Our adoption and foster care conference is back, and bigger than ever! This year, on February 1st and 2nd, 2008 in Edmonds, we'll have two days of talks for parents and professionals, from a panel of local and national experts. With the "Resilient Rascals" conferences, we and our colleagues at Nurturing Attachments and Cascadia Training try to schedule a lineup of talks that we'd be excited to attend, and give ourselves a push to do talks that go beyond "Adoption 101".

We're very excited to be able to host Dana Johnson, MD, this year. Dr. Johnson directs the University of Minnesota International Adoption Clinic, which is the country's longest-running IA clinic. He has been a passionate advocate for children, and Dr. Bledsoe and I are fortunate to count him as a mentor.

Dr. Johnson and his colleagues have been responsible for much of the seminal research on international adoption. They've just completed an truly impressive study: the Bucharest Early Intervention Project, which is the first and hopefully the last randomized controlled study of foster care versus orphanage caregiving. Results have recently been published in Science, and Dr. Johnson has a remarkable presentation prepared on what they've found. Not to be missed - Dr. Johnson is a dynamic speaker, and this is a landmark study.

But wait, there's more:

• I'll be covering "The Nature and Nurture of the Brain", which will review the latest brain research, and how it can help us parent and advocate for fostered and adopted children.
  
• Paulette Caswell, MSW, will address domestic foster care research and outcomes.
  
• Stephen Glass, MD, will cover Sensory Processing and other facets of neurology that impact our kids.
  
• Gwen Lewis, PhD, will answer the question "Why Does My Rascal Go Ballistic?" with a talk on the executive functions, the brain skills that help us regulate our behavior.
• Julie Bledsoe, MD, will review research-based "Interventions for the Fetal Alcohol Spectrum".
• Margaret Cashman, MD, a child psychiatrist and sleep specialist, will present on the use of psychiatic medications in fostered and adopted children.
• We'll have a whole panel of folks addressing the ever-present problem of "Sleep and Adoption".
• In "Om a Little Teapot", I'll put you to sleep (in a good way) with practical techniques for relaxation and self-regulation.
• Deborah Gray, MSW, will present "Five Faves for Anxious Children", an upbeat skills-building workshop for parenting children with anxiety or traumatic stress.
• Plus plenty of time for Q&A, and we'll wrap things up with a panel to discuss some challenging cases.
  

As ever, we'll aim to be informative and entertaining, and to filter the latest research through a practical parenting lens. Sign up now at the Cascadia Training website! We hope to see you there ...
 

In our practice we see a unfortunate number of children with friendship problems. It can be one of the more painful issues that arises for our clients. But there is also hope - some good resources are available to help children with social skills difficulties, and there is much that parents can do to help.

What we hear from some of our families is that their children “feel” younger than they are, and gravitate towards younger children, or are more drawn to adults than peers. It can be hard for them to “share” conversation; they may divulge too much personal information, or have difficulty finding interests in common. They may have trouble joining their classmates in play. They often lack a sense of how to be a good host when having friends over (controlling the play, etc). Boys may take things too far, getting too rough or out of control. Girls may be clingy or bossy. Children may not get invited to play-dates or parties, and may lack a good friend.

Childhood friendship problems is a topic that raises strong feelings in many adults. I don’t know anyone that had a perfectly socially successful childhood, and just reading the previous paragraph can bring up memories of loneliness and rejection. When we see our children having such difficulties it’s truly challenging to stay present and clear-minded about what’s going on. But it is important to find a balance of appropriate concern and involvement. Blaming the peer group, assuming things will be better in another school, or otherwise neglecting the issue isn’t helpful; neither is overreacting, anxious hovering in social situations, or trying to bribe or force other children to include your child.

Causes of Friendship Problems in Fostered and Adopted Kids

Social skills problems in the context of foster care and adoption have not been well-researched, but the causes likely lie in a combination of:

• Lack of early secure attachments leading to more anxious/controlling behaviors in later relationships
• Rough and unsupervised early interactions with peers
• Poor social boundaries and judgement, difficulty reading others’ social cues
• A higher prevalence of impulsivity, ADHD, and externalizing (acting-out) behavioral problems
• Poor emotional regulation (quick to anger at perceived slights and rejection, etc)
• Delayed social/emotional development
• Challenges in social communication and language, making it hard to keep up with the increasingly fast-paced world of their peers

These risks are not shared by all of the adopted children that we see, but they are more common. In the world of social skills interventions, many of the participants are children (boys, usually) with ADHD, acting-out behavioral problems, or autistic spectrum issues. If you substitute "institutional autism", or general lack of appropriate formative social experiences, that's a combination of issues that fits many adopted and fostered children.

