Are you considering adopting or fostering? Or taking in a relative's child? Do you suspect or know that the birth mom used drugs or alcohol during pregnancy? Join us today to learn how these substances might impact the child and how you parent. Our guest is Dr. Lisa Prock, a Developmental and Behavioral Pediatrician, Director of the Developmental Medicine Center at Children’s Hospital, Boston, and Clinical Director of the Translational Neuroscience Center at Harvard Medical School and Children's Hospital Boston. She is an Assistant Professor of Pediatrics at Harvard Medical School.
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Dawn Davenport 0:00
Welcome everyone to Creating a Family talk about foster adoptive and kinship care. I'm Dawn Davenport. I am the host of this show, obviously, as well as the director of the nonprofit creating a family.org. Today, we're going to be talking about an introduction to prenatal exposure. This is, needless to say an important topic for all of our demographics, both our foster families, our adoptive families and our families who are taking care of kin. Today, we'll be talking with Dr. Lisa Prock. She is with Boston Children's Hospital, where she is the Associate Chief of the Division of Developmental medicine, as well as the director of the developmental Medicine Center. She is also an assistant professor in pediatrics at Harvard Medical School. Welcome Dr. Prock to Creating a
Speaker 2 0:50
Family the morning. Glad to be here. Well,
Dawn Davenport 0:53
as I said at the very beginning, prospective parents be they foster adoptive or kinship parents, regardless whether and if it's adoptive parents, regardless whether they're domestic infant or foster care, adoption, or international adoption, all of these parents need to consider whether they are the right family and are there they're equipped to parent a child with prenatal alcohol and drug exposure. And the US government now estimates, and this is astonishing, if you really think about it, that about 10% of children born in the US have been prenatally exposed to alcohol, drugs, or both. And for children in the foster care system, that estimates are depending on who you're looking at is who you're talking to, or is over 70%. So let me break this down. And let's see what you think as far as let's start with the adoptive demographic. How common in your experience is prenatal substance exposure, both alcohol and drugs and domestic infant adoption?
Speaker 2 1:57
I think that's a very important question. We don't keep very good numbers about this. So there's not a lot of research evidence, what I will say is anecdotally of the patients referred to me, for infant domestic adoption, more than three quarters have a history of prenatal substance exposure of some type, I will acknowledge that it's possible families are contacting me because of that exposure. And it may be a lower level. But the agencies that I work with locally, and I've asked them this question multiple times, say about the same, you know, three quarters or more of their birth, parents looking to place a child for infant domestic adoption report themselves, a history of prenatal substance exposure, including alcohol, I think alcohol is important to talk about, but it's not the most commonly reported substance that children are exposed to these
Dawn Davenport 2:52
days. And we will talk about the long term and short term impacts of all these exposures in just a minute. But it's hard to know, isn't it whether or not alcohol is simply less common or just less reported? I mean, we've done such a good job in the US, or at least I think we've done a good job. I when I talk with provincial people, they would probably disagree with me. But there is certainly there are very few people who would not know that drinking in pregnancy is something you shouldn't do. So isn't it hard to know. And this would go with foster adoption, but also fostering? Isn't it difficult to know if a child has been exposed? Because can we rely on expectant moms? To tell us?
Speaker 2 3:34
I think you're correct. There's another part of that, which is we often rely on the history, of course, is provided by a pregnant person. But we also do do some toxicology screening and can look at urine after birth, meconium hair etc. And alcohol is much more rapidly metabolized. So we know what the demographics are of what people report using in the United States, opiates and marijuana at the top list right now. And we know that it's much harder to detect alcohol shortly after exposure, so it's a complicated situation. But I do agree with you the majority of birth parents, no, alcohol is not something we should be using during pregnancy. And there are parents who do continue to use during pregnancy because they have a substance use disorder. But it's not easy to parse out was there wasn't not alcohol exposure in a particular situation.
Dawn Davenport 4:34
Then the statistic I gave earlier for children in foster care. We do agree with that one being upwards of 75% or 70%.
Speaker 2 4:43
I would agree I mean, every state so state is foster care is state dependent. And so different states have different requirements of screening engagement in foster care. But I would say my experience is yes, the majority of children transitioning into foster care. do so because they're Usually a parental history of substance use. If we flip it around, we know that of those children significantly affected by alcohol, for example, there's a preponderance of them who end up in the foster care system. So I think that it makes sense to say, children come into foster care, because all isn't going well with their situation. And we have to be prepared that there might be some substance exposure, most foster parents have limited knowledge of what a child has been exposed to. Because often at the time that there's an urgent placement in foster care that isn't known. So if no one knows it can't tell, and foster parents are coming in to care for kids, they're not coming in with a diagnostic algorithm or making a decision yes or no relate to substance exposure. But I would say, I do agree with what you said much more likely to have substance exposure for a child in foster care than the average child who's not in foster care.
Dawn Davenport 5:58
And from our experience, we would extend that to kinship care. Because for the very reasons you said, Children do not come into kinship care when things are going well in their home. And the number one reason that kids end up being cared for by grandma or auntie, your cousin or older sibling is because the substance abuse with their parents, right? Yes.
Speaker 2 6:21
Okay. I think the demographics of kinship care are even less well understood in foster care.
