• Describe 3 factors related to addiction severity.
• Assess their own attitude about drug use and abuse in pregnancy.
• Discuss 3 risks of substance abuse to both pregnant and post-partum women.
• Identify the common names of 3 illegal drugs used and describe their effects on the woman.
• Identify 5 potential effects of intrauterine drug exposure on the newborn.
• Identify at least 5 symptoms of drug withdrawal in the newborn.
• Describe 3 techniques parents can use to comfort babies who were exposed to drugs in utero.
• Identify 5 psychosocial/environmental factors of addiction.
• Demonstrate knowledge of the meaning of addiction.
• Describe 3 important factors in beginning intervention with mothers who are substance abusers.
• List 6 stressors of working with this population.
• Describe one long-term effect of each drug (cocaine, heroin, marijuana, alcohol, smoking and prescription drugs) on the growth and development of prenatally exposed children.
• Describe the types of resources that may be needed to optimize development in the children who are drug exposed.

9 hours

A. Introduction/Attitudes about drug use/abuse in pregnancy
B. The substance abusing pregnant woman
C. Commonly used substances and their effects on mother and infant
D. Techniques parents can use to comfort the substance exposed infant
E. Working with mothers who are substance abusers
F. Long-term effects of prenatal drug exposure on child development & behavior
G. Intervention approaches
H. Summary and review

• Ryan, L., Ehrlich, S.J. & Finnegan, L. (1987). Cocaine Abuse in Pregnancy: Effects on the Fetus & Newborn. Pergamon Journals ltd, Vol. 9, pps. 295-299.
• Puttkammer, C. (ed.) (1994). Working with Substance-Exposed Children. Arizona:Therapy Skill Builders.
• McGoldrick, M. (1985). Genograms in Family Assessment 1st ed. N.Y.: Norton.
• Attitudes about drug abusing during pregnancy: Staff questionnaire. (Handout #1)
• Drug Effects on Mother (Training Aid #1)
• Obstetric Complications Associated with Addiction (Training Aid #2)
• Drug Information Guide (Handout #2)
• Drug Effects on Child (Training Aid #3)
• Identified fetal risks from cocaine (Training Aid #4)
• Neonatal Withdrawal Symptoms (Training Aid #5)
• Cigarette Smoking (Training Aid #6)
• Abnormalities Due to Prenatal Alcohol Exposure (Training Aid #7)
• How to Comfort Infant (Handout #3)
• Case Study (Handout # 4)
• Case Studies (Handouts # 5a, b, c & d)
• Video "Treatment Issues for Women" National Institute on Drug Abuse. NCADI Video Resource Program.
• Role Play Feedback (Overhead #1)
• Post Unit Test (Handout #6)
• Post Unit Evaluation (Handout #7)
• Baby Doll
• Blankets
• Video Equipment: video camera, tripod, tape, VCR, and TV

• Read above article - Cocaine Abuse in Pregnancy.
• Review Working with Substance-Exposed Children.
• Determine what support groups are available for substance abusing women with children in your local area.
• Review video.
• Meet with local support groups and solicit their participation.
• Prepare handouts and transparencies from training aids.
• Become knowledgeable about public assistance eligibility in your area; contact experts for assistance.
• Try out video equipment. Set up camera to videotape role plays.

1. Begin the session with the attitude survey (Handout #1).
2. Collect survey and keep them; participants will repeat the survey at the end of the training and compare.
3. Have an open discussion about the three most provocative issues on the survey. (Suggestions # 2, 4, 10, 30, 33, 35)

1.Discuss the following factors assessed when evaluating addiction severity:

a. Biological/Consumption Indices:

• For example, how often, for how long, how much, what drugs.

b. Economic Indices:

• For example, for maintaining employment, criminal behavior - how much is spent.

c. Social Indices:

• For example, unstable environment including relationships, housing, income, support systems.

d. Personal/Personality Indices:

• This is related to addiction not to a specific drug.
• For example, denial about our behavior, low self-esteem, depression, mood fluctuations, distrustful of others, unintentional pregnancy. At some level, the unintentional pregnancy could be related to emotional and financial needs.

2. Lecture format. Give out Drug Information Guide (Handout #2). You could enlist the aid of a police drug education officer to familiarize PSS with drug paraphernalia if appropriate.

1. Distribute Handout #3, review each technique in detail. May use doll to demonstrate various holds, wrapping or cuddling techniques.
2. Discuss other ways to be of support to a mother who is a substance abuser.