Patterns of Peer Problems 

The literature on social skills problems in general suggests that there are a few patterns of peer problems that are most worrisome, and deserving of intervention. Researchers in this field often categorize children by interviewing their peers to come up with how liked (or not) and influential they are. This all sounds a bit harsh, but no one knows better how children are doing socially than their peer group, and the categories that follow aren’t nearly as hurtful as peers can be. In this research context, children are grouped as:

• Average (well-enough liked and influential)
• Popular (desired as a friend and influential)
• Neglected (not influential)
• Controversial (both liked and disliked, also influential)
• Rejected (disliked)

Interestingly, “popular” as derived from peer ratings is not the same as just asking who’s popular. The “sociometrically popular” kids are well-liked, good problem-solvers, and trustworthy - a good friend. The “popular kids” are actually seen as dominant and “stuck-up”. Neglected children may be shy or less motivated to join peers; they seem do well academically, and can start over in new groups and shed the “neglected” status. Controversial children are sociable but tend to use more social aggression and hostility; this also may not be a very stable category over time.

Rejected Children 

But the “rejected” group is the most concerning. Children with rejected status in one group tend to be rejected in new groups as well. Without intervention, they are likely to stay rejected over time, and are more likely to have later difficulties with delinquency and adult maladjustment.

Children who are classified by observers as socially withdrawn, plus rejected by peers (thus, not withdrawn by choice), are more likely to have internalizing problems like depression and anxiety. There are two sub-groupings of boys who are “rejected”: rejected plus aggressive (verbal aggression, rule-breaking, etc), and rejected with odd, immature, or “quirky” behaviors. The rejected-aggressive boys are more likely to have academic difficulties and ADHD. Girls have rates of rejection similar to that of boys, but are a lot less likely to be referred to social skills interventions; it may be that rejected boys stand out more and have more externalizing behaviors, while rejected girls have fewer overt problem behaviors.

If this sounds like your child, you should consider learning more about how to help your child with play dates and friendships (since you’ve got the potential to make a big positive impact), and explore local options for social skills groups. Here are a few tips, but the resources that follow will be more helpful:

Help your kids with the basics of social interactions

• Teach your child learn appropriate social greetings-and-responses, and what degree of physical contact is appropriate for whom (how not to be a "space invader")
  
• Encourage and model use of positive statements like praise and agreement
• Help your kids learn to share a conversation (reciprocity)
  
• Practice these skills over and over and over
  

Help children have frequent, successful play dates

• For younger/less mature children, having shorter, more structured play dates can help
• Practice being a good host beforehand, and come up with possible activities that their guest may enjoy
• When it comes to games, emphasize shared fun over winning/losing, and "good sport" behaviors (make sure to model these as well!)
  
• As a parent, stay aware of how things are going without hovering

Support your child in making and keeping friends

• Make friends with neighbors with children, allow your kids to get to know each other
• Get to know the parents of your kids potential friends (and enemies!)
• Make your child's friends feel welcome in your home (greet them warmly, compliment them directly and to their parents when they pick them up)
• Socialize across generations: make time for extended family, hang out with other entire families together, look for a range of ages for your child to get to know. Such shared family gatherings can provide models of interaction, unhurried time for children to get to know each other, and can keep parents in touch with how their kids are doing socially.
  

Help your children deal with the pain of rejection

• Remember that some pain around peer issues is inevitable and a normal part of childhood; try not to overreact or get too caught up in your own issues
• Don't nurture resentments, add fuel to feuds, or attempt to coerce other children into including your child
  
• But do employ "active listening"; acknowledge and reflect back the emotions that you see your child having
• Once your child feels heard and understood, help your child with self-soothing strategies like deep breathing, muscle relaxation, and active play
• If bullying at school is involved, insist that it be appropriately addressed; most schools these days have policies, if not effective interventions, in place to deal with bullying
• If your child falls into the "rejected status" category above, seek further help (see below)
  

Resources for Families 

One book for parents that I’ve really liked is “Best of Friends, Worst of Enemies: Understanding the Social Lives of Children”. Several of the tips above come from this book, which deftly summarizes the research about how children’s friendships evolve as they mature, and has solid suggestions for each developmental stage. Another book is "It's So Much Work to Be Your Friend: Helping the Child with Learning Disabilities Find Social Success". But having a good book probably isn’t enough for children that fall into the socially rejected category. That’s where social skills groups come in ...