Dawn Davenport 6:27
I couldn't agree with you more. I could not agree with you more.
Speaker 2 6:31
I think that the demographics of who transitions into foster care kinship here is very similar. Yeah, there are some children who transition to kinship care more proactively when a parent realizes they have concerns. So that's a positive. I mean, I think there's situations like that. But in general, you know, I'm optimistic about children's outcomes. I do think with kinship care, families get much less support than they would if a child is in the routine foster care system and a non kinship placement. So the demographics are probably the same. With respect to exposure, the supports are a lot less for many children in kinship care with their family.
Dawn Davenport 7:10
And just to round out our circle of the people who we serve. We've talked about fostering, we've talked about adopting from foster care. We've talked about kinship care. We've talked about one type of or two types of adoption, we've talked about both domestic infant and then families who end up adopting from foster care. What about international adoption? How common is prenatal substance to alcohol and drugs? And what you see from international adoption?
Speaker 2 7:41
That's a very interesting question. international adoption has evolved a great deal over the past few decades. So we have some information about prenatal exposure to substances including alcohol. With international adoption, I would say that the majority of children are currently seeing being adopted internationally, are now coming either from very low resource countries, where we have limited epidemiologic information, saying countries in Africa, or they're coming from countries in Asia where we have some good medical information, but have limited information about prenatal substance exposure. So for example, children being referred from Taiwan, at the current time, have very similar prenatal exposure. In my experience to foster care adoption here in the United States, there are issues with opiates, alcohol, that the feta means marijuana, etc. Children being adopted from South Korea, are more likely to have medical concerns, possible alcohol and other exposure, probably a little less likely to have prenatal exposure than children domestically adopted here in the US. And then for a lot of countries where we're having limited information or children are in care. And then they're placed internationally, we just don't know. So a lot of countries in Africa, some ongoing referrals from South America, we just have very limited information. I think what you said at the beginning is children come into care around the world for very similar reasons. And it's primarily because birth parents can't care for a child often substance use or major trauma for the family as a factor. I presume substance exposure can be a risk for most children internationally adopted, but we have a lot less information about current international referrals than we did 20 years ago when we knew for example, former Soviet Union, alcohol was a given like it was expected. We don't see referrals from that part of the world much anymore although there have been a fair number of children and adopted from Ukraine in the past few years. And certainly substance exposure, especially with alcohol is a major issue there.
Dawn Davenport 10:07
All right? Are there signs and symptoms of a child that may have been exposed to alcohol or drugs in utero? Absent confirmation from the mother or background information that is available from interviewing neighbors or family members or whatever? Are there signs and symptoms that parents can can look to the child to see?
Speaker 2 10:29
Yes, I mean, history is really important. So you mentioned gathering the history from the birth parents, the neighbors, all that really matters. Previous use of substances is very predictive of use during pregnancy. older child with a known history of substance exposure to alcohol, for example, is very predictive of future use. At the time of birth, we do see some signs related to prenatal exposure to a variety of things. So for example, opiate exposure, things like heroin, oxycodone, or opiate replacements, like Suboxone. Children who are prenatally exposed are much more likely to have withdrawal in the newborn period. That typically looks like challenges with regulation, difficulty soothing oneself, difficulty sleeping, eating, perhaps increased vomiting, diarrhea, etc. And children often require behavioral and or medical support, including opioid replacement at that time. So opiates is where we really see the most behavioral evidence in the newborn period. Physically, children who are exposed to alcohol are more likely to have low birth weight, be very small at birth, may have significant facial features, flattening of the philtrum, that space between the nose and upper lip may have small head size, but might not. I think if there's a known history of alcohol exposure, and a child is born with classic fetal alcohol syndrome features, we can make that diagnosis sometimes. But oftentimes those features are not visible in the newborn period.
Dawn Davenport 12:07
Is it correct that only if the mom drank excessively during a very short period of time during her pregnancy? Would the child show them the facial features of facial dysmorphology?
Speaker 2 12:20
The facial dysmorphology is thought to occur, you're right because of a high level of alcohol at one particular point in time. But in a while, it's nice to say, what if somebody drinks in the first trimester versus second or third? Most people who are drinking in the first drink throughout the third. And most people don't start drinking in the third trimester. So it's kind of an artificial description mix. But yes, we know from animal models that the facial feature changes do occur with higher levels of alcohol exposure at particular points in pregnancy. What I'm saying is that those facial features suggest to me significant alcohol exposure, but the absence of those features doesn't rule out alcohol exposure. And I think for families who are parenting children, that didn't come to them by birth, we can't rule out alcohol exposure because you don't have the facial features. Right? So some evidence would suggest 90% of children affected developmentally, cognitively by alcohol, don't have those facial features. So if there's a history of alcohol use, if somebody observes and post parent using alcohol during pregnancy, I presume that alcohol exposure happens. And we can provide some supportive interventions after birth, but there's not necessarily a cure. I mean, to go back to your question about what do parents What are you looking for when a child joins you? I think a child is very behaviorally dysregulated could have been exposed to an opiate or also could have been exposed to alcohol, other substances including cocaine, methamphetamine, etc. All prenatal exposure has population based outcomes, but we can't not sure look at one child and say, Okay, this is definitely because of X exposure.
