This study compared the mental health symptoms in CE and NCE children of similar race and socioeconomic status at 6 years of age, using child self-report and caregiver report. CE children reported more symptoms of oppositional defiant disorder (ODD) and attention deficit hyperactivity disorder (ADHD) than NCE children. There were no differences based on prenatal cocaine exposure when caregiver report on the CBCL was used.
CE children report more mental health symptoms than NCE children, supporting several lines of evidence suggesting a link between cocaine exposure and symptoms consistent with ODD and ADHD. First, CE animals have been found to be more reactive to environmental stressors (Molina, Wagner, & Spear, 1994
; Spear et al., 1989
). This reactivity may lead to impulsivity if regulation of the child's reaction to stress is impaired. Greater reactivity, combined with stressed living conditions may interact to increase the likelihood that CE children will have difficulty managing their behavior (Mayes, Grillon, Granger, & Schottenfeld, 1998
). Second, research on animal populations has shown significant monoaminergic deficits and behavioral changes as a consequence of prenatal cocaine exposure (Glatt, Bolanos, Trksak, & Jackson, 2000
; Johns et al., 1998
; Johns, Lubin, Lieberman, & Lauder, 2002
; Kosofsky & Wilkins, 1998
). Monoaminergic deficits in humans have been linked to impairments in arousal and attention regulation (Mayes et al., 1998
). Finally, cocaine exposure has been linked to poor attention in infants (Singer et al., 1999
; Singer et al., 2000
), and preschoolers, (Noland, Singer et al., to press
) as well as generalized cognitive deficits (Singer et al., 2004
; Singer, Arendt et al., 2002
) in children. Poor attention and low IQ have been shown to be related to the development of ODD and CD (Loeber, Burke, Lahey, Winters, & Zera, 2000
). Longitudinal follow-up studies have further demonstrated impulsivity in older infants, toddlers, and school age children exposed to cocaine (Bendersky & Lewis, 1998a
; Leech, Richardson, Goldschmidt, & Day, 1999
). These latter studies are consistent with the finding of CE children's report of difficulties with attention and irritability.
Consistent with some recent reports (Accornero et al., 2002
; Bennett et al., 2002
), caregiver report of child behavior was unrelated to prenatal cocaine exposure after control for confounding variables. Effects of adoptive or foster care status, however, were noted on both child report and parent report, most notably for CE children in adoptive or foster care on scales that assess externalizing behaviors. On a number of behaviors, adoptive or foster caregivers rated their CE children more negatively than did maternal or relative caregivers of CE children or mothers of NCE children.
Several reasons may account for these findings. First, CE adopted or foster care children may actually exhibit more behavior problems than CE children in maternal or relative care and NCE children. Some studies have supported the hypothesis that in general adopted children experience more adjustment difficulties than nonadopted children (Miller et al., 2000
; Sharma, McGue, & Benson, 1998
), specifically externalizing behavior problems (Simmel et al., 2001
). An alternative explanation is that CE children in adoptive or foster care may have caregivers who are more sensitive to adjustment difficulties (Miller et al., 2000
), with this increased sensitivity accounting for the elevated rates of behavior problems. Furthermore, these caregivers may also be involved with clinical services or have better resources to obtain services and education regarding mental health problems. Research has shown that adopted children are referred for and utilize services at a greater rate than nonadopted children (Warren, 1993
). Finally, it may be that the adoptive or foster placement itself had a disruptive effect on children's adjustment because of loss of significant attachment figures. In an effort to address this issue, we investigated the correlation between length of placement in the adoptive or foster care home and the rate of externalizing symptoms and the relationship was not significant.
Our findings do not indicate adoption or foster care is necessarily a negative event for CE children. Indeed, recent research has shown that adjustment of adopted drug-exposed children is similar to that of adopted nonexposed children (Barth & Needell, 1996
). Further, in this sample, we previously found that adoptive or foster care status was protective for cognitive outcomes at age 4. That is, CE children in adoptive or foster care demonstrated performance on a standardized IQ test similar to NCE children (Singer et al., 2004
). However, despite living in more cognitively stimulating home environments, CE children in adoptive or foster care in this analysis did not show the same protective effect on mental health outcomes that was seen for cognitive outcomes.
It may be that adoptive or foster homes provide greater structure and rules. As such, children's violations of those rules may lead to parent and child conflict, which appears logically related to ODD and externalizing behaviors. Alternatively, it is possible that adoptive or foster caregivers may have higher standards than the biological caregivers of CE children. Still another possibility is that adoptive or foster caregivers have developed an expectancy of more negative behavioral outcomes in CE children based on media reports. Although some effects of the adoptive or foster caregiver environment on children's mental health outcomes were mediated by characteristics such as maternal psychological distress and IQ, which differed by caregiver status, there were independent effects of adoptive or foster care status on child outcomes beyond these characteristics.
In this sample, the percentage of children in the probable clinical range for specific phobias and separation anxiety was high. Additionally, the rates of ODD and CD in this sample were higher than population based studies which have found diagnostic prevalence rates of 2–8% (Loeber, Farrington, Stouthamer-Loeber, & Van Kammen, 1998
). However, as noted, child self-reports are not equivalent to diagnostic classification and are not comparable to epidemiologic studies that establish a diagnosis. Moreover, children in both groups of this sample were at very high psychosocial risk from birth, and the rates of mental health problems reported here are not markedly discrepant from those reported in other urban low income, primarily single parent families with parental drug and alcohol abuse as well as mental health difficulties (see Qi & Kaiser, 2003
). Also, because the DI is a new assessment, it will be important to continue to validate its use with populations other than its normative sample, especially in underrepresented minority populations.
Several limitations of this study should be noted. Maternal drug use was evaluated based on retrospective reports. While the infant's meconium was collected at birth and used for classification purposes, estimation of drug use prior to pregnancy and throughout the pregnancy was based on maternal report at the child's birth; therefore, these retrospective reports may underestimate or overestimate actual drug use. The DI measure used in this study has not received extensive psychometric testing, and the results may be affected by unknown psychometric characteristics of this test. Caution has been raised regarding the use of DSM-based assessments with children (Cantwell, 1996
) and the issue of whether the reporting of these symptoms are stable should be investigated in future studies. Nonetheless, studies have shown young children's self-report to be predictive of later mental health and academic outcomes (Ialongo, Edelsohn, & Kellam, 2001
) and despite problems associated with categorical approaches to diagnosis, efforts to validate the use of DSM-based diagnostic measures are extensive (Shaffer et al., 1996
; Silverman, Saavedra, & Pina, 2001
). Another limitation is that too few NCE children were placed in adoptive or foster care to assess the effects of caregiving status on parental report, except within the cocaine group. Thus, our findings must be restricted to CE children. Nevertheless, our findings could not be attributed to other factors, which differentiated the groups, such as caregiver distress, IQ, the home environment, and severity of cocaine exposure.
It will be important to continue to assess mental health outcomes in CE populations. Obtaining the child's self-report will be an important dimension to consider as symptom presentations, as demonstrated here, may vary based on the informant (child or parent). It will continue to be of interest to assess caregiving status in relation to child outcome. Future studies with independent ratings of CE children's behavioral and mental health symptoms should help differentiate whether adoptive or foster caregivers' perceptions of their CE children are based on unrealistic standards, negative expectations from media stereotypes, or reflect true behavioral differences. In all cases, caregiver support and counseling may be necessary, in so far as CE children at 6-years of age self-reported more symptoms of oppositional defiant disorder and attention deficit hyperactivity disorder. Replication of these findings may shed insights into effective intervention strategies for use with drug-exposed children and their parents.