stress associated with cocaine withdrawal. In L. Harris (Ed.), Problems of drug dependence, 1991: Proceedings of the 53rd Annual Scientific Meeting. The Committee on Problems of Drug Dependence, Inc. [Research Monograph 119] (p. 272). Rockville, MD: National Institute on Drug Abuse.

This ongoing clinical investigation is examining the effects on the fetus (N = 8) of acute cocaine withdrawal. Gestational age at the time of study has ranged from 24 to 34 weeks.

• There was considerable variability in hourly fetal movement counts; however, these measures did not clearly correlate with day of withdrawal or maternal ratings of cocaine craving.
• Daily biophysical profiles and nonstressed fetal health rating testing over the course of the hospitalization (5–10 days) indicated that no fetus was in danger at any time during the withdrawal period.
• Results of umbilical arterial Doppler assessment of blood flow suggested that acute cocaine withdrawal may be associated with decreased fetoplacental blood flow.
• Overall, findings suggest maternal cocaine withdrawal is associated with some indicators of fetal stress.

Comfort, M., Smith, A., & Kaltenbach, K. (1994). Perinatal outcome of infants born to women in treatment: Differences according to maternal drug of abuse. In L. S. Harris (Ed.), Problems of drug dependence, 1993: Proceedings of the 55rd Annual Scientific Meeting.  The Committee on Problems of Drug Dependence, Inc. [Research Monograph 141] (p. 115). Rockville, MD: National Institute on Drug Abuse.

This report examines the effects of prenatal drug exposure according to maternal drug use: (a) opiate users maintained on methadone (n = 48); (b) opiate/cocaine users (n = 68); (c) cocaine users (n = 41); and (d) cocaine users who remained drug free after treatment enrollment (n = 44).

• Overall, 69% of the infants were full term.
• Among preterm infants, birth weight, length, head circumference, or mean length of hospitalization did not differ as a function of maternal drug use.
• Opiate-exposed infants were more likely to be small for gestational age as compared with non-opiate-exposed infants.
• Opiate-exposed neonates had a significantly longer mean length of hospital stay (16 days) as compared with non-opiate-exposed neonates (6 days).
• Findings highlight the importance of type of maternal drug use and term status in evaluating perinatal outcomes.

Funkhouser, A. W., Butz, A. M., Feng, T. I., McCaul, M. E., & Rosenstein, B. J. (1993). Prenatal care and drug use in pregnant women. Drug and Alcohol Dependence, 33, 1–9.

This case control study compared demographic and drug use characteristics of pregnant inner-city women with low versus regular prenatal care. Cases (N = 81) had registered for prenatal care at or beyond 28 weeks gestation or had fewer than four prenatal visits. Controls (N =128) were matched to cases for date of delivery and had registered for prenatal care before 28 weeks and had four or more prenatal visits.

• Mean gestational age at first prenatal visit was 20 weeks for cases as compared with 14 weeks for controls. Mean number of prenatal visits was two for cases and six for controls.
• Overall, 19% of all study subjects were frequent drug users, and 25% had used illicit drugs during their pregnancies based on self-report or urine toxicology screen. Additionally, 11% of subjects reported frequent alcohol use. Frequent drug and/or alcohol use was found in 26% of subjects. Heroin use was reported by 77% of frequent users, cocaine by 61%, and marijuana by 32%.
• Women with low prenatal care were 2.5 times more likely than control women to be frequent drug users.
• A significantly higher proportion of neonates born to women with low prenatal care were small for gestational age. Neonates born to cases also had a lower average birth weight. Cases and controls did not differ in mean gestational age at delivery or rates of abruptio placentae, fetal bradycardia, or meconium staining.

Griffith, D. R., Azuma, S. D., & Chasnoff, I. J. (1994). Three-year outcome of children exposed prenatally to drugs. Journal of the American Academy of Child and Adolescent Psychiatry, 33, 20–27.