Dawn Davenport 14:09
Hmm, that makes sense. I want to go back to something you just mentioned, and that is that a child who is exposed to opioids are some of the replacements that are the sign of neonatal abstinence syndrome, some of the being born dependent. I think a lot of people believe that that means that if a child is not born dependent, that they were not exposed to opioids or any of the other drugs form dependency, can we make that assumption that the absence of neonatal abstinence syndrome means that the child did not have exposure?
Speaker 2 14:47
No, I haven't experienced with a lot of birth parents who honestly report significant substance use high levels of opiate exposure. They're prescribed medications to treat a significant Hit opiate use disorder and their children may not have withdrawal in the newborn period. So, like alcohol, the absence of neonatal abstinence syndrome does not mean no exposure. Children are resilience. So some children can be exposed to a fair amount of opiates or alcohol, and not have long term effects. But we won't know until a couple of decades down the road. So it's not always easy in the newborn period to sort out long term effects, we can see short term effects and we can sort of address those if there's opiate withdrawal. But it doesn't eliminate long term possible concerns if you have no concerns in newborn period.
Dawn Davenport 15:41
Okay. You alluded to some of this, but what is known about the timing of alcohol or drug use, and the impact the long term and short term impact on the baby or the child,
Speaker 2 15:55
a lot depends on the substance. So alcohol is probably best studies. We think, early alcohol exposure early in pregnancy, first trimester more likely to affect structural parts of the brain. But if a birth mother were just stopped using alcohol, that second and third trimester, probably less effect on executive functioning, we might not see some of the challenges with attention, organization that we would see if someone is exposed to alcohol throughout the pregnancy. I want to reiterate what I said earlier, is that I think from a research perspective, we can say early exposure versus late exposure, different outcomes. But from a real world experience, and from a public health perspective, someone who has challenges with using a substance like alcohol will use throughout pregnancy, unless they're in a treatment program are incarcerated. And if that happens, you can ameliorate the risk. And it's always good to stop using alcohol. I don't want to minimize that. But in general, people use throughout so that's alcohol per se. Some other substances, we commonly see marijuana, for example, we don't have great long term studies with marijuana, we do know that many of the receptors that marijuana does affect come online, later in pregnancy or even early in life. So early exposure to marijuana say the first trimester is less likely to have concerns. And if someone doesn't know they're pregnant is using marijuana they stop the likelihood that that will affect the child long term is really quite small. We have a lot of good evidence about long term effects of marijuana use for adolescents and young adults, we have very little information about long term effects on development with marijuana exposure in utero, we do know that similar to cigarette use, it can reduce blood flow to the placenta. So a child may be born smaller to outside smaller at birth than if they were not exposed. And we do know that regulation can be a concern. If a child is exposed to high levels of marijuana, they may show some signs of withdrawal from that and be more irritable, fussy, more challenging to console. There are a lot of other substances we haven't talked about much
Dawn Davenport 18:18
we're going to come to that in just a minute, I
Speaker 2 18:19
would say I would say that cocaine, less likely to have an effect early in pregnancy much more likely to affect executive functioning later in pregnancy. Methamphetamine also can affect especially children at the end of pregnancy. So a lot depends on what's the substance that we're talking about. Okay. Hey, guys, have
Dawn Davenport 18:42
you heard about our 12 free courses that we offer? Thanks to our partners that jockey Bing Family Foundation, you have these for no cost, no charge at all. You can go to Bitly slash j, b, f sport and check them out. That's Bitly bi T dot L y slash j, b f support and tell a friend about him as well. Okay, so now I want to talk about the short term and long term impacts. And I want to go through the most common substances that we see. But I'd love for you to throw in any that you're seeing because you would have a better view of it than we would. We've talked a lot about alcohol, some of the impacts, but also how we can determine it. Do you see many short term infant sea based for a child who has been exposed to alcohol during pregnancy? And then I'm going to ask you what the long term impacts would be, but what will you see long term?
Speaker 2 19:43
So I think alcohol exposure, we're less likely to see concerns in the newborn period around regulation. The facial features as I described, or difficulties with growth are the most common things we see for newborns with significant alcohol exposure in terms of later outcome, As long term issues with alcohol exposure, we can see developmental delays. But that requires expectation of developmental milestones like walking and talking, which doesn't happen until the end of the first year. The most common concerns we see with alcohol exposure are overall developmental delays, maybe intellectual disability, if that continues, and significant challenges with executive functioning, executive functioning, being the ability to organize yourself to get a task oriented activity completed. So for example, getting out of the house in the morning, you know that you need to eat breakfast, go to the bathroom, brush your teeth, organize yourself, get your bag ready. And for those who cannot plan have no executive functioning, that is really difficult, and it affects every aspect of their life. We often don't see clear signals of executive dysfunction until children are school aged or older. So that's one thing was youth alcohol. We also see signs of ADHD Attention Deficit Hyperactivity Disorder, not in every child alcohol exposed, but more common than not. And that can look as distraction hyperactivity, impulsivity, poor judgment. So with alcohol, I would say children often look relatively okay in the newborn period, with the exception of the facial features and growth delays that I mentioned. But many times the developmental and behavioral issues are not clear until children are school age or older.
