CHAPTER I: Common Questions and Honest AnswersIn recent years, teachers in preschool programs and elementary schools have been reporting increasing numbers of children who display troubling behaviors and learning problems. These include:
· Short attention span;
· Extreme distractibility;
· Difficulty coping with changes;
· A higher frequency of speech and language delays and disorders, including poor articulation, limited vocabulary, and limited expressive language skills;
· Aggressive and disruptive behavior;
· Lack of social competence; and
· Difficulty forming healthy relationships with peers and teachers.Many teachers wonder whether prenatal exposure to alcohol and other drugs may be causing or contributing to these problems, although they probably will never know the answer to this question. They wonder, too, about the effects of living in families involved with the abuse of alcohol and other drugs, or in communities where the sale and use of substances is common.
In this manual, when we talk about children affected by substance abuse, we are including both those from families and communities involved with abuse of alcohol and other drugs, and those about whom there is direct knowledge of prenatal exposure. Most commonly, this knowledge will be a diagnosis of Fetal Alcohol Syndrome, but in a few cases the program may have other verified knowledge about prenatal exposure to drugs.
COMMON QUESTIONS AND HONEST ANSWERS
Q:What about all the behavior problems I'm seeing in children-what is causing them?
A: The research is still inconclusive. Research has revealed some of the impacts of maternal factors (before birth) on children's later development. But complex risk factors affect children who live in families that abuse alcohol and other drugs, and/or live in communities affected by drug trafficking and substance abuse. Family circumstances that can sometimes affect how children develop include inadequate prenatal care, limited care giving skills, and exposure to neglect and abuse at home. Community circumstances play a part, as well-especially the widespread violence in communities that have high rates of drug trafficking and drug abuse. When factors such as these accumulate, children's healthy development is especially at risk.
Q:Do I have some children who actually were prenatally exposed to drugs in my program?
A: Very probably-only you don't necessarily know who they are. Prenatal exposure to drugs can only be confirmed by toxicity screens administered at birth, or by self-report from parents. Such self-reports are often unreliable, even when parents try to report accurately, because they may not know themselves what substances they used, or in what amounts. The main value of a positive determination of prenatal exposure to drugs is not to predict long-term outcomes, but to identify children at risk who might benefit from early intervention.
Research to date has not indicated a profile for children prenatally exposed to drugs. The children bring with them a wide range of behaviors, dispositions, and learning styles.
Q:What about prenatal exposure to alcohol?
A: The reality is that many women drink during pregnancy and some bear children affected by prenatal exposure to alcohol; the dose-response pattern is not clear. We know that some children prenatally exposed to alcohol may show the effects associated with FAS (Fetal Alcohol Syndrome). These can, but do not always, include cognitive impairment. While teachers and staff may suspect that they have enrolled a child with FAS, the diagnosis should be made by a specialist, such as a physician.
Q:So it isn't helpful for administrators or teachers to label a child as drug exposed?
A: No. And certainly, labeling children as "drug exposed" does nothing to help improve their developmental or educational prospects. It is more accurate-and more useful to think in terms of "children affected by substance abuse," which acknowledges the influence of family and community factors on the child's development. Another useful term is "children at risk."
Q:Will preschool children affected by substance abuse need special education services?
A: Maybe, but not necessarily. Children affected by substance abuse show a wide range of abilities and problems; they are not necessarily children with special needs. Some, though, may need special services. And some who do not appear to need special services when they are young may demonstrate the need for services when they are older.
Q:What can Head Start do?
A: Early interventions that begin when the child is still very young, targeted to both the child and the family, show the most promise and can help offset the effects of children's behavioral, emotional, and cognitive problems, whatever the cause. Most interventions will be directed to improving the family context. Some may be directed at compensating for diagnosed biological, physical, or neurological limitations.
Even if children in your regular Head Start program did not receive any early intervention, though, it is not too late. You can make program modifications that will support the development of children within an inclusive setting. That is what this manual is about-the practical ways that the Head Start management team can make changes in policy and practice, improve services to children and families, enhance staff capacity, and collaborate with other community agencies to support the healthy development of children at risk.
RESEARCH ACROSS DISCIPLINES: THE CLUES IT PROVIDES
Many studies of newborns, carried out in university hospital settings, have described the initial effects of documented prenatal exposure to alcohol and other drugs. As increasing reports from teachers describe some of the behaviors observed among toddlers and preschool children, one wonders whether these behaviors are also the result of prenatal exposure. Nearly twenty years of work has described, at length; the harmful effects of varying severity that can be directly attributed to prenatal alcohol exposure. Illicit drugs are another story. Just as has been the case with other groups of children at risk (such as those who were pre-term or small for gestational age), it may be some time before conclusive data are published on the long-term impact of illicit drugs on child development.
