III. Children of Substance-Abusing Parents:
    SPECIAL RISKS

    As a child enters a Head Start program, he or she has had two major spheres of influence on his or her development. The first is his or her biological background, including prenatal events, conditions of delivery, and, later, illnesses, accidents, surgeries, physical circumstances. The second major influence upon development is the child's environment, including the physical care, nurturing, and support the child has received; his or her contacts and relationships with caregivers, peers, and other individuals; and past experiences in developing a sense of security, autonomy, and trust. In some cases, biological experiences may exert more influence than environmental background; in other cases, environmental circumstances may outweigh biological conditions.

    There is a complex interplay between biological and environmental events. This chapter describes the health and development of children who were affected by substance abuse, whether by prenatal exposure to alcohol and/or other drugs, or by living in substance- abusing households.

    Throughout this discussion of the common health concerns and developmental patterns that have been observed in children, it is important for Head Start staff to consider the following issues with respect to biological factors:

    Polysubstance Abuse. The majority of substance abusers use multiple drugs or alcohol and other drugs in combination. In some cases, this polysubstance abuse may occur without the user's knowledge, since it is common practice among street dealers to substitute drugs and to "cut" the purity of illicit substances with a variety of adulterants. Further, while parents may report use of only alcohol or another single drug, such statements regarding drug and alcohol use often are unreliable, in part due to parental inaccuracy in recalling their actual drinking or use of other drugs during periods of intoxication.

    Range of Outcomes. Any use of alcohol or other drugs during pregnancy can potentially affect fetal health and well-being. There are no known "safe" levels of prenatal alcohol or other drug use. However, among infants who have been prenatally exposed to these substances, a wide range of health and development patterns have been observed. The medical and developmental complications associated with prenatal substance abuse are discussed in this chapter. Because there is a broad continuum of effects of prenatal alcohol and other drug exposure, outcomes for individual children cannot be predicted.

    Multiple Causes. While there clearly are adverse immediate and long-term effects of substance abuse during pregnancy, there also are a number of other maternal health, nutritional, and lifestyle factors that greatly affect fetal growth and development. These factors also significantly contribute to the increased risk of poor pregnancy outcome.

    However, children in substance-abusing families are at double jeopardy: in addition to biological factors, they are also environmentally at risk. The interplay between biological and environmental factors is extremely significant, since biological problems can be aggravated or improved by environmental influences. Moreover, teasing out the contribution of each of these factors to child development is very difficult. Most documentation about the serious side effects of prenatal alcohol and other drug exposure in infants and children has evolved from data on alcoholic and drug-dependent mothers. Little is known regarding the effects of chronic paternal substance abuse. Further, we have limited knowledge about experimental or recurrent drug and alcohol use during pregnancy, in part because the identification of such users is much more difficult. Finally, the standardized measures currently used to evaluate infants and children of substance-abusing mothers are not sufficiently sensitive to subtle behavioral and cognitive deficits.

    Keeping in mind the above issues and the fact that many important questions regarding the effects of maternal as well as paternal abuse of alcohol and other drugs remain unan swered, the following sections will discuss the more common complications that have been observed in infants and young children from substance-abusing families. Developmental patterns that have been observed in this high-risk population will also be described. It is important to note that the descriptions contained in this chapter are intended to provide general information. If staff have specific concerns about an individual child, they may need to obtain the appropriate consents to discuss these issues with the child's pediatrician and other service providers.

NEWBORN AND INFANT COMPLICATIONS

    Infants may experience a number of medical complications associated with prenatal substance abuse. The following is a partial list of the more common conditions seen in this group of children:

Newborn Behaviors

    As early as 24 hours after birth, some infants who have been prenatally exposed to drugs will exhibit a variety of disturbed behaviors, including irritability, tremors or jitteriness, prolonged or high-pitched crying, frantic sucking of hands, uncoordinated sucking, and disturbances in sleep patterns.

Prematurity

    Prematurity is defined as birth at less than 37 weeks' gestational age. (A normal pregnancy or gestational period is 40 weeks.) In and of itself, prematurity is associated with a variety of complications that include respiratory problems and subsequent neurological problems (such as cerebral palsy, visual handicaps, and a higher risk for later learning difficulties). Preterm delivery generally occurs in less than 10% of the newborn population. However, the risk of prematurity among substance-exposed infants is higher.