Dawn Davenport 21:34
Oftentimes, we'll see him around the age of four. And I think it's because parents coming and showing concern, I think it's because up to the age of four, we have very little expectation. And when we excuse things, we say, those are the terrible twos. Forget the twos, these threes are going to be a handful. And sometime around four, we start having these things that we kind of we started expecting a little more. So we could sometimes see parents say there's just something he's not like a regular four year old. And so yeah, not that there's anything magical about the age of four. But one thing that we hear from people is that I didn't drink alcohol I just had, but I had beer, or BI not drinking, but you know, a glass of wine, is, you know, mommy's juice or whatever. You know, I kept that up that type of thing. I hear that a lot from the prevention folks. And we also hear that from people who are trying to diagnose children. So does it matter the type of alcohol you consume?
Speaker 2 22:32
That's a really good question. I think it's probably the level of actual alcohol in the bloodstream that affects child's development. And if you're having a beer, which has a lower alcohol content, than vodka, the likelihood that if you have a beer a day, it will cause long term concern is much less than if you drink vodka. Realistically, there's, there's a level of alcohol exposure that I would say, if somebody has a glass of wine with dinner, and they're pacing themselves, it's less likely to be concerned than if someone is binge drinking. So it's really, if you're taking a large amount of alcohol over a period of time, I think, back in the last century, when I did driver's education, we talked about blood alcohol content, and how it affects your driving. And if you have a beer over an hour, you probably metabolize that quite well. But if you have multiple shots of alcohol, vodka, mixed drinks, etc, over a period of time, your blood alcohol levels going to be quite a bit higher. So it's, it's really the type of alcohol how therefore the alcohol content and the amount of time over which it's consumed. And it's really that level of alcohol exposure. That probably is the most predictive of affecting a child. So birth mother who says, Yeah, I have three or five drinks on a Saturday night, over two hours, is actually more concerning to me than a birth mother who says, Yeah, I have a glass of wine couple times a week with dinner. Let's be honest, though most children come into foster care, aren't having parents who are sitting down and having a glass of wine with dinner. We do see that sometimes. But it's often drinking to relieve stress or address underlying concerns and there's more of a binge to get a higher level of alcohol. It's more of a concern.
Dawn Davenport 24:34
That makes sense. All right, so our we've discussed the short term and the long term impacts of alcohol exposure. Let's move on to methamphetamines. In some areas of the country methamphetamines is still one of the highest we speak of the opioid crisis, but there are definitely places where meth is even more of a concern. So what would we expect to see short term in infancy? From methamphetamine exposure, and then what would we expect long term to see of a child with a child who has been exposed?
Speaker 2 25:07
Yes. One caveat on methamphetamine is that our longitudinal studies aren't great, even though it's been around for a long time. And often, children who are exposed to methamphetamine who are in research studies may continue to be involved with a family who's using methamphetamine. So I think that's a important caveat. In general, we think methamphetamine exposure does not necessarily affect your overall development and IQ. In other words, unlike alcohol doesn't reduce your overall cognitive abilities. However, in newborns, methamphetamine expose, we often see what I'm calling regulation challenges a child who has a really hard time being soothed, can't sleep well, isn't eating well. Now granted, many newborns don't eat and sleep incredibly well. But I'm separating it from the typical newborn dysregulation to a child in the newborn period, who's very hard to soothe, even with experience nursing staff over time. What we continue to see with methamphetamine is children, who have a hard time regulating regulating their mood. So they may be more anxious, more sad, more angry. And they also may have a harder time regulating sleeping, and eating and self soothe. That tends to persist into adulthood for children who are methamphetamine exposed. We don't have great studies looking at previous genetic predisposition because of parent concerns. But that's what we typically see with methamphetamine. I think, in addition, with methamphetamine exposure, because it's often associated with significant nutritional deprivation during pregnancy, we're often seeing children who are much smaller at birth, but that tends to improve that is not typically a long term concern for methamphetamine exposure.
Dawn Davenport 27:03
Okay, what about Adderall and other ADHD medication?
Speaker 2 27:08
So evidence would suggest if you were prescribed Adderall, and you're taking it as prescribed, and it's a therapeutic dose for a birth mother, that's actually much less likely to cause a concern. If you're buying Adderall on the street, and using a large amount to get a high. It's much more like methamphetamine outcomes. But studies that have looked at women, for example, diagnosed with ADHD who are treated with Adderall or other stimulants do not show these significant concerns in terms of regulation for their children long term.
Dawn Davenport 27:46
Interesting. Okay. All right now for the topic that we hear most about, especially in the news is our opioids. Let's talk about both prescription opioid use and illegal opioid use. What are the you've mentioned earlier that that's the concern for neonatal abstinence syndrome. But what are the short term, ie those in infancy type of impacts? Versus what do we see for kids long term whose moms have abused opioids during pregnancy?