Social Skills Interventions 

Social skills interventions for children do exist that have been well-studied, and show measurable improvements in parent and teacher ratings of social success. One such intervention is Children’s Friendship Training, which was developed at UCLA. Some of their work has specifically looked at children with ADHD, ODD (oppositional-defiant disorder), ASD (autistic spectrum disorders), and even FAS (fetal alcohol syndrome). I like this approach, as they’ve evaluated it with the types of problems my patients have, they have a rigorous approach to testing their program in general, and they include an important parent educational component which helps the gains children make in group generalize to the rest of their lives.

There are two local groups I’m aware of that draw on this intervention for their social skills groups. One is BeFriended, which runs social skills and friendship groups in collaboration with Nurturing Attachments. The other is FASt Friends, a family support group for families impacted by prenatal alcohol exposure, who run Children’s Friendship Training groups for teenagers.

In the interests of full disclosure, BeFriended was started by my lovely and talented wife, Kim. I’ve been a bit involved with its conception ... for professionally selfish reasons, I’ve really wanted to see an adoption-savvy social skills intervention come to town! But I also want to be fair to the other good folks in town that I don’t happen to be married to. I’ve heard nice things about all of the following social skills practices, and I’m happy for people to post more in the comments. Choice is a good thing. Best of luck to all of our families that are struggling with this issue!

Puget Sound Social Skills Groups:

• BeFriended
• FASt Friends Teen Groups
• Wally’s Club
• Friendship Group
• Carla Brooks and Associates
• Your child’s school may have a social skills program or friendship group as well
  

Raising Resilient Rascals:

Integrative, Brain-Based and Practical Ways
to Nurture Adopted and Fostered Children

 
Save the date! On Feb 2nd we'll be hosting an all-day conference with Deborah Gray and colleagues.  We're aiming to be interesting and informative for both parents and professionals interested in adoption. Check out the topics below, and sign up at the Cascadia Training website.

Topics include:

 

The "Decade of the Brain" Came and Went - What Have We Learned?

The past 10 years brought many advances in neuro-imaging, and better understanding of the effects of prenatal drug and alcohol exposures, malnutrition, maltreatment, lack of attuned care giving, and stress on the developing brain.  What can the latest research tell us about how these all-too-frequent influences affect the neurodevelopment of adopted and foster children?  We will explore different regions of the brain, and aspects of learning and behavior, with an emphasis on avenues for intervention at home and school.

Loving the Child Who Bites You - Disciplining Scared/Aggressive Kids. 

Children who have been maltreated or lost attachment figures desperately need to form secure attachments with their parents.  Often the children are aggressive and/or immature and impulsive.  What strategies are useful when children show limited empathy?  We will look at approaches designed to bring out the best in children whose histories of maltreatment have resulted in dysregulation and behavior problems.

From Snake Oil to Fish Oil - Integrative Medicine and Adoption. 

A lively romp through the wilderness of complementary/alternative therapies commonly used by adoptive families, from an "alterna-friendly" pediatrician.  We'll review the evidence or lack thereof, safety, and cost of interventions ranging from vitamins, minerals, essential fatty acids, and other "nutriceuticals", herbs and homeopathy, elimination diets, chelation therapy, bodywork and chiropractic, developmental movement therapy, sensory and auditory integration, and bio/neurofeedback.  We'll also cover ways to evaluate therapies and practitioners, and the cardinal signs of quackery.

Adderall and Risperdal et al. - Meds and Adoption.  

In this part of our talk, we'll address the use of psychiatric medications with adopted and fostered children.  Stimulants, antidepressants, mood stabilizers, blood-pressure medications, and atypical anti-psychotics are being used more and more with younger and younger children.  Unfortunately, the evidence for safety and efficacy in children for many of these drugs is lacking (as are the child psychiatrists!)  What do we know about these meds and children?  What goes into the decision to medicate a child for specific psychiatric conditions like ADHD, depression, anxiety, and bipolar disorders, as well as less defined emotional and behavioral problems?  What sort of monitoring is important?

Creating Resilience in Children: What areas promote competencies in children?  What are we doing well?  What are we missing?   How should we be doing it? 

The remarkable increase in the number of adoptions of children adopted after trauma and neglect has pushed the need for support.  But, professionals and parents alike need to know when to obtain support.  This talk describes symptom clusters in childhood trauma, neglect's impact on children's functioning,  and best practices in providing help.  We will also discuss what to look for in acquiring help and what to avoid.