1. Ask participants what they think is a good definition of addiction. Write this on a flip chart. Discuss the dictionary definition and compare it to their definition. Have trainees share any experiences they have had with people who abuse and are addicted to substances.

Definition of addiction: From Webster’s Dictionary "A compulsive need for and use of a habit-forming substance characterized by tolerance and by well-defined physiological symptoms upon withdrawal." Drug addiction is a disease. This is behavior driven, has a biochemical element, and there is continued use even though it is harmful. This is a medical problem requiring treatment.

2. Psychosocial/Environmental Factors of Addiction

a. Characteristics and behavioral expectations

• hyperactive state on cocaine; lethargic state on heroine.
• low self-esteem
• emotional/mental health issues
• poor hygiene
• poor eating habits
• poor communication/interactive skills
• poor parenting skills
• dysfunctional family units
• short term incarceration

Discuss each of the above factors and their potential influences on parenting and on involvement in the PIP program.

b. Environmental factors of addiction

• transiency
• economic issues
• surroundings - people and places

Discuss the above factors and how they might effect working with these mothers.

3. Cycle of Addiction

a. Generational

• history of intergenerational drug dependency
• history of physical, sexual and/or psychological abuse
• unstable caregiving environment
• history of criminal activity

Introduce the use of genograms to map family history. This can be used with mothers in the PIP program to facilitate their understanding of their addiction.

Use case study (Handout #4) to do a genogram as a group. Have everyone involved in diagraming the family. Make a special notation on each member in which there has been drug abuse. Discuss how families can impact their members. Refer to Training Unit 6, Working With Families.

b. Present day stressors

• loss of employment
• lack of basic necessities
• personal loss
• loss of social support
• impact of welfare reform

Watch video "Treatment Issues for Women" and discuss salient issues and their potential impact on the PIP mothers and the PSSs working with them.

Since welfare criteria are changing, be able to discuss the present status of welfare in your area or bring in an expert who can speak in detail to the trainees.

4. How to begin intervention

• Review paperwork already completed.
• First contact should be in the hospital before discharge.
• "Window of opportunity" - schedule first home visit within 48 hours of the homecoming. This is most likely when the mom will be clean.
• Acknowledge drug use; extend support, respond to expressed concerns and then proceed to the project’s priorities i.e. parenting, child development, health care utilization.

Practice the initial home visit with one PSS playing that role and one PSS playing the role of the new mother. Be sure everyone has a chance to play both roles. Use role play feedback form (Overhead #1) to guide discussion.

5. Stressors on PSSs - much frustration is experienced when working with this population. The situations that follow are some of the most common frustrations:

• phone disconnected
• having the wrong address/transiency
• falsification of information by the mother
• unreliability regarding scheduled visits and groups
• denial that anything is wrong
• clients often disappear only to reappear when their needs are great.
• use of PIP as a protector against legal issues and government entitlement issues, i.e., drug treatment may be mandated by child protective services as the basis for keeping the children in the home. Mother gives our name as fulfilling this obligation although we do not do primary drug treatment.
• placement of infant with a variety of people.
• many agencies involved; unclear as to roles of each one.

Review each stressor. Have trainees discuss how they may be affected by these situations.

6. How to keep up PSSs motivation to work with these mothers who are substance abusers.

• Have clear program policies and procedures that set the boundaries of program.
• Team support both in 1 to 1 and group situations.
• Find satisfaction in small steps of progress.

Discuss how these techniques could help the PSSs. Elicit other strategies that they think will be useful.

7. Use case studies (Handouts #5 a,b,c) to have group identify important issues to focus on at different points in the intervention.

• Difficult to follow long term, most only to age 2 or 3 years.
• Multiple drug use common, difficult to tell effects of a single drug because combined.
• Mother’s report of what she used, how often, and how much may not be reliable.
• Mother may not provide environment conducive to good development.
• Children often are outplaced and have multiple foster situations; over 30% receive placements.
• Increased rate of prematurity and developmental risks associated with prematurity.

• Many have lower birth weight (but also more prematurity) and smaller head size (a measure of brain growth) at birth.
• Growth improves showing catch up to normal peers but head size often remains smaller.

• Most studies do not find differences in overall IQ when tested at 2 and 3 years.
• A few studies find more language delay after 2 years.
• Low SES population, in which there is higher rates of cocaine use, generally have low average IQ and language is greatest area of weakness.