Developmental outcomes at 3 years were compared for infants exposed to cocaine, typically in combination with marijuana and alcohol (n = 93); infants exposed to marijuana, alcohol, and/or opiates (n = 24); and infants of alcohol- and drug-free controls (n = 25).

• Drug-exposed children had significantly smaller head circumference at 3 years of age than did drug-free control children. No single drug or drug interaction was found to predict small head size.
• There were no significant differences across the three groups on overall test scores on the Stanford-Binet Intelligence Scale (SBIS). However, cocaine/polydrug children scored significantly lower on the SBIS verbal reasoning subscale, and polydrug/noncocaine children scored significantly lower on the SBIS abstract/visual reasoning subscale.
• However, in the present study, cocaine accounted for only 9% of the variance in verbal reasoning; marijuana for only 13% of the variance in abstract/visual reasoning; and the combination of cocaine, marijuana, and alcohol for only 5% of the variance in abstract/visual reasoning. These findings highlight the importance of postpartum environmental factors in predicting intellectual functioning.
• Among cocaine/polysubstance-exposed children, those continuing to live in drug-using households were more likely to evidence significant impairment on the SBIS verbal reasoning subscale than those living in drug-free environments.
• On the Child Behavior Checklist, drug-exposed children were rated by caregivers as engaging in more destructive behaviors than drug-free control children. Also, a greater proportion of drug-exposed children expressed externalizing behaviors as compared with control children.
• As noted in the earlier 2-year follow-up study of these children (Chasnoff et al., 1992), mean smaller head circumference observed at birth for drug-exposed as compared with drug-free infants is sustained through 3 years of age. This may be an important marker for poorer long-term developmental outcomes.

This research was supported by a National Institute on Drug Abuse grant (DA04103).

Howard, J., Beckwith, L., Espinosa, M., & Tyler, R. (1995). Development of infants born to cocaine-abusing women: Biologic/maternal influences. Neurotoxicology and Teratology, 17 (4), 403–411.

This study examined the interrelationship among biological effects of prenatal drug exposure and postpartum environmental rearing factors affecting development outcomes of drug-exposed children (N = 51).

• Out of an original sample of 74 women, 51 (69%) retained custody of their infant from birth to the 6-month follow-up assessment. No differences in maternal age, education, parity, number of children in maternal custody, or years of maternal cocaine, alcohol, or marijuana abuse were observed between women who did versus did not retain custody of their infants.
• Women reported cocaine as their primary drug of abuse, with the majority also reporting abuse of alcohol, marijuana, and nicotine. Fewer than 5% of the women reported being abstinent for 30 days prior to delivery.
• Overall, cocaine-abusing women evidenced impairment in caregiving behaviors as assessed by low scores on the Maternal Caregiving Behavior Rating Scales. However, there was a significant relationship between gestational age and maternal caregiving, such that responsive caregiving was found to be increased by decreased gestational age.
• Infants' scores on the Mean Developmental Index of the Bayley Scales of Infant Development were positively correlated with birth weight and sensitivity scores on the Maternal Caregiving Behavior Rating Scales.
• A relationship was observed between the mother's predelivery personality factors and observer-rated quality of caregiving at 6-months postpartum. Specifically, women who had elevated scores at the time of baseline pregnancy assessment on the histrionic-gregarious, narcissistic, borderline-cycloid, and paranoid classification scales on the Millon Clinical Multiaxial Inventory (MCMI) were observed to be less facilitating and to show more negative regard, less delight, and less sensitivity to their infants at the 6-month assessment.
• Women with elevated scores during pregnancy on the MCMI drug abuse scale were less facilitating, had poorer physical contact, showed more negative regard, and were less stimulating and sensitive with their infants at the 6-month follow-up.
• These findings highlight the importance of a variety of factors including maternal personality, caregiving sensitivity, and prenatal drug exposure as developmental determinants of drug-exposed infants.