Effects of Prenatal Exposure to Alcohol
The long-term effects of prenatal exposure to alcohol on child development vary widely, ranging from normal development to attention and memory deficits, distractibility, and poor organization to mental retardation. They also appear to be related in part to the quantity and frequency of maternal alcohol consumption. On this continuum, the more serious and specific diagnoses that have evolved from research include Fetal Alcohol Syndrome (FAS), Fetal Alcohol Effects (FAE), and Alcohol-Related Birth Defects (ARBD). All of these diagnoses can involve permanent physical disabilities, cognitive impairment (ranging from minor to severe), decreased problem-solving ability, and fine and gross motor problems.
Effects of Prenatal Exposure to Other Drugs
Research findings regarding the effects of prenatal exposure to illicit drugs have also reported a continuum of outcomes, although no consistent syndrome has emerged. Maternal use of illicit drugs during pregnancy can be identified through urine toxicology screens administered to both mothers and newborns following delivery (as well as on the basis of maternal self-report, although these may not be accurate).
Drug use during pregnancy is associated with an increased incidence of pre term births, small-for-gestational-age births in both pre term and full-term infants, and smaller head circumferences in full term births. Opiates, such as heroin, can results in neonatal abstinence syndrome, characterized during the newborn period by irritability, tremors, sleep disturbances, gastrointestinal and respiratory problems, and occasionally seizures. Although the specific long-term effects of prenatal exposure to individual substances remain largely unknown, pre term birth, small-for-gestational-age birth, and reduced head size at birth all have been studied in other populations and have been demonstrated to interfere with long-term development in some children. Further, adverse initial effects (such as those seen in newborns prenatally exposed to heroin) have not been investigated over the long term, nor studied for their implications in specific developmental areas, such as fine motor skills and self regulation.
The outcomes of existing studies vary enormously. The initial effects seen in infants may vary with the type of substance used; how much was used, how often, and at what point during pregnancy; and the kind of prenatal care the mother receives. Despite the diversity in outcomes, there are some parallels to related research where the effects are well-documented. For example, inadequate prenatal care, poor nutrition, and smoking are also known to contribute to lower birth weight. As a result, biomedical researchers can express legitimate concern about the possibility of long-term effects from drug use during pregnancy-that is, developmental and learning difficulties that may be expected to appear in the future. They can accurately describe the infants under their scrutiny as being "at risk." They can record the week-old infant's difficulties at birth and, looking ahead, express concern that the same child may well carry some developmental difficulties into preschool.
All of this research reports on risk status within whole groups of children. It is important to bear in mind that no one can predict the outcome for any individual child. What long-term effects will be discovered through longitudinal studies remains to be seen. We do know that something disrupts the normal development of many children. Therefore, it is also useful to take a closer look at what is known about the family and community where the child spends three or four years before enrolling in a preschool program.
Effects of Living in At-Risk Families and/or Communities
Many newborn babies leave the hospital and go home to families and neighborhoods dramatically affected by substance abuse. Instead of looking only at the drug culture and its physiological effects on infants before they are born, we must look at the drug culture and its effects on families after the children are born. How does a parent's involvement with illicit drugs, or with alcohol, affect the child's care giving environment? How does drug trafficking affect the community where the family lives?
A child-rearing environment that is not supportive and nurturing can have a negative impact on child development, regardless of the presence or absence of biological risk factors (such as prenatal drug expo sure or low birth weight). Conversely, a supportive and nurturing environment can significantly enhance developmental outcomes, as longitudinal studies of other groups of at-risk children have shown.
In communities that are affected by substance abuse, violence, and poverty, a number of major environ mental factors affect development before and after birth:
· Low maternal weight gain during pregnancy;
· Lack of prenatal care;
· Lack of social support for the family;
· Inadequate care giving skills;
· Exposure to family and community violence;
· Child abuse and neglect; and
· Multiple foster care placements.Many of these factors threaten the healthy development of children from all economic backgrounds, but they are especially threatening for low-income families whose economic and personal resources to face these challenges may be more limited. In addition, the number of children whose family income is at or below the poverty level has risen substantially over the past two decades, expanding the pool of families who have the least resources to handle these issues.