Infectious Diseases

    Infants with prenatal substance exposure frequently also are exposed to infectious diseases, either prenatally or at the time of delivery. A mother who has multiple sexual partners, a history of prostitution, or a history of intravenous (IV) drug use is at increased risk of acquiring a variety of infectious diseases. Infectious diseases most commonly seen in infants of substance abusers with multiple sexual partners are gonorrhea, syphilis, herpes, chlamydia, hepatitis B, and acquired immune deficiency syndrome (AIDS).

Fetal Alcohol Syndrome (FAS)

    Drinking alcohol during pregnancy may result in a pattern of physical and intellectual birth defects known as Fetal Alcohol Syndrome, which is seen in more than one out of 1,000 births. The diagnosis of FAS in an infant is based upon three factors: low birth weight and/or microcephaly (abnormally small head), abnormal neurological development, and at least two abnormal facial features. Infants who display some of the symptoms associated with Fetal Alcohol Syndrome but who do not meet all of the diagnostic criteria are diagnosed with Fetal Alcohol Effect (FAE). Children who have FAS are different from children who have FAE. Fetal Alcohol Syndrome is a specific, diagnosable entity, whereas the term Fetal Alcohol Effect is used to describe a situation where a child has certain characteristics that suggest prenatal alcohol exposure. A definitive diagnosis for FAE is not possible. Older children with FAS are often mentally retarded. Youngsters with FAE may have motor delays, hyperactivity and impulsivity, and/or impaired learning ability.

Sudden Infant Death Syndrome (SIDS)

    Children who were prenatally exposed to drugs may have an increased risk of dying from Sudden Infant Death Syndrome (SIDS). SIDS, more commonly known as "crib death," is defined as the sudden death of an infant under one year of age from unknown causes. We do not know why prenatally substance-exposed infants run a higher risk of dying from SIDS.

Failure to Thrive (FTT)

    Children with failure to thrive do not have adequate weight gain and may be slow in achieving developmental milestones. There are both biological and environmental causes for failure to thrive. Biological causes may include problems with feeding (uncoordinated suck), vomiting, and congenital heart disease. Infants whose failure to thrive is due to environmental factors may fail to gain weight because they are not given sufficient protein and calories. This may occur if the caregiver mixes formula improperly, does not feed frequently enough, or fails to respond to the infant's signals when he or she is hungry.

    In children who were prenatally exposed to alcohol and other drugs, failure to thrive may be due to both biological and environmental factors. A pattern of poor sucking and distractibility has been observed in many of these children during the first few months of life. In addition, youngsters who live in multi-problem, substance-abusing families are at increased risk for parental neglect and for receiving inadequate nutrition on a consistent basis.

DEVELOPMENTAL ISSUES

    Some infants and young children who were prenatally exposed to alcohol or other drugs are at risk for developmental problems. While Head Start staff are not likely to know enough about a child's early life to determine if the child was prenatally exposed to substances, the Head Start Program Performance Standards address a broad range of health services which can assist the child and family in meeting their current needs. These include: (1) ensuring that children receive comprehensive health services that include a broad range of medical, dental, mental health, and nutrition services to promote their physical, emotional, cognitive, and social development toward the overall goal of social competence; (2) promoting preventive health services and early intervention; and (3) providing children's families with the necessary awareness and skills, and otherwise attempting to link families with ongoing health care systems to ensure that children continue to receive comprehensive health care even after leaving the Head Start program. Since Head Start staff are not likely to know which children were prenatally exposed, medical and developmental screening becomes an even more critical tool in early identification of health and developmental problems. This identification is key to ensuring that children receive early intervention services, such as those provided by Head Start programs.

    Infants and children who were exposed prenatally to alcohol or other drugs display a wide range of developmental behaviors. It bears repeating that these patterns are the result of complex interactions among biological and environmental factors, and that not all children from substance-abusing families experience developmental difficulties. However, the troublesome behaviors that are most commonly seen in prenatally substance-exposed children include:

Infancy (0-15 Months)

Toddlerhood (15-36 Months) Preschool (3-5 Years)     As has been stated previously, the above-mentioned characteristics may be the result of other needs or stresses, and not related to prenatal exposure at all.

CONCLUSION

    This chapter has highlighted briefly some of the most common biological and environmental problems demonstrated by children from substance-abusing families. This information can be used in two ways. First, it can help staff focus on the types of questions to ask caregivers about the background of children in the program. This, in turn, can provide more information about the children's progress and enable staff to help caregivers begin to under stand their children's behaviors. Second, the information can alert staff to potential stresses when there is a new baby in the family who may have been exposed to alcohol and/or other drugs.