Speaker 2 28:20
So, opioids continued to be prescribed for some people in pregnancy, if there are severe pain issues, if there's a surgery, and at a therapeutic indication, we think that opioids in pregnancy are not contraindicated, that is really different from what we're talking about with the opioid epidemic where use of opiates that might start his prescription, move to purchasing on the street and then moved to using heroin or fentanyl or anything like that. So for all opiates, whether they're prescribed or not, at a higher level of use during pregnancy, we're more likely to see withdrawal, as I mentioned before, that looks like neonatal abstinence syndrome, challenges eating, sleeping, regulating just a very, very fussy baby, often treated based on clinical scales with an opioid replacement. And we can actually titrate that down over time in the newborn period. So whether it's a prescription opiate, or something purchased on the street, we see those same outcomes for children. Some birth mothers who are using a very high level of methadone, for example, as prescribed are more likely to have a child who has withdrawal because methadone has a much longer half life so it takes longer for the body to metabolize that. And we may not see symptoms of withdrawal for three or four days. For women who are using heroin daily. Using prescriptions that are quick acting like oxycodone or Oxycontin. We often see withdrawal within the first few days of life, so it's hard to know what the outcome will be until the child is born with opiate exposure. But I generally say if there's been known exposure, expect neonatal abstinence, but it might not happen. And as you asked me before, not happening doesn't mean it wasn't exposure. Long term, we actually have pretty good evidence that opiates, while I don't recommend them, they don't really lead to good interactions for children in the newborn period, are not likely to cause long term cognitive development or behavioral issues. So in other words, some studies that have looked at nearly 10,000 children are being exposed, including heroin, fentanyl, opioid replacements, like methadone or Subutex, do not show a significant long term outcome in terms of developmental behavioral issues related purely to the opioid exposure. Effect brings up an important question that I think is important for parents who are parenting child that weren't born to them by birth. So why is someone using opiates is a really important question. Is this a first person who has significant ADHD, mood concerns, anxiety, other opiates, self medicating those challenges? That's not always easy to sort out? Has there been significant trauma? Was it possible that a birth parent 10 years earlier, did not have mental health concerns? And if it wouldn't have been for their environment, they might not be using opiates. And those are really challenging things that I don't think our research is sorted out particularly well, it's very hard. Yeah. And when I'm talking to parents, and we talk about opiate exposure, the thing that I often talk about is, the opiates by themselves may not lead to a long term development or behavioral concern. But let's think about birth parents, both birth mother birth father, what do we know? Is this someone who is really known to have a mood problem or ADHD? If so, if you see that in your child get early identification and treatment, because that is going to ameliorate the long term risks and the likelihood of recurrent use of substances in a
Dawn Davenport 32:21
child. And I think, not putting words in your mouth. But what I think I hear you say is that the opioids themselves may not be causing a problem. But the mental health issues that lead some parents to take the opioids are heritable, inherited genetic connection, and your child may inherit that tendency to have this mental health issue. And we can't tell whether your child's anxiety or depression was caused because they were opioid exposed, but it could be opening exposure, but it also could be that the parents, the birth parents, either the mother or the father struggled with anxiety or depression.
Speaker 2 32:59
Right. I know, we're talking here about prenatal exposure and long term outcomes. But I think when you're looking at a child's history, I look at opioid exposure or other prenatal substance exposure as a symptom, a symptom of challenges for the birth parents and maybe they're biologically driven. Or maybe they're environmentally driven by trauma or other concerns.
Dawn Davenport 33:24
Okay. Now, we've talked about general opioids, and can we lump in heroin and fentanyl is into this category and say the same thing would be okay. I think
Speaker 2 33:36
opiates broadly defined include heroin, fentanyl, Oxycontin, oxycodone, morphine, and opiate replacements, methadone and suboxone Subutex. Okay, they all have the same mechanism of action with respect to newborn withdrawal. And they're all hypothesized to have the same impact in terms of long term functioning. Now, we haven't been using opiate replaces like Subutex, as long as we've seen heroin, but so far, the evidence is pretty clear that they have very similar effects.
Dawn Davenport 34:14
Let me pause for a second to speak to those of you who are involved with training, or doing support groups or foster adoptive or kinship families. Creating a family has a great resource that we are offering. It is an all in one curriculum designed to make running, engaging high quality groups or trainings easy. And our goal is to combine skill building with peer to peer support. These are interactive video based trainings. We have a curriculum library of I think 24 or 25. Each one contains a video, a facilitator guide, handouts, and an additional resource sheet as well. So it's all in one you can take it off that virtual shelf and do your training are run your support group with very little effort. Go to parent support groups.org today and check it out. Okay, so up to this point, we've talked about what a lot of people consider the heavy drugs, the really bad stuff. So let's talk now about I want to introduce marijuana. Now you've referred to that before in general. So you said that if a mother was heavily using marijuana, that you might see some impact in the infancy stage and the newborn stage. But other than very heavy usage, we would not say necessarily any type of withdrawal or anything. What do we know about the longer term impacts of marijuana use?
