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1.  Protective Factors Can Mitigate Behavior Problems After Prenatal Cocaine and Other Drug Exposures 
Pediatrics  2012;130(6):e1479-e1488.
BACKGROUND:
We determined the role of risk and protective factors on the trajectories of behavior problems associated with high prenatal cocaine exposure (PCE)/polydrug exposure.
METHODS:
The Maternal Lifestyle Study enrolled 1388 children with or without PCE, assessed through age 15 years. Because most women using cocaine during pregnancy also used other substances, we analyzed for the effects of 4 categories of prenatal drug exposure: high PCE/other drugs (OD), some PCE/OD, OD/no PCE, and no PCE/no OD. Risks and protective factors at individual, family, and community levels that may be associated with behavior outcomes were entered stepwise into latent growth curve models, then replaced by cumulative risk and protective indexes, and finally by a combination of levels of risk and protective indexes. Main outcome measures were the trajectories of externalizing, internalizing, total behavior, and attention problems scores from the Child Behavior Checklist (parent).
RESULTS:
A total of 1022 (73.6%) children had known outcomes. High PCE/OD significantly predicted externalizing, total, and attention problems when considering the balance between risk and protective indexes. Some PCE/OD predicted externalizing and attention problems. OD/no PCE also predicted behavior outcomes except for internalizing behavior. High level of protective factors was associated with declining trajectories of problem behavior scores over time, independent of drug exposure and risk index scores.
CONCLUSIONS:
High PCE/OD is a significant risk for behavior problems in adolescence; protective factors may attenuate its detrimental effects. Clinical practice and public health policies should consider enhancing protective factors while minimizing risks to improve outcomes of drug-exposed children.
doi:10.1542/peds.2011-3306
PMCID: PMC3507246  PMID: 23184114
behavior problems; cumulative risks; prenatal cocaine exposure; protective factors
2.  Externalizing Problems in Late Childhood as a Function of Prenatal Cocaine Exposure and Environmental Risk 
Journal of Pediatric Psychology  2012;38(3):296-308.
Objective To examine whether prenatal cocaine exposure (PCE) predicts externalizing problems in late childhood. Methods Externalizing problems were assessed using caregiver, teacher, and child ratings and a laboratory task when children (N = 179; 74 cocaine exposed) were