This work was supported by a National Institute on Drug Abuse grant (R18 DA06490).

Howard, J., Beckwith, L., Rodning, C., & Kropenske, V. (1989). The development of young children of substance-abusing parents: Insights from seven years of intervention and research. Zero to Three, 9, 8–12.

This article provides methodological recommendations for research with substance-abusing families based on the research experiences of these investigators with the UCLA Department of Pediatrics.

• Clinical services for the affected families are necessary both for ethical reasons and as a primary strategy for maintaining families in the research project.
• Infancy professionals must often assume the primary protective role for children reared by substance-abusing parents. The first goal is to maintain the child's visibility in the community in order to monitor the child's safety.
• Long-term continuity in the clinical and research staff is critical to promote a trusting relationship between research participant and staff. This relationship increases the likelihood that the subject will maintain contact even during difficult periods, and also enables the staff to relocate the subject as a result of their familiarity with the patient and community.
• Successful completion of home and laboratory assessments requires familiarity with the daily patterns of the families' lives. Scheduling and testing need to accommodate these routines.
• Findings have highlighted the importance of including unstructured, free play situations in the research assessments. In these unstructured contexts, drug-exposed children show significant deficits.

Howard, J., Tyler, R., Espinosa, M., & Beckwith, L. (1996). Birth outcome in cocaine- abusing women following three months of drug treatment. In L. S. Harris (Ed.), Problems of drug dependence, 1995: Proceedings of the 57th Annual Scientific Meeting. The College on Problems of Drug Dependence, Inc. [Research Monograph 162] (p. 360). Rockville, MD: National Institute on Drug Abuse.

Polydrug-using (cocaine plus other drugs) pregnant women (N = 72) participated in a drug treatment program including regular urine toxicology testing.

• Women who decreased their drug use at least 50% from intake gave birth to infants with longer gestational periods, higher birth weights, and larger head circumferences.

This research was supported by a National Institute on Drug Abuse grant (DA06380).

Jarvis, M. A. E., & Schnoll, S. H. (1994). Methadone treatment during pregnancy. Journal of Psychoactive Drugs, 26, 155–161.

This review article examines research findings on the effects of methadone maintenance and other more recent opiate pharmacotherapies on pregnancy outcomes.

• Overall, clinical studies demonstrate that methadone maintenance at appropriate doses, combined with prenatal care and comprehensive supportive services, can significantly improve fetal and neonatal outcomes of pregnant, opiate-dependent women.
• Animal research has suggested that precipitated opiate withdrawal induces more fetal stress than acute opiate intoxication, and that repeated bouts of opiate intoxication and withdrawal can lead to severe fetal consequences. These findings highlight the importance of stabilization on a long-acting narcotic to prevent fluctuations in opiate blood levels.
• There is some evidence of accelerated methadone metabolism during late pregnancy, suggesting the potential need for increased dosage levels to prevent withdrawal symptoms during this period. Also, recent findings have suggested the effectiveness of splitting the methadone dose into a twice-daily administration schedule for reducing fetal stress and decreasing maternal discomfort.
• Methadone withdrawal during pregnancy is associated with high relapse rates, thus it generally is not recommended as a therapeutic intervention. Among those women successfully withdrawn without a return to illicit drug use, no adverse obstetrical outcomes were reported and no neonatal withdrawal symptoms were observed in the newborns. If necessary, withdrawal recommendations include a blind dose protocol so that the patient is unaware of the rate of dose reduction; a decrease of no more than 2 mg per day in an inpatient setting and no more than 10 mg per week for outpatient detoxification; daily monitoring for withdrawal symptoms and fetal stress; and intensive psychosocial support to address the women's anxieties and needs that will develop during the dose reduction protocol.
• Studies have shown a positive correlation between maternal methadone dose level and the severity of neonatal withdrawal symptoms.
• Multiple clinical trials have demonstrated improved maternal and neonatal outcomes when prenatal care is delivered in well-coordinated multidisciplinary treatment programs. The need for comprehensive care is highlighted by the frequent polysubstance abuse/dependence observed in opiate-dependent pregnant women.