Resilience Panel

The day will end with a panel to include all the speakers and a few invited guests.  The panel will discuss resilience factors, resilience gene, adult influences, orphanage interventions, goodness of fit, what can parents do to prepare/promote resilience?  There will be plenty of time to take attendee questions.

About the presenters:

Julia Bledsoe, MD, is a Clinical Associate Professor of Pediatrics at the University of Washington, and a staff pediatrician at the UW Fetal Alcohol Syndrome Diagnostic and Prevention Network in Seattle.  She founded the Center for Adoption Medicine, and has worked in the field of international adoption for ten years, with travels to Russia, Romania, China, and Guatemala.  She has two children adopted from Korea, one of whom has Tourette's Syndrome and ADHD.

Julian Davies, MD, is a Clinical Assistant Professor of Pediatrics at the University of Washington, and the other pediatrician at the UW FAS Clinic.  He is also the Co-Director of the Center for Adoption Medicine, where he provides pre-adoption consultations, post-placement evaluations, and ongoing general pediatric care for adopted children.  He is the primary author for www.adoptmed.org, an online resource for medical and developmental issues in adoption and pediatrics.  He has traveled, clowned, and volunteered extensively in Russia, with an arts rehabilitation program and summer arts camp for Russian orphans.

Deborah Gray, MSW, MPA, is a national trainer, a psychotherapist in private practice, and the author of the well-received book, Attaching in Adoption: Practical Tools for Today’s Parents, Perspectives Press, 2002. Deborah has spent 20 years helping children develop attachments and work through trauma and grief. She teaches in the Trauma Certificate Program at the Univ. of WA School of Social Work and both graduate adoption therapy programs at Portland State University and Northwest Adoption Exchange. Her second book on best practices with children after neglect and trauma is in preparation.

About the particulars:

Location: Tukwila Community Center
When: February 2nd, 2007
Hours: 8:30am-5:00pm
Fee: $65.00 US
CEU info: 7 CEU's 
Cascadia Training is approved by the NASW, Washington State Chapter, to provide continuing education units to Licensed Social Workers, Mental Health Counselors and Marriage and Family Therapists.  Certificates of Completion are awarded to attendees at the end of each workshop.  Provider number #1975-118; Cascadia is an OSPI approved provider of in-service education.  This is a "Washington State Approved Clock Hour Offering Workshop."

This is a handy list of medical resources in China for travelling families, graciously shared by Todd Ochs, MD. 

Anhui Province

Hefei - Anhui Provincial Hospital
No. 1 Lujiang Road
0551-2652797
(VIP section for foreigners)
Hu Yunwen, MD

Anhui Provincial Children’s Hospital
No. 39 East Wang Jiang St.
230051 Hefei
Shan Hua, MD
0551-367103-3035 (off.)
13966681963 (cell)
<hua888@mail.hf.ah.cn>

Beijing - International SOS Clinic
No. 1 North Road, Xing Fu San Cun
Chaoyang District
8610-64629117 (clinic)
8610-64629100 (alarm)

Click to read more ...

Here are some fab resources on this subject from a pediatric toilet training guru - (a dubious honor, for some, but you can't be in pediatrics without a healthy appreciation for the bodily functions).

• Parent Guide: Toilet Training Basics (start here)
• Parent Guide: Toilet Training Resistance (if you're having trouble)
• Parent Guide: Stool holding - When your child holds back bowel movements and is not toilet trained (uhoh)
• Parent Guide: Using Incentives to Motivate Your Child (you might need this)

Dr Parker, a developmental pediatrician with a mighty fine blog, has a this post on the Poop Wars:

• Poop Culture: Potty Training Your Child
  

Elizabeth Pantley, author of several "No-Cry" and other excellent parenting books, has several articles on this topic as well, which she permitted us to excerpt here:

• Quick Facts About Potty Training
• Potty Training Readiness Quiz
• Potty Training - Get Ready, Get Set, Go!

And if these Pantley tips don't work, you can always try the Pantless method ... take one warm weekend, add one rug-free room or backyard, a nearby potty or 2, and a toddler tanked up on fluids. Subtract clothes (theirs).

By Elizabeth Pantley, Author of The No-Cry Potty Training Solution

Potty training can be natural, easy, and peaceful. The first step is to know the facts.