Speaker 2 35:48
I think we're early in understanding what's happening with marijuana use. And I think marijuana use this changed dramatically, especially over the last five to 10 years. In other words, the concentration of THC, which is the most psychoactive substance in marijuana has gone up dramatically. Over the last 10 or 20 years, we're seeing legalization of marijuana across the country, which is changing the culture of its acceptance. And there are a lot of people are looking at marijuana outcomes, and advocating for marijuana use for everything from anxiety to ADHD. So the answer is I'm not sure yet. I think what the evidence shows is that heavy marijuana use over time clearly affects your executive functioning. It can affect your cognitive abilities, your ability to really think and retain information, your working memory. With respect to that in utero exposure. We don't have a lot of good research that separates out in utero exposure only, versus continuing to be in a family that's using marijuana. So for example, you know, secondary smoke exposure for smoking marijuana is very different than no exposure. Edible marijuana, which may be ingested, might have different effects, but we just haven't studied it. Well. I would look at heavy level marijuana exposure is more likely causing challenges with the executive functioning over time for children. In the newborn period, we can see withdrawal. A little marijuana use many birth mothers report I used marijuana in the first trimester, I was nauseous it helped me versus daily marijuana use throughout the pregnancy, very different level of exposure, similar to what we talked about with opiates and alcohol. Why is someone using marijuana daily basis? Are they self medicating, ADHD, anxiety, etc. The long term studies are kind of all over the place, people who are prescribing marijuana for mental health concerns describe that outcomes are unaffected for children. We don't have great well controlled trials yet looking at marijuana use in children and see what they look like as adolescents and young adults. And I think that that's what really matters. I mean, toddlers are important and preschoolers matter. But if those things improve, it's not going to affect children as much long term. So marijuana is a bit of a black box still. And I think it's, it's something that I would not recommend in pregnancy, but we're seeing much more commonly. And I would differentiate occasional marijuana use, especially in first trimester, probably not likely to have such significant concerns because the cannabidiol receptors, that marijuana effects in the brain don't come online until longer in pregnancy. So that's a little bit different than the daily marijuana use by somebody throughout the entire pregnancy, which is much more likely to cause challenges with regulation and the newborn period and potentially long term executive function difficulties.
Dawn Davenport 39:06
So what about ecstasy or any any of the inhalants?
Speaker 2 39:12
So ecstasy and other things that are considered clubbed drugs are also not something that are well studied, they're more often used intermittently during pregnancy. Most people use ecstasy, not that I'm an expert, but what I'm told is use it intermittently. So we think that it does have some similarities to methamphetamine. And again, someone who says I use ecstasy a few times a week, much more concerning in terms of long term developmental outcomes and regulation than someone who says I use ecstasy once or twice. We really don't have great information from human studies. We know in animals that it's very similar to methamphetamine outcomes.
Dawn Davenport 39:50
It's something that parents don't often think about whether they be pregnant parents are adopting foster or kinship parents, and that is tobacco use. We don't think of it as As a drug, we think that it's bad for the person who is inhaling it certainly a precursor to lung cancer, but we don't think about the impact on the fetus. So what do we know about the short and long term impacts of tobacco use, and that would include both smoking cigarettes as well as vaping.
Speaker 2 40:19
So, with respect to cigarette use, this goes in the category I've never recommended during pregnancy, we do know that routine. Cigarette smoking, nicotine exposure reduces birth weight of newborns. These may be infants who are a little bit more jittery. If they have withdrawal from nicotine, if there's a higher level of exposure, we do think that the long term effects are relatively minimal. Again, don't recommend it during pregnancy. But if you look at the epidemiology, people born in the United States in the 1960s, and 70s, more than 50% were exposed to more than a pack a day of cigarettes. And while we might even function better if we didn't have that exposure, it's not as devastating as some of the other prenatal exposures. Now vaping is a little bit of a different situation, it's very akin to what we talked about with marijuana. So vaping of today is not the same as smoking a cigarette 20 or 30 years ago, higher level of nicotine exposure, much more likely to have significant withdrawal in the newborn period in terms of nicotine withdrawal, that we just don't know about long term outcomes at this point. It's hypothesized from animal models, that there will be more concerns with executive functioning, self regulation, ADHD type symptoms. And it's also the devils in the details. So somebody who vapes a few times, not the same as somebody who's vaping, incessantly during the day, every day during pregnancy. And so those that high level of nicotine exposure, we think probably is going to cause more withdrawal and newborn period, and possibly longitudinal concerns with with regulation. We're someone who says, oh, yeah, I smoke eight cigarettes a day, or a half a pack per day, that is less likely to cause long term concerns for childhood withdrawal and newborn period. All right,
Dawn Davenport 42:21
we've been talking about these exposures, substance exposures in isolation. And I think that's important, because oftentimes, parents are making decisions on whether they're the right parent based on records that indicate individual exposures. But I think the reality is that so many of these kids are dually exposed. And I say that specifically with alcohol. So in your experience, how common is it for children to have dual exposure either to different drugs, or perhaps more commonly to alcohol and a specific drug.
Speaker 2 42:56
I expect poly substance exposure, I think in the United States where we have easy access to alcohol, cigarettes, marijuana vapes, and not minimal exposure to other substances that can be purchased illegally. Most birth mothers who are using substances are using more than one and the epidemiology is really often if you're using an opiate, then you use something as a stimulant to bring yourself up to kind of maintain some homeostasis in terms of your functioning. So poly exposure is definitely the norm. I think you're right that we can talk about each substance individually when we think in terms of longitudinal outcomes, but most birth, parents were using a substance or using more than one.
Dawn Davenport 43:42
One question we often get from parents is does my child because of their prenatal substance exposure, have a greater tendency in adolescence and adulthood to also struggle with substance abuse disorder or to experiment with drugs?