• Shift from being overactive in newborn period to being more lethargic and difficult to engage after 3 months. May still show some hyperactivity and transient hypertonia, tremulousness at 4 months. Possible risk then for mother to feel less successful in interaction with infant.
• Another study of full-term cocaine exposed infants found no behavioral differences after birth.
• Preschool play behavior indistinguishable from unexposed peers.
• Greater tendency for children from low SES, dysfunctional families to show greater hyperactivity, poor attention and aggression.

• Greater incidence of prematurity increases incidence of disabilities associated with prematurity: Respiratory difficulties, learning disability, attention problems, cerebral palsy, mental retardation.
• Increased incidence of strokes in utero. May have hemiplegia.
• Increased incidence of malformations, especially of genito-urinary tract.

• Smaller at birth but normal weight and length by 12 months - improved feedings after first few weeks.
• May be persistent small head circumference as in cocaine.

• No difference in IQ scores or motor development - scores in normal range at 6 months and after.
• Some reports of delay in fine motor and language skills - but some studies find no differences.

• Newborn behaviors of irritability, overreaction to sound.
• For some persistence of irritability up to 6 months, but there is improved interaction and responsiveness.
• Later behavior marked by poor attention and impulsivity; contribute to management problems; one study says 40% need special education due to behaviors.

• Children of IV drug abusers and partners of IV drug users at risk for AIDS. Mother who is HIV+ can transmit to infant about 1/3 of the time.
• Baltimore study of pregnant poly drug users found 40% were HIV positive.
• If HIV positive mother takes AZT during pregnancy she reduces transmission rate to infant by 2/3.
• HIV positive infants show two pictures:

a) Rapidly become symptomatic and die by age 2.

b) Long period of asymptomatic become symptomatic in preteen but may live into teens.

c) Some revert to normal - serum conversion when baby develops own antibodies and not displaying moms ( up to 2 years).

• Symptomatic infants show failure to thrive, pneumonia, eczema, motor deterioration; chronic illness.
• Many participate in medication trials.
• High rate of STD’s among poly drug users which may be transmitted to infant; as result of STD can have damage to the central nervous system or vision.
• Infants exposed prenatally to methadone may have higher risk for SIDS.

• Small for gestational age.
• Usually continue to show poor growth with frequent diagnosis of failure to thrive.

• Children with full syndrome (FAS) generally show borderline to mild retardation but can show full range to severe retardation as well.
• Children with Fetal Alcohol Effects (FAE) usually borderline to low average intelligence and learning disabilities.
• FAS children often show motor delays and may have joint contractures that impair mobility.
• Fine motor and perceptual skills often delayed.
• Show poor auditory memory.

• Usually are sociable but show very poor attention and impulsivity. This is seen even in those children reared in foster care.
• As grow show poor judgment and inability to foresee consequences of actions.

• Poor suck and vomiting can persist the first 6-7 months so they are frustrating to feed.
• Continue to show poor appetite and weight gain.

• Low birth weight and decreased fat stores.
• Suggests hypoxic effect also seen from cigarette smoking.

• Very few studies: One showed no differences in developmental scores of 12 or 24 month, but at 4 years exposed children had poorer memory and verbal scores on an IQ test.

• Significantly smaller at birth.

• Some suggestions of poor attention and learning disabilities.

• Increased respiratory illness if exposed prenatally but especially from passive exposure postnatally.
• Increased risk of SIDS.

• Valium, Clonipin, Xanax - some reports of increased incidence of cleft palate.
• Thorazine - Can cause urinary retention and dystonia in infant; may be a mild withdrawal syndrome

• Parent needs to be aware of early behavior patterns for consoling, engaging and for feeding.
• Provide recommendations helpful for managing attention deficits and hyperactivity.
• Need clear expectations, regular routines, help with transitions.
• Avoid overstimulation and fatigue.
• Use of positive reinforcement and time-out for managing aggression.

• If a parent is very dysfunctional, daycare program for infant may be helpful.
• At preschool level direct to Headstart.
• Attention deficits may make eligible for special education - smaller classes, more structured program.
• As ready for school entry, full developmental assessment may be needed to determine special educational needs.

1. Rephrase the objectives on the first page of this unit, with the exception of the first objective, as a question. Ask for volunteers to answer each question.
2. Repeat Attitude Survey test/Review and discuss changes since first attitude survey.
3. Distribute post-unit test.
4. Distribute post-unit evaluation.