This work was supported in part by National Institute on Drug Abuse grants (DA00189, DA06094).

Kaltenbach, K., & Finnegan, L. P. (1986). Perinatal and developmental outcome of infants exposed to methadone in-utero. In L. Harris (Ed.), Problems of drug dependence, 1986: Proceedings of the 48th Annual Scientific Meeting. The Committee on Problems of Drug Dependence, Inc. [Research Monograph 76] (p. 276). Rockville, MD: National Institute on Drug Abuse.

This study compared outcomes for methadone-exposed and non-drug-exposed infants at birth and 6 months postdelivery.

• Methadone-exposed neonates had lower mean birth weights than non-drug-exposed infants.
• There were no differences between drug-exposed and comparison infants on mean Bayley Mental Development scores at 6 months of age.
• Study findings suggest that although methadone exposure is associated with lower birth weights, these infants do not experience significant developmental sequelae.

Kaltenbach, K., & Finnegan, L. (1988). Children exposed to methadone in-utero: Cognitive ability in preschool years. In L. S. Harris (Ed.), Problems of drug dependence, 1987: Proceedings of the 49th Annual Scientific Meeting. The Committee on Problems of Drug Dependence, Inc. [Research Monograph 81] (p. 253). Rockville, MD: National Institute on Drug Abuse.

This report compared the results on the McCarthy Scale of Children's Abilities for preschoolers exposed to methadone during pregnancy (N = 27) and non-drug-exposed comparison children (N = 18).

• No differences were observed between methadone-exposed and non-drug-exposed children on the McCarthy General Cognitive Index and any of the six subscales.
• Findings suggest no decline in general cognitive abilities for preschoolers exposed to methadone in utero.

Kandall, S. R., Gaines, J., Habel, L., Davidson, G., & Jessop, D. (1994). Relationship of maternal substance abuse to subsequent sudden infant death syndrome in offspring. In L. S. Harris (Ed.), Problems of drug dependence, 1993: Proceedings of the 55rd Annual Scientific Meeting. The College on Problems of Drug Dependence, Inc. [Research Monograph 141] (p. 114). Rockville, MD: National Institute on Drug Abuse.

This report examined rates of sudden infant death syndrome (SIDS) in drug-exposed infants.

• Between 1979 and 1989 in New York City, the SIDS rate in drug-exposed infants was 5.83 as compared with 1.39 in non-drug-exposed infants, a threefold increase in risk.
• Higher rates of SIDS were associated with maternal opiate use than with maternal cocaine use.
• There were declines in the rates of SIDS across the 10-year monitoring period both in drug-exposed and nonexposed infants.
• Although differences in rates of SIDS were observed as a function of racial/ethnic group in nonexposed infants, no racial/ethnic differences were observed in drug-exposed infants.

Knisely, J. S., Christmas, J. T., Dinsmoore, M., Spear, E., & Schnoll, S. H. (1993). The impact of intensive prenatal and substance abuse care on pregnancy outcome. In L. Harris (Ed.), Problems of drug dependence, 1992: Proceedings of the 54th Annual Scientific Meeting. The College on Problems of Drug Dependence, Inc. [Research Monograph 132] (p. 300). Rockville, MD: National Institute on Drug Abuse.

This study compared birth outcomes for cocaine abusers enrolled in a comprehensive program for perinatal addiction less than 30 days at the time of delivery (n = 11), cocaine abusers enrolled in treatment at least 30 days at time of delivery (n = 33), and controls recruited from the OB clinic of a large metropolitan hospital (n = 160).