Speaker 2 43:59
Well, that's an interesting question. It depends, right? So there's some evidence that there are some people who use substances like alcohol, and then more likely to become dependent that's a genetic risk factor that is truly there. But studies that look at children with prenatal exposure, and then are adopted and look at does your birth family or your adoptive family predict your substance use? Hands down your environment, your adoptive family is much more predictive of substance use than your genetic risk factor if your parents had a history of substance use, I think if you control for parental mental health concerns, including ADHD, anxiety mood, if you treat those in a child, the likelihood of substance use drops to the typical population risk. So I feel that substance use is a symptom of parental mental health just like it's a symptom of potential risk for children. I would say for foster kinship adoptive parents pay it attention to what else is going on with your child. And just like adding whether another substance exposure, knowing what's going on with your child. Identifying healthy coping strategies rather than substance use goes a long way to preventing later substance exposure. And remember, environment of an adoptive family is much more important than birth family birth sibling substance use exposure in terms of predicting long term risk.
Dawn Davenport 45:27
Hey, guys, let me stop here and ask if you are a regular subscriber to our newsletter, regular or irregular, we want you to subscribe to our monthly e newsletter, you can find it at Bitly slash C A F guy that's bi T dot L y slash C A F guy. And the reason the URL has C A F Guide, which stands for creating a family guide, is because if you subscribe, you will get a FREE guide from us right now the guide we're offering is parenting a child exposed to trauma. It is a terrific guide, and it is free to you for subscribing to our monthly newsletter, go to Bitly slash C A F guy. Alright, so one of the things that that parents are frustrated by is how do they get a child diagnosed. And I'd like to break this now between alcohol and drug exposure because as we talked about, at the very beginning, the ways that we can figure out if a child has been exposed to differs depending on what they're being exposed to. So let's talk about alcohol. Oftentimes, as you point out, people who are fostering or who have adopted from the foster care system or international adoption, or kinship care, or even domestic infant adoption, may not know at the beginning. And so they're looking at a child who is four, eight, and they're trying to figure out okay, or what I am seeing now with this child, is this a result of prenatal substance exposure. And that can be important because for diagnosis and forgetting services, depending on how impacted the child. So let's start with alcohol. What's the parent to do if they suspect as we mentioned, as a child ages that something is just not right. And we know that we think that the mom may have drank.
Speaker 2 47:18
If a parent has any concerns, started dressing and as soon as you have a concern, I would personally suggest starting with your pediatrician and ask the pediatrician. Do you feel comfortable discussing this? Or do you recommend that I speak to someone who's more of a specialist, majority of pediatricians have heard of alcohol exposure not being great, they may not feel comfortable making that diagnosis. Within the United States, it's a very state specific access to services. So I recommend that people Google fetal alcohol syndrome, or fetal alcohol spectrum disorder in their state, and see what state resources show up. Often there will be a person who is identified as an expert, there may be parents support groups, I think that's a helpful place to start. If you have concerns about your child being exposed to alcohol, it's great to know how are they doing in school, evaluating through the school system can be helpful. Most school systems don't make a diagnosis of alcohol exposure, that's going to require a medical diagnosis. Some developmental behavioral pediatricians or psychiatrist or neurologist or geneticists do feel comfortable making that diagnosis. Some don't feel comfortable talking about that and will refer to other people. So it's I wish it were a better answer than that. It's very locally dependent. And I would just encourage parents to keep looking. Ultimately, the diagnosis of fetal alcohol spectrum disorder is helpful, I think in terms of understanding while child is having challenges and planning for the future. And as you said, providing access to resources in some states can be incredibly helpful.
Dawn Davenport 49:03
And even contacting some of the prevention organizations and there is more funding for prevention. Therefore, almost every state or I would say every state has some prevention services, contacting them and asking who diagnosis in your state. And generally speaking, we either see clinical geneticist or developmental pediatricians as the ones who most often are doing this, but like you say, ask around because it could be different in your area
Speaker 2 49:32
can be different in your area. Yes, I think you're very right. There's a lot of resources that are being shared with states that are mostly going to prevention, and I'm all for primary prevention, say but the families that we're talking with here, it's too late. Yeah. So I think then we're in the situation of okay, who can help you identify what's going on and to be really honest, the services it's not as if you were diagnosed with alcohol exposure. It's an open estimate to provide the appropriate intervention. It's just a lens that I think helps families, caretakers, educators, other therapists and physicians to understand Oh, right. alcohol exposure might be impacting all of this, we still have to address the behavioral the learning the developmental concerns in the same way we typically would. But what's really helpful is for families to be able to know and then inform others because that's really how it happens. That the teacher knows, right, Johnny knows not to run across the street and to bolt if there's a car coming down the street, but he might not be able to stop himself. And that's not a behavioral problem. That's a neurologically based problem because of alcohol exposure. And the difference between those is whether you primarily focus on behavioral supports, which many children with alcohol exposure cannot respond to, they don't get cause and effect. So understanding I'm punished because of x isn't helpful to them. But it is helpful for those who are working with kids to know Oh, this is why this is why, despite cognitive skills are much higher. This is a child who can't respond.