    Finally, an awareness that each child presents with his or her own unique set of biological and environmental experiences is essential if we are to accurately identify individual emotional, social, intellectual, language, and physical abilities and needs.

    Based on this information, the Head Start team can work with family members to develop an individualized plan for each child which incorporates strategies that can be used within the center-based program as well as within the family setting. Although it may seem difficult to focus on each child's own special circumstances, a team approach that incorporates ongoing assessment, regular communication among staff members, and formal periodic review of each child's progress can work.

IV. Comprehensive Family Assessment

    Parental substance abuse usually impacts all family members and every aspect of their life together. In order to determine how to best meet the wide-ranging needs of an individual family, it is important for Head Start staff to work together as a team to gather a variety of information about the child, his or her caregivers, and the family's home environment. Such a comprehensive, family-focused assessment can help staff not only identify areas of family need, but also more effectively connect caregivers and children with appropriate services and better support families during recovery.

    This chapter begins with a discussion of ways to gather information in situations in which substance abuse is either suspected or acknowledged. Guidelines are then provided for developing a comprehensive assessment that addresses family strengths, resources, and areas of vulnerability. Attention is given to specific points that need to be explored with respect to infants and children, parents, the home environment, relative caregivers, and foster parents.

GATHERING INFORMATION

    Gathering information about the extent and nature of the abuse of alcohol and/or other drugs within a family can be difficult if family members do not want anyone to know about their problem. It is not uncommon for individuals who abuse alcohol or other drugs, as well as for non-substance-abusing family members, to deny the problem and resist efforts to address it. Thus, in order to develop a realistic and comprehensive family assessment, Head Start staff need to work together as a team to coordinate their efforts in gathering information from a number of sources. As a supportive relationship is established with the family, family members may gradually become more open about discussing substance abuse and more willing to listen to staff concerns and ideas about setting goals to address the problem.

    The Head Start staff team can gather information regarding a substance-abusing family in a variety of ways, including:

Interactions with Parents and Other Family Members

    During interactions with staff members, it is possible that a caregiver may reveal that he or she has a problem with alcohol or other drugs, or that a spouse in the home has a substance abuse problem. Such an acknowledgment can provide an important opportunity for initiating a referral to substance abuse treatment or for offering supportive services to help the family cope with the behavior of the substance-abusing household member. In addition, by exploring with the caregiver how the abuse has affected the health, schooling, and social life of each family member, staff may be able to identify additional family service needs.

    In their interactions with caregivers, staff also may become aware of possible parental substance abuse through more indirect ways. For example, a parent may not describe problems with alcohol or other drug use but may exhibit behavior or symptoms that are highly suggestive of substance abuse, including:

    Thus, in assessing families for substance abuse, staff should not rely only upon oral communication. Observation of non-verbal behavior and appearance can be a valuable way of identifying problems with alcohol or other drugs, even when such information is not directly provided by the caregiver.

    It is very important, also, to focus on any parental, family, or community strengths on which the parent can draw for support and encouragement.

Visits to the Family Home

    Home visits can be another especially important way of gathering information in situations involving parental substance abuse, for a variety of reasons.

    To make the most out of home visitation and to plan appropriately for all family members, it is important for Head Start staff to set clear goals for each visit. The following are specific kinds of information that can be gathered within the family home: Observations of the Child

    Frequently, problems with parental substance abuse become known through comments by the child or through observations of the child's interactions with other children, staff members, or parents. For example:

Contacts with Other Service Providers

    Because of their complex service needs, substance-abusing families frequently are involved with a wide range of community agencies and professionals. These commonly include physicians, nurses, social workers, teachers, members of the clergy, mental health professionals, substance abuse counselors, attorneys, parole and probation officers, and child protective services caseworkers. When a Head Start family is receiving services from such agencies and professionals, it is helpful for staff to contact other service providers directly in order to determine how Head Start can work collaboratively with them to the benefit of family members. In communicating with these sources, however, it is important that staff be familiar with the guidelines for confidentiality that govern Head Start practice with respect to the sharing of confidential information, as well as those specialized, very stringent, and federally regulated confidentiality requirements that apply to substance abuse.

Areas of Strength

    As noted above, it is very important for Head Start staff to focus on the resources within the parent, the family, and the community on which the parent can draw for positive support, insight, and leverage in working to resolve substance abuse issues.



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