• Almost all cocaine abusers (93%) used additional substances, with more than half using cannabis and/or alcohol.
• Overall analyses showed no differences in mean infant body weight, gestational age, or APGAR scores for the three groups (all p > .50).
• Length of time from program admission to delivery was positively correlated with weight, length, head circumference, gestational age, and APGAR scores.
• Length of drug exposure was negatively correlated with weight, length, head circumference, gestational age, and APGAR scores.

This work was supported by a National Institute on Drug Abuse grant (DA06094).

MacGregor, S. N., Keith, L. G., Bachicha, J. A., & Chasnoff, I. J. (1989). Cocaine abuse during pregnancy: Correlation between prenatal care and perinatal outcome. Obstetrics and Gynecology, 74, 882–885.

This retrospective study examined birth outcomes for cocaine-abusing women who received prenatal care in a specialized clinic for substance-abusing women (N = 120), cocaine-abusing women with little or no prenatal care (N = 21), and drug-free control patients (N = 120).

• The mean number of prenatal visits was comparable for cocaine-abusing women enrolled in a specialized obstetric clinic for substance-abusing women and drug-free control patients.
• Cocaine-abusing women with little or no prenatal care had the poorest birth outcomes (gestational age at delivery, birth weight) and the highest frequency of pregnancy complications (preterm delivery, abruptio placentae) as compared with cocaine-abusing women who participated in a specialized OB clinic and drug-free control patients.
• Cocaine-abusing women who received regular prenatal care had significantly improved birth outcomes and fewer prenatal complications compared with cocaine-abusing women who received little or no prenatal care; however, overall outcomes were still significantly poorer than those of drug-free controls.

This project was supported by a National Institute on Drug Abuse grant (DA04103-01).

McCaul, M. E., Svikis, D. S., & Feng, T. (1991). Pregnancy and addiction: Outcomes and interventions. Maryland Medical Journal, 40, 995–1001.

This retrospective study examined psychosocial characteristics and birth outcomes as a function of cocaine versus other drug use for pregnant substance-abusing women receiving prenatal care at an urban medical center. Preliminary findings also are presented for the effects of participation in a weekly on-site support group led by a substance abuse specialist.

• Sixty-four percent of women referred to the substance abuse specialist identified cocaine as their primary drug.
• Cocaine-abusing and other drug-abusing pregnant women were comparable in demographic characteristics. However, cocaine-abusing women were rated as being in greater need of medical, drug, and psychiatric treatment, as well as employment counseling.
• Rates of HIV-seropositivity also were significantly higher in cocaine-using women than in other drug-using women.
• There was a trend for lower mean birth weights and higher placental abruption rates for cocaine-using women.
• Support group attenders and nonattenders were comparable in demographic characteristics and in the severity of their drug and alcohol problems.
• Overall, support group attendance was positively correlated with birth weight, such that more frequent group attenders gave birth to higher weight infants.

Neuspiel, D. R., Zingman, T. M., Templeton, V. H., DiStabile, P., & Drucker, E. (1993). Custody of cocaine-exposed newborns: Determinants of discharge decisions. American Journal of Public Health, 83, 1726–1729.

A retrospective cohort design examined custody placements for newborns who tested positive for cocaine or its metabolite benzoylecgonine (n = 99).

• Toxicology testing was conducted because of known history of drug use (n = 64), clinical signs of drug use in mother or newborn (n = 6), lack of prenatal care (n = 31), and delivery outside the hospital (n = 11).
• Custody at newborn discharge was to birth mothers (38%), other family members (25%), or foster care agencies (36%).
• Significant predictors of nonmaternal placement at birth included:
  • previous involvement of the mother with the child welfare agency;
  • black race;
  • lack of prenatal care;
  • mother's lack of her own home;
  • lower maternal age at first delivery;
  • older maternal age at index delivery.
• Investigators express concern that indices of social deprivation (e.g., housing, accessible health care) may predispose to loss of child custody.

This research was supported by a National Institute on Drug Abuse grant (1-R18-DA06929-01).