Strongly
Agree

Agree

Not
Sure

Disagree

Strongly
Disagree

1. Most infants with prenatal cocaine exposure have no long-term deficits.

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2. The best thing to do for a drug-exposed baby is to place it in foster care.

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3. There are clear differences in the effects of prenatal exposure to alcohol and cocaine.

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4. In general, illegal drugs seem to have more serious consequences for prenatally exposed babies than legal drugs.

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5. The government is not doing enough to stop the influx of illegal drugs.

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6. As a result of the increase in cocaine use, there are many more preterm babies with serious medical problems.

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7. Substance abusers usually stick to a single drug rather than using a variety of drugs.

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8. The withdrawal from cocaine experienced by infants can last several months.

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9. Women often use cocaine to induce abortions.

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10. Black women are more likely to use drugs than Whites or Hispanics.

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11. It is difficult for pregnant women to get treatment for substance abuse.

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12. Health care professionals who deal with mothers and babies should be taught how to identify signs of substance abuse.

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13. Prenatal addiction causes changes in the brain that make a child more likely to become an addict or alcoholic later.

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14. Pregnant women who use drugs should be put in jail.

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15. Cocaine is often used by women who don’t abuse other drugs.

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16. Alcohol and drug use are caused by genetic traits.

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17. All pregnant women should be given a urine screen for drugs.

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18. Cocaine is more damaging to the newborn than other drugs.

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19. Women who use drugs and alcohol usually associate with men who do too.

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20. Among alcoholic women, the risk for having a child with fetal alcohol syndrome increases with each pregnancy.

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21. Taking care of the infants who are born sick or addicted as a result of their mother’s drug abuse places unfair burden on the rest of us.

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22. Alcohol is the most often abused drug in the United States.

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23. Drug addicts forget about their babies when they leave the hospital.

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24. Cocaine abusers, unlike alcoholics, rarely recover from their addiction.

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25. Drug and alcohol exposed babies should be given developmental screenings regularly to detect problems early.

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26. Most alcoholics and drug addicts can’t stop themselves from abusing even though they know that they will hurt their unborn children.

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27. Society needs to provide care and treatment for affected children.

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28. Recent research indicates that at least 20% of pregnant women use or abuse illegal drugs.

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29. Among young women, cocaine abuse is a bigger problem than alcohol abuse.

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30. Abusing drugs makes people manipulative and unreliable.

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31. Substance abusing women should have their tubes tied.

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32. Alcoholics Anonymous (AA) is an effective treatment for any women with a drug or alcohol problem.

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33. When I see the effects of alcohol and drug abuse on infants, I feel angry at their mothers.

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34. There should be more drug and alcohol treatment available for pregnant women.

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35. Drug and alcohol abuse by women that endangers children is best handled through the legal system.

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PHYSICAL SYMPTOMS

LOOK FOR

ALCOHOL

(beer, wine, liquor)

Intoxication, slurred speech, unsteady walk, relaxation, relaxed inhibitions, impaired coordination, slowed reflexes

Smell of alcohol on clothes or breath, intoxicated behavior, hangover, glazed eyes

COCAINE

(coke, rock, crack, base, whitegirl, snow)

Brief intense euphoria, elevated blood pressure and heart rate, restlessness, excitement, feeling of well-being followed by depression

Glass vials, glass pipe, white crystalline powder, razor blades, syringes, needle marks

MARIJUANA

(pot, dope, grass, weed, herb, hash, joint, reefer)

Altered perceptions, red eyes, dry mouth reduced concentration and coordination, euphoria, laughing, hunger

Rolling papers, pipes, dried plant material, odor of burnt hemp rope, roach clips

HALLUCINOGENS

(acid, LSD, PCP, MDMA, Ecstacy, psilocybin, mushrooms, peyote)

Altered mood and perceptions, focus on detail, anxiety, panic, nausea, synaesthesia (ex: smell color, see sounds)

Capsules, tablets, "microdots", blotter squares

INHALANTS

(gas, aerosols, glue, nitrates, Rush, White Out)

Nausea, dizziness, headaches, lack of coordination and control

Odor of substance on clothing and breath, intoxication, drowsiness, poor muscular

NARCOTICS

Heroin (junk, smack, dope, Black Tar, China White); Demerol Dilaudid (D’s); Morphine; Codeine

Euphoria, drowsiness, insensitivity to pain, nausea, vomiting, watery eyes, runny nose

Needle marks on arms, needles, syringes. Spoons, pinpoint pupils, cold moist skin