The purpose of this study was to investigate the neuropsychological outcome of children ages four to 11 years old whose mothers had attended the SCWC during pregnancy and the child's first two years of life. The screening was designed to capture neuropsychological functions connected with prenatal substance exposure, such as attention deficit and learning problems. All children had test results in the normal range in all domains. Some children in both the user and the comparison groups had test results in the clinical range (> - 2 SD), but only in single tests. Children of substance-abusing mothers often have impaired development [6
]. The results of our study with all children scoring within the normal range of the domains, suggest that the children benefited from their mother's attendance at the SCWC, where emphasis is placed on stopping or reducing substance use. However, the age range of the children was wide and they were still quite young (mean age at testing, 7.9 years); adverse effects of substance abuse may manifest at an older age.
We wanted to study if there were differences in the test results between the user groups and the comparison group. The ANOVA analysis showed significantly lower test scores in the short-term use group than the comparison group regarding the domains (1) learning and memory, (2) visual scanning, planning and attention and (3) executive functions. This may point to some disturbed function in children of substance abusers. Test scores in the lower range of many different domains indicate impaired development. These three domains are frequently correlated with attention deficit and hyperactivity [37
] and with learning difficulties [39
The linear regression analyses revealed, however, that being in foster care for more than 50% of lifetime was the only factor that was significantly associated with the screening results in the three domains (1) learning and memory, (2) visual scanning, planning and attention and (3) executive functions. Children of mothers in the short-term use group mostly lived with their biological mothers and they were probably exposed to a significant amount of negative environmental factors that may have disturbed their development. An unsafe environment may stem from the mother having a limited network, i.e., few friends who do not use substances, and from the mother often changing addresses and partners. Lack of cognitive stimulation may also contribute to a less satisfactory performance in the neuropsychological screening.
There was no difference among any of the groups regarding the time necessary to complete the test or vigilance. This was initially not expected because of the relatively short time used to perform the test tasks. This result indicates that all children participated well and endured the situation surrounding the testing in a satisfactory manner.
Children of long-term users did not differ significantly from the comparison group on the test results in the bivariate analyses, with the exception of "executive functions". This was in contrast with the neonatal findings, which demonstrated that long-term users were more likely to experience adverse birth outcomes compared with the comparison group [21
]. Fetus in the long-term use group had been exposed to various doses of substances at irregular intervals throughout the pregnancy. These children were more often premature and a significantly larger proportion of them had a birth weight < 2500 g. There are few reports on the development and environmental conditions of children that are prenatally exposed to illicit substances, either early in pregnancy or from time to time throughout pregnancy [42
]; however, different neuropsychological problems have been observed, such as decreased general cognitive functioning and deficits in learning and memory tasks [6
]. One important issue in the recommendation of opioid replacement therapy in pregnancy is the prevention of variations in the concentration level of substances as such variations may cause adverse reactions in the fetus. In our study, the fetus in the long-term use group had been exposed to various doses of substances at irregular intervals throughout pregnancy. However, the substance abuse during pregnancy was monitored and found to be considerably reduced, even in the long-term group, and only one newborn needed treatment for neonatal abstinence syndrome [26
The environment in which children are raised seems to be one of the most important factors of determination of their development [11
]. Foster homes are thought to ensure the safety of children and to help optimize their development. In Norway in 2006 2.6% of children 0-17 years received help from the Child Welfare System, 0.4% were placed in foster care. Of the SCWC children, 21 (51%) were or had been in foster care. This is an indication that the children are born into an environment of great risk.
The results of the neuropsychological screening indicate that adverse environmental factors had a negative association with the development of SCWC children that was as significant as the prenatal exposure to substances.
In early stages, and primarily before the age of five, the plasticity of the child's brain allows responding to a good and safe environment [43
]. The average age of the children placed in foster care in our study was 2.6 years; thus, they had the possibility to compensate for prenatal adverse effects of substance abuse.
The multivariate analyses revealed that being in foster care were associated with positive test scores in all the three domains where we found significant differences in the bivariate analyses. Being born before 38 weeks of gestation was associated with low test scores in the domain learning and memory. This might be related to the adverse birth outcome of the long-term substance abusing group as mothers who used some substances throughout pregnancy more often gave birth before 38 weeks of gestation and more often relapsed to substance abuse after the child was born [21
We have not measured environmental factors in this study. However the results indicate that other elements than the use of substances in pregnancy influence the development of the children. Other confounding factors may not have been discovered in this sample.
One important aim of the SCWC is to try to optimize the development of the children by ensuring them a safe environment in which to grow up. The close monitoring of parents and infants in the first years of the child's life may have contributed to the discovery of adverse conditions and, thus, was instrumental in placing the child in foster care. The long-term use mothers were often asked by the child welfare service to continue to provide urine specimens after the child was born, which allowed the easy detection of relapse to substance abuse. The support and guidance of the SCWC, in addition to the help provided by other initiatives, may have contributed to the enhancement of the mothers' parenting skills during the first years. As the child grows older, the demands on the mother's parenting skills change. The child will challenge the mother in a way that calls for determination and attention. This might cause stress and relapse to heavy substance abuse, leading to the need for foster care for the child.