Dawn Davenport 51:15
Yes, we say all the time that if we can shift the attitude of the adults in this child's life, we have made a huge impact on this kid. This is not a bad kid. This is a kid coping with the brain damage of prenatal substance exposure. And just that shift changes everything and how we respond to a child. So yeah, I will get off of my soapbox, but I couldn't agree with you more.
Speaker 2 51:37
No, I, I mean, I think I think that there are some educators who really get that and do an incredible job. And then there are still some people who are stuck, because they say he or she looks fine. Yeah, I think this is a parenting problem. Yep. And that's where I'm like, well, just give up with this teacher this year, you know, so,
Dawn Davenport 51:58
yeah, it's it's not helpful. So we've talked about alcohol and the diagnosing of fetal alcohol spectrum disorders is, it is complicated. So we've talked about alcohol. Now, let's move on to children who have been exposed to drugs. And specifically, let's talk about those drugs that are habit forming or dependency for me.
Speaker 2 52:19
So I think honestly, besides alcohol, we don't have an easy way to make a diagnosis of a syndrome that causes long term effects. So as a developmental behavioral pediatrician, mostly working with children who have developmental behavioral issues, when they wouldn't be seeing me, I look at prenatal exposure of any of the other things that you talked about as a risk factor. And I try to figure out, what do we need to do to help a child now whether this is executive functioning related to cocaine or methamphetamine exposure, I'm going to try to provide behavioral supports and or medical interventions that are the same. So I think the diagnosis is really related to one of the developmental, behavioral and emotional issues, which might come through a developmental behavioral pediatrician, or neuro psychologist to help understand what are any child's strengths or weaknesses, but I think separate from alcohol, the rest are really risk factors. And we just say, risk factors, but we address the long term issues, if that makes sense.
Dawn Davenport 53:23
So there's not a diagnosis per se, for opioid exposure are methamphetamine.
Speaker 2 53:30
There's a diagnosis that we use to put in the medical record, but it's in the billing world or the ICD 10 diagnostic world. It tells you this is a risk factor. But you know, all of us as humans have some vulnerabilities, but also resilience. So many children with significant exposure do incredibly well long term. And a lot of that relates to their environment, it does relate to their exposure. And then there are children who have some exposure that don't do well. And that relates to other factors, too. So I think the biggest issue is when a child is preschool, school age adolescence, if they have a history of prenatal exposure to something that's just part of their history, it's not their fate. Alcohol is the one situation where I would say, Okay, I level alcohol exposure meeting criteria for FASD. That is something that will impact your development, but the others are more variables. And I don't want to minimize the impact of families that children are living with to impact their long term outcomes. But understanding that these are things that contributed I think, also help understand that there may be genetic risk factors for the child inattention, emotional regulation, etc areas.
Dawn Davenport 54:45
All right, so what should parents or caregivers consider when trying to decide if they are the right family? To parent this child with prenatal substance exposure?
Speaker 2 54:57
I think it's always a family's choice and They have to go with their gut. And if they don't feel comfortable, they shouldn't feel comfortable. I think understanding what are the potential risk factors, understanding your local resources, talking to an agency, if you're working with an adoption agency, talking with the foster care, social workers and others, contacting medical providers to get as much information as possible. So you understand is really important. Whether you have a child by birth, or other, there are a lot of unexpected outcomes. And I would say, plan for the most potentially concerning and hope for the best. And identify, Hey, what are your resources locally, who you talk to? If this is a concern? How would you feel if you have a child who isn't able to complete high school on a typical manner, and they may need to have extended supports? If you don't feel comfortable with that? I don't think a child should be adopted, who has a long history of alcohol exposure into that family. So I think a lot is knowing what do you feel comfortable with and trying to educate yourself pre adoptively
Dawn Davenport 56:02
Don't go in just assuming either the worst or the best going in prepared for either? Exactly. Yes, every
Speaker 2 56:08
child does much better with a caring and supportive family and environment can make a lot of difference, but it can't remove everything. So kind of knowing what's possible is helpful.
Dawn Davenport 56:18
And creating a family has a prenatal substance exposure training for parents, foster adoptive and kin parents, as well as for daycare, preschool teachers and after school programs. And it is designed to help parents recognize the symptoms or parents and staff teachers to recognize the symptoms. But most importantly, it is to help train them on best practices and techniques to work with these kids to help them thrive. Because it goes down to what you were saying earlier. We have to train parents on what to do once they realize that their child and shifting that attitude and that understanding makes all the difference in the world, for the parents especially are the caregivers. Thank you. Right. Thank you so much, Dr. Lisa proc for being with us today to talk about prenatal exposure. He helped give us an introduction to this. We really appreciate it. Thank you very much. I want to thank hopscotch adoptions for their long term support of this show, as well as for the nonprofit creating a family they have been with us for a long time. They put their money behind their vision and behind our vision and we are so thankful for them. Hopscotch adoptions is a hate accredited international adoption agency placing children from Armenia, Bulgaria, Croatia, Georgia, Qian, Morocco, Pakistan, Serbia, and Ukraine. They specialize in the placement of children with Down Syndrome and other special needs. In addition to kinship adoptions, they place kids throughout the US and offer home study services as well as post adoption support to residents in North Carolina and New York.
Transcribed by https://otter.ai