• The perfect age to begin potty training is different for every child. Your child's best starting age could be anywhere from eighteen to thirty-two months. Pre-potty training preparation can begin when a child is as young as ten months.
• You can begin training at any age, but your child's biology, skills, and readiness will determine when he can take over his own toileting.
• Teaching your child how to use the toilet can, and should, be as natural as teaching him to build a block tower or use a spoon.
• No matter the age that toilet training begins, most children become physically capable of independent toileting between ages two and a half and four.
• It takes three to twelve months from the start of training to daytime toilet independence. The more readiness skills that a child possesses, the quicker the process will be.
• The age that a child masters toileting has absolutely no correlation to future abilities or intelligence.
• There isn’t only one right way to potty train – any approach you use can work - if you are pleasant, positive and patient.
• Nighttime dryness is achieved only when a child's physiology supports this - you can't rush it.
• A parent's readiness to train is just as important as a child's readiness to learn.
• Potty training need not be expensive. A potty chair, a dozen pairs of training pants and a relaxed and pleasant attitude are all that you really need. Anything else is truly optional.
• Most toddlers urinate four to eight times each day, usually about every two hours or so.
• Most toddlers have one or two bowel movements each day, some have three, and others skip a day or two in between movements. In general, each child has a regular pattern.
• More than 80 percent of children experience setbacks in toilet training. This means that what we call “setbacks” are really just the usual path to mastery of toileting.
• Ninety-eight percent of children are completely daytime independent by age four.
  

This article is an excerpt from The No-Cry Potty Training Solution: Gentle Ways to Help Your Child Say Good-Bye to Diapers by Elizabeth Pantley (McGraw-Hill, 2006). Used with permission.

By Elizabeth Pantley, Author of The No-Cry Potty Training Solution

Potty training is easier and happens faster if your child is truly ready in all three areas: physical, cognitive and social. But the big question is: how do you know when your child is ready? If you have never traveled this road before, you likely don’t even know what signs to look for. Take this quiz to find out where your child is on the readiness spectrum.

1. I can tell by watching that my child is wetting or filling his diaper:
a. Never.
b. Sometimes.
c. Usually.

2. My toddler's diaper needs to be changed:
a. Frequently, every hour or two.
b. It varies.
c. Every two to three hours--sometimes less frequently.

3. My child understands the meaning of wet, dry, clean, wash, sit, and go:
a. No.
b. Some of them.
c. Yes.

4. When my child communicates her needs, she:
a. Says or signs a few basic words and I guess the rest.
b. Gets her essential points across to me.
c. Has a good vocabulary and talks to me in sentences.

5. If I give my child a simple direction, such as, "put this in the toy box," she:
a. Doesn't understand or doesn't follow directions.
b. Will do it if I coach or help her.
c. Understands me and does it.

6. My child can take his pants off and put them on:
a. No.
b. With help he can.
c. Yes.

7. When I read a book to my child, he:
a. He ignores me.
b. Sometimes listens, sometimes wanders off.
c. Sits, listens and enjoys the story.

8. My toddler wants to do things “all by myself”:
a. Never.
b. Sometimes.
c. All the time!    

9. I think that it's the right time to begin potty training:
a. No.
b. I'm undecided.
c. Yes.

Total the number of responses for each letter:
a. __________
b. __________
c. __________

Most answers are a: Wait.
Your little one doesn't seem to be ready just yet. Test again in a month or two.

Most answers are b: Time for pre-potty training--get ready!
Your child is not quite ready for active training, but you can take many steps to prepare your toddler for the future. Gradual introduction of terms and ideas will make potty training easier when the time comes.

Most answers are c: Your toddler is ready to use the potty!
It's time to start your potty training adventure. Good luck, and have fun!

Are you between two scores?
Just like any parenting situation, there are choices to make. If your child is hovering between two categories, it's time to put your intuition to good use. Your knowledge of your own child can direct you toward the right plan of action.

This article is an excerpt from The No-Cry Potty Training Solution: Gentle Ways to Help Your Child Say Good-Bye to Diapers by Elizabeth Pantley (McGraw-Hill, 2006). Used with permission.

By Elizabeth Pantley, Author of The No-Cry Potty Training Solution

 

Get Ready

If your child is near or has passed his first birthday, you can begin incorporating pre-potty training ideas into his life. They are simple things that will lay the groundwork for potty training and will make the process much easier when you're ready to begin.