Also among the short-term users, contact with the SCWC may have helped identify children living in high risk environments and mothers' relapse into substance abuse. In cases where adverse conditions were suspected, it was, however, often difficult to make the mother realize that it would be good for the child's development if she agreed to receive help and guidance. In cases where substance abuse or major neglect was not present, any help was dependent on the mothers' consent. The test results indicate that children in the short-term use group had experiences in their environment that may have had negative influence on their neuropsychological development. Our study shows that a stronger effort is needed to follow children who are being raised by former substance-abusing mothers.
Overall, four mothers had received replacement therapy at the time of the children's testing. All had temporarily lost custody of their children because of relapse to substance abuse and got their children back after being stabilized. Fear of losing their children may be a reason why the craving for substances is often a problem that the users try to hide from the SCWC personnel. Therefore, replacement therapy rarely becomes an issue. A more open discussion of this topic may have been helpful to try to avoid placement in foster care.
In Norway, most of the resources necessary to help mothers with special needs are available through the child welfare system. This investigation indicates that it is of great importance to pay extra attention to a child of a substance abuser, even if the mother has managed to stop her substance abuse behaviour. It is crucial to realize that it is necessary to provide help and support to the mother to prevent problems for the children as they grow older.
There were some limitations to this investigation. There was no randomization and no fixed treatment program. Randomization was not possible, as each user who got in contact with the SCWC had to be helped, for ethical reasons. Pregnant women were given individual treatment, according to their needs. Help was also provided by other institutions, such as the social welfare system, the child welfare service, substance abuse counselling and community health services or the hospital. However, SCWC had the main responsibility of following up the medical issues related to the pregnancy, and the clinic had the resources necessary to give the mothers more attention than is given at an ordinary child welfare clinic.
Another limitation of this study was that we did not register the exact amount of substances used during pregnancy. The women who attended the SCWC were, however, known to have serious substance abuse problems, according to various social and substance abuse services in the community. Urine specimens were used to confirm the cessation of substance use.
Some environmental factors that might be important confounders are not in the analysis. All, but one child in the user groups lived with their mother in single parent families where the mother often had had several new partners, while all children in foster homes lived in two parents families. In the comparison group 20% of the children lived in single parent families.
The home environment has not been measured in the study. If adverse environmental conditions were discovered by the SCWC, necessary resources, such as home based intervention, help with respite care or economic support to allow the child to be placed in a nursery school, were provided by the Child Welfare System, if the mother agreed. Before a child is placed in foster home, voluntary measures should be tried as long as there is no direct danger to the child. Most mothers in the short-term use group did, however, not accept SCWC' offers of support.
The home environment in the foster homes was not measured, but we consider that they offer a good environment for the child.
The age range of the children was broad. To recruit a number of children that was sufficient for statistical analysis, we investigated the first eight years of operation of the SCWC. We made an effort to use tests that were validated for the specific age range. Moreover, z-scores were calculated for different age groups to be able to compare the results across ages. In the analyses, the age of the children did not influence the results.
The sample size was small. We wanted to investigate children older than four years of age, as the establishment of special child welfare clinics is now recommended in all municipalities of Norway and little is known about the development of the children who attend these clinics. A larger sample size was not within the scope of this investigation. The significant differences observed between the groups in the test scores may be considered as being reliable. However, important differences may have been overlooked. It is important to consider our results in the light of the settings of the SCWC. Additional research on the children of mothers with substance abuse living in Scandinavia is required, as the treatment is often given in small local initiatives in these countries.
The strength of this study was that we succeeded in establishing contact with all but one pregnant substance-abusing woman within the relevant region, and that all but two of the children in the target age group participated in the neuropsychological screening. Although the identities of the children of substance-abusing mothers were known to the main investigator, they were not revealed to the psychologist who performed the neuropsychological screening. We intended to ensure that the result of the screening was not influenced by the identity of the subjects. However, a fully blinded investigation was not within the scope of this research.
We anticipate that initiatives such as the SCWC will be important to support substance abusing women in their efforts to stay free of substances and to help and advise them on how to parent their children. Additional follow-up investigations are needed to assess how to prevent impaired neuropsychological function in children born and raised by substance-abusing mothers. In order to help mothers with substance abuse problems to become better parents a screening of early bonding and attachment could be of use. Guiding, for instance by means of Video-feedback Intervention (for instance Marte Meo [44
]) in order to encourage the mothers to use "their own strength" to advance and stimulate developmental processes. If the mother/child attachment is strong it will be easier for the mothers to make good decisions regarding the child's home environment [45