Even one of the above factors can threaten a child's development. When they accumulate, they significantly increase the risk of language disorders, emotional difficulties, and behavior and learning problems. For children in poverty, that is frequently what happens. The behavior and learning problems reported by educators across the country are most likely due to a complex constellation of risk factors and an on-going set of interactions that occur over time. These interactions involve: (1) the vulnerability of the infant at birth; (2) the social and economic inadequacy of that child's family, especially if the caregivers continue to abuse alcohol or other drugs; and (3) the violence, on the streets and in the home, that is associated with drug trafficking in poor neighborhoods.
In low-income families, mothers are more likely to have low maternal weight gain and have received poor prenatal care. As a result, their babies are born small. Fragile infants go home from the hospital with numerous (though often temporary) health problems and may be very hard to care for, comfort, and console. An infant with these problems is a challenge for any mother. When the mother is herself very young, undereducated, and/or struggling with addiction, the chances for a successful attachment between mother and child are reduced even further. Frequently, it is the grandmother or aunt, and not the mother, who raises the baby.
In addition to the family itself, the community environment also has an impact on child development. In areas where alcohol and/or other drug use is widespread, there is often an increased incidence of neighborhood violence, gang activity, theft, and pressure by drug pushers for residents (including children) to start using them. All of these stressors can affect the behaviors of family members and, in turn, affect the development of young children. Even a family that is healthy and functioning well is not immune. The anxiety, depression, anger, and fear that result from living in a troubled and volatile neighborhood can also harm families that are not involved in the abuse of alcohol and other drugs.
Environmental stressors can sometimes contribute to or exacerbate alcohol and other drug abuse problems, poor health, mental health problems, financial difficulties, unemployment, domestic violence, and child abuse and neglect. Like children living in war-torn countries, children who are sexually or physically abused, abruptly uprooted from a familiar home environment, or exposed to violence on the streets or in their homes often show the symptoms of "post-traumatic stress disorder." These symptoms may include violent outbursts, difficulty concentrating, depression, and reduced involvement with the out side world. The later developmental effects of this type of trauma over time may include impaired cognition, impaired emotional capacity, memory problems, learning disorders, and poor school performance.
Recognizing all of this, we need to remember that development is a dynamic process, and that children and families-even in the presence of discouraging odds-can make positive changes in their lives. A good example of this is provided in a study conducted in Kauai, Hawaii, that followed high-risk infants for thirty years. This investigation found that the combination of perinatal risk and disadvantaged home environment was more devastating than perinatal risk alone. The children who had the fewest developmental problems were those who had supportive and stable care giving from the adults in their lives. Findings such as these have led to the concepts of "resiliency" and "protective factors" as described by David Hawkins (1985) and others who have looked at the conditions that help children prevail.
Clinicians and researchers observe that these protective factors reside as much in the child's world as in the child. The love and support of a caring grandparent can help foster healthy development, even if a child's own parent cannot do so. Likewise, communities can provide support for vulnerable families. To make a difference in a child's life, programs need to focus on improving both the family and the community where the child lives.
HEAD START'S POTENTIAL FOR SUPPORTING CHILDREN AT RISK
From the beginning, the Head Start model was based on the following central principles:
· Early intervention, and intervening in partnership with parents, can make a difference to a child's health and well-being.
· Individualized classroom activities, prosocial skills, and developmentally appropriate learning are the keystones of successful classroom experiences for preschool children at risk.
· Families and children benefit most from an approach that is comprehensive, not just instructional. A hungry child, or a sick one, cannot learn well.
· Rather than expect an individual child to shoulder successfully the burden for overcoming risk, it is necessary to strengthen the entire family.
· Head Start programs cannot do it all; they need to have strong relationships with partners in the community.The recommendations proposed in the following chapters are founded in interdisciplinary research and in the promising practices of Head Start programs across the country. Given the prominence of the ecological model in Head Start principles and practice, some of these strategies will sound familiar. The model programs that work with children who display learning and behavior problems, including children prenatally exposed to alcohol and other drugs, have borrowed many of these keystones from Head Start. In the process, they have affirmed the value of Head Start program components while adapting them in new ways. Today, Head Start principles and practices take on new credibility and a new imperative. (NOTE: For administrators who want to learn more about the findings from the literature review and field search, the monograph Risk and Reality: Implications of Prenatal Exposure to Alcohol and Other Drugs is available from the National Clearinghouse for Alcohol and Drug Information, Box 2345, Rockville, MD 20847-2345, 301-468- 2600) .