• During diaper changes, narrate the process to teach your toddler the words and meanings for bathroom-related functions, such as pee-pee and poo-poo. Include descriptive words that you'll use during the process, such as wet, dry, wipe, and wash.
• If you're comfortable with it, bring your child with you when you use the toilet. Explain what you're doing. Tell him that when he gets bigger, he'll put his pee-pee and poo-poo in the toilet instead of in his diaper. Let him flush the toilet if he wants to.
• Help your toddler identify what's happening when she wets or fills her diaper. Tell her, "You're going poo-poo in your diaper." Have her watch you dump and flush.
• Start giving your child simple directions and help him to follow them. For example, ask him to get a toy from another room or to put the spoon in the dishwasher.
• Encourage your child to do things on her own: put on her socks, pull up her pants, carry a cup to the sink, or fetch a book.
• Have a daily sit-and-read time together.
• Take the readiness quiz again every month or two to see if you're ready to move on to active potty learning.
  

Get Set

• Buy a potty chair, a dozen pairs of training pants, four or more elastic-waist pants or shorts, and a supply of pull-up diapers or disposables with a feel-the-wetness sensation liner.
• Put the potty in the bathroom, and tell your child what it's for.
• Read books about going potty to your child.
• Let your child practice just sitting on the potty without expecting a deposit.
  

Go

• Begin dressing your child in training pants or pull-up diapers.
• Create a potty routine - have your child sit on the potty when she first wakes up, after meals, before getting in the car, and before bed.
• If your child looks like she needs to go - tell, don't ask! Say, "Let's go to the potty."
• Boys and girls both can learn sitting down. Teach your son to hold his penis down. He can learn to stand when he's tall enough to reach.
• Your child must relax to go: read a book, tell a story, sing, or talk about the day.
• Make hand washing a fun part of the routine. Keep a step stool by the sink, and have colorful, child-friendly soap available.
• Praise her when she goes!
• Expect accidents, and clean them up calmly.
• Matter-of-factly use diapers or pull-ups for naps and bedtime.
• Either cover the car seat or use pull-ups or diapers for car trips.
• Visit new bathrooms frequently when away from home.
• Be patient! It will take three to twelve months for your child to be an independent toileter.
  

Stop

• If your child has temper tantrums or sheds tears over potty training, or if you find yourself getting angry, then stop training. Review your training plan and then try again, using a slightly different approach if necessary, in a month or two.
  

This article is an excerpt from The No-Cry Potty Training Solution: Gentle Ways to Help Your Child Say Good-Bye to Diapers by Elizabeth Pantley (McGraw-Hill, 2006). Used with permission.

Excerpted from our review article for health care providers - Prenatal Alcohol and Drug Exposures in Adoption, originally published in Pediatric Clinics of North America - © 2005 Elsevier Inc. All Rights Reserved.

Overview

Methamphetamine abuse has increased dramatically in the United States in the past decade, especially in the western and midwestern states [105]. In Russia, cheap imported heroin still prevails, but abuse of home-produced ephedrine-based “vint” and other injectable amphetamines is on the rise and already predominates in certain cities, including Vladivostok and Pskov [106]. Methamphetamine abuse is a significant problem in Southeast Asia as well, with 19% of Thai female students using methamphetamine in one school-based study [107]. The UNODC reports large increases in methamphetamine production and abuse in China, Singapore, and Thailand [35]. Because methamphetamine is relatively cheap to manufacture from readily available products, “home labs” are becoming increasingly common in many parts of the world. Unfortunately, the chemicals and byproducts involved are highly toxic and flammable.

Methamphetamine is a CNS stimulant that releases large amounts of dopamine, resulting in a sense of euphoria, alertness, and confidence [108]. It can be injected, smoked, snorted, or ingested orally. Prolonged use at high levels results in dependence and erratic behavior [105]. Evidence on the effects of prenatal methamphetamine use is still emerging, but effects on prenatal growth, behavior, and cognition have been described.

Mechanism

Studies of adult methamphetamine abusers have shown potential neurotoxic effects on subcortical brain structures, namely, decreased dopamine transporters, brain metabolism, and perfusion [108]. Although the impact of methamphetamine use during human pregnancy is currently unknown, animal studies have demonstrated neurotoxic effects of amphetamines and remodeling of synaptic morphology in response to prenatal methamphetamine exposure [109]. One study did describe a smaller putamen, globus pallidus, and hippocampus in methamphetamine-exposed children [108].

Pregnancy

Women using methamphetamine during pregnancy may have an increased rate of premature delivery and placental abruption [110]. Methamphetamine use during pregnancy is linked to fetal growth restriction and, occasionally, withdrawal symptoms requiring pharmacologic intervention at birth [111]. Clefting, cardiac anomalies, and fetal growth reduction have been described in infants exposed to amphetamines during pregnancy. These findings have been reproduced in animal studies [112].

Child Health

Late effects on child health resulting from prenatal methamphetamine use are unknown. Children who live at or visit methamphetamine home labs face acute health and safety hazards from fires, explosions, and toxic chemical exposures, however. The caregiving environments of methamphetamine users are often characterized by chaos, neglect and abuse, and criminal behavior as well as the presence of firearms, contaminated sharps, and other risks [113].

Behavior and Cognition

The scant research describing the outcomes of methamphetamine-exposed children describes possible links with aggressive behavior, peer problems, and hyperactivity [114], [115]. A small recent study found that methamphetamine-exposed children scored lower on measures of visual motor integration, attention, verbal memory, and long-term spatial memory [108]. In rats, even low doses of prenatal methamphetamine exposure can alter learning and memory in adulthood [116].

Selected References

[105]   Anglin M.D.,  Burke C.,  Perrochet B.,  History of the methamphetamine problem. J Psychoactive Drugs (2000) 32 : pp 137-141.
[106]   Rhodes T.,  Bobrik A.,  Bobkov E.,  HIV transmission and HIV prevention associated with injecting drug use in the Russian Federation. Int J Drug Policy (2004) 15 : pp 1-16.  
[107]   Sattah M.V.,  Supawitkul S.,  Dondero T.J.,  Prevalence of and risk factors for methamphetamine use in northern Thai youth: results of an audio-computer-assisted self-interviewing survey with urine testing. Addiction (2002) 97 : pp 801-808.
[108]   Chang L.,  Smith L.M.,  Lopresti C.,  Smaller subcortical volumes and cognitive deficits in children with prenatal methamphetamine exposure. Psychiatry Res (2004) 132 : pp 95-106.
[109]   Weissman A.D.,  Caldecott-Hazard S.,  Developmental neurotoxicity to methamphetamines. Clin Exp Pharmacol Physiol (1995) 22 : pp 372-374.
[110]   Eriksson M.,  Larsson G.,  Winbladh B.,  The influence of amphetamine addiction on pregnancy and the newborn infant. Acta Paediatrica Scandinavica (1978) 67 : pp 95-99.  
[111]   Smith L.,  Yonekura M.L.,  Wallace T.,  Effects of prenatal methamphetamine exposure on fetal growth and drug withdrawal symptoms in infants born at term. J Dev Behav Pediatr (2003) 24 : pp 17-23.
[112]   Plessinger M.A.,  Prenatal exposure to amphetamines. Risks and adverse outcomes in pregnancy. Obstet Gynecol Clin North Am (1998) 25 : pp 119-138.
[113]   Swetlow K.,  Children at clandestine methamphetamine labs: helping meth's youngest victims 2003. Washington, DC: US Department of Justice, Office of Justice Programs, Office for Victims of Crime.  
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[115]   Eriksson M.,  Billing L.,  Steneroth G.,  Health and development of 8-year-old children whose mothers abused amphetamine during pregnancy. Acta Paediatr Scand (1989) 78 : pp 944-949.
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Excerpted from our review article for health care providers - Prenatal Alcohol and Drug Exposures in Adoption, originally published in Pediatric Clinics of North America - © 2005 Elsevier Inc. All Rights Reserved.

Overview

Cocaine has received much attention since the 1980s, when crack cocaine began to plague urban America. Early alarmist predictions about an epidemic of neurologically damaged “crack babies” gave way to guarded optimism with early reports of neurodevelopmental functioning reporting no differences attributable to cocaine exposure. Follow-up studies with more specific measures, however, suggest effects of prenatal cocaine abuse on aspects of neurobehavior and language, as demonstrated with specific developmental tasks.

The rate of prenatal cocaine exposure in the United States ranges from 0.3% to 31% depending on the population surveyed and method of ascertainment [77], [78] and was 10% in the ongoing Maternal Lifestyle Study [34]. In our clinic's experience, reports of cocaine exposure in the international adoptee population are quite rare. The UNODC estimates the lifetime prevalence of cocaine consumption to be approximately 2% to 5% in a study of Guatemalan teenagers; in Russia, China, Korea, and other frequent countries of international adoption, the prevalence seems to be much less [35].

Mechanism

Cocaine and its metabolites readily cross the placenta, concentrating in amniotic fluid, and may produce direct neurotoxic effects, disturb monoaminergic (eg, dopamine, norepinephrine, serotonin) pathways, and cause vascular-mediated damage [91].

Pregnancy

The use of cocaine in pregnancy has been associated with a number of obstetric complications, such as stillbirth, placental abruption, premature rupture of membranes, fetal distress, and preterm delivery [92]. Growth restriction is often reported but may require higher levels of exposure and does not seem to persist after birth [93]. There may be a dose-response effect of cocaine on newborn head circumference [94]. Other CNS lesions (eg, stroke, cystic changes, possible seizures), cardiac defects, and genitourinary (GU) anomalies have also been reported, but the few available large, controlled, population-based studies on cocaine exposure and malformations have reached contradictory conclusions [95].

Behavior and Cognition

Prenatal cocaine abuse may cause specific neurobehavioral and learning problems, although it is not associated with global cognitive deficits [96], [97]. The largest matched cohort study to date found no significant covariate-controlled associations between cocaine exposure and mental, psychomotor, or behavioral functioning through 3 years of age [98]. Infant neurobehavioral abnormalities like irritability or excitability, sleep difficulties, and state regulation difficulty as well as transient neurologic abnormalities like tremor, hypertonia, and extensor posturing have been reported [99], [100]. Heavy prenatal cocaine use has been linked to poor memory and information processing in infancy [101]. At 3 years of age, increased fussiness, difficult temperament, and behavior problems were described [102]. Language delay has also been described, with foster or adoptive caregiving described as a promising protective factor [103], [104].

Selected References

[91]   Chiriboga C.A.,  Fetal effects. Neurol Clin (1993) 11 : pp 707-728.
[92]   Kain Z.N.,  Mayes L.C.,  Ferris C.A.,  Cocaine-abusing parturients undergoing cesarean section. A cohort study. Anesthesiology (1996) 85 : pp 1028-1035.
[93]   Nordstrom-Klee B.,  Delaney-Black V.,  Covington C.,  Growth from birth onwards of children prenatally exposed to drugs: a literature review. Neurotoxicol Teratol (2002) 24 : pp 481-488.
[94]   Bateman D.A.,  Chiriboga C.A.,  Dose-response effect of cocaine on newborn head circumference. Pediatrics (2000) 106 : pp E33-.
[95]   Vidaeff A.C.,  Mastrobattista J.M.,  In utero cocaine exposure: a thorny mix of science and mythology. Am J Perinatol (2003) 20 : pp 165-172.
[96]   Wasserman G.A.,  Kline J.K.,  Bateman D.A.,  Prenatal cocaine exposure and school-age intelligence. Drug Alcohol Depend (1998) 50 : pp 203-210.
[97]   Singer L.T.,  Minnes S.,  Short E.,  Cognitive outcomes of preschool children with prenatal cocaine exposure. Obstet Gynecol Surv (2005) 60 : pp 23-24.  
[98]   Messinger D.S.,  Bauer C.R.,  Das A.,  The maternal lifestyle study: cognitive, motor, and behavioral outcomes of cocaine-exposed and opiate-exposed infants through three years of age. Pediatrics (2004) 113 : pp 1677-1685.
[99]   Tronick E.Z.,  Frank D.A.,  Cabral H.,  Late dose-response effects of prenatal cocaine exposure on newborn neurobehavioral performance. Pediatrics (1996) 98 : pp 76-83.
[100]   Chiriboga C.A.,  Brust J.C.,  Bateman D.,  Dose-response effect of fetal cocaine exposure on newborn neurologic function. Pediatrics (1999) 103 : pp 79-85.
[101]   Jacobson S.W.,  Jacobson J.L.,  Sokol R.J.,  New evidence for neurobehavioral effects of in utero cocaine exposure. J Pediatr (1996) 129 : pp 581-590.
[102]   Richardson G.A.,  Prenatal cocaine exposure. A longitudinal study of development. Ann NY Acad Sci (1998) 846 : pp 144-152.  
[103]   Delaney-Black V.,  Covington C.,  Templin T.,  Expressive language development of children exposed to cocaine prenatally: literature review and report of a prospective cohort study. J Commun Disord (2000) 33 : pp 463-480.
[104]   Lewis B.A.,  Singer L.T.,  Short E.J.,  Four-year language outcomes of children exposed to cocaine in utero. Neurotoxicol Teratol (2004) 26 : pp 617-627.