Schneider, J. W., & Chasnoff, I. J. (1992). Motor assessment of cocaine/polydrug exposed infants at age 4 months. Neurotoxicology and Teratology, 14 (2), 97–101.

Cocaine/polydrug-exposed infants (n = 74) were compared with non-drug-exposed infants (n = 50) using the Movement Assessment of Infants (MAI), a test of muscle tone, primitive reflexes, automatic reactions, and volitional movement using an a priori profile of normal 4-month-old motor behavior.

• Mean total risk score on the MAI was higher for cocaine/polydrug-exposed infants as compared with non-drug-exposed infants.
• Subscale risk scores for muscle tone, primitive reflexes, and volitional movement were significantly higher for cocaine/polydrug-exposed infants as compared with non-drug-exposed infants.
• Study findings demonstrated that the relative risk for psychomotor development delays was approximately 40 times higher in cocaine/polysubstance exposed infants as compared with nondrug-exposed infants.

This project was supported by a National Institute on Drug Abuse grant (DA04103-01).

Svikis, D. S., McCaul, M. E., Feng, T., Johnson, T. B. R., & Stokes, E. J. (1992). Can a weekly support group for pregnant addicts improve maternal and fetal outcome? In L. Harris (Ed.), Problems of drug dependence, 1991: Proceedings of the 53rd Annual Scientific Meeting. The Committee on Problems of Drug Dependence, Inc. [Research Monograph 119] (p. 271). Rockville, MD: National Institute on Drug Abuse.

The present study examined the usefulness of a weekly substance abuse support group offered on-site in an inner-city hospital-based obstetric clinic.

• No differences were observed for demographic characteristics or drug use severity between women who did not attend (zero or one visit) and who did attend (two or more visits) the support group.
• Support group attenders showed greater maternal and fetal weight gains during pregnancy, improved 1-minute APGAR scores, and significantly fewer low-birth-weight infants (< 2,500 gm) than group nonattenders.
• There was a significant reduction in medical costs incurred for infants of attenders as compared with nonattenders.

Wang, C. H., & Schnoll, S. H. (1986). Prenatal cocaine use associated with down regulation of receptors in human placenta. In L. Harris (Ed.), Problems of drug dependence, 1986: Proceedings of the 48th Annual Scientific Meeting. The Committee on Problems of Drug Dependence, Inc. [Research Monograph 76] (p. 277). Rockville, MD: National Institute on Drug Abuse.

Placental tissues were collected from women with histories of cocaine use during pregnancy (N = 8) and age-matched controls.

• Cocaine users had a significantly lower number of b-adrenergic receptor binding sites and µ- and d-opiate binding sites (Bmax). There was no reduction in binding affinities at the three receptor sites, suggesting a true down regulation of the receptor population.
• This down regulation of b-adrenergic receptor binding sites is probably a result of decreased catecholamine reuptake caused by cocaine administration.

Wingkun, J. G., Knisely, J. S., Schnoll, S. H., & Gutcher, G. R. (1995). Decreased carbon dioxide sensitivity in infants of substance-abusing mothers. Pediatrics, 95, 864–867.

Carbon dioxide sensitivity was assessed in newborns of substance-abusing mothers (n = 12) as compared with drug-free controls (n = 12) to examine possible abnormalities in control of breathing.

• In response to a carbon dioxide challenge, control infants had a substantial increase in tidal volume and an associated increase in minute ventilation as compared with infants of substance-abusing mothers.
• Thus, carbon dioxide sensitivity was significantly blunted in infants of substance-abusing mothers.
• Because testing was conducted within the first 3 days following delivery, it was unclear whether decreased carbon dioxide sensitivity was a result of a neonatal drug abstinence syndrome or a direct effect of the drug.
• Findings may be related to the reported increased risk for sudden infant death in infants of substance-abusing mothers.

This research was supported in part by a National Institute on Drug Abuse grant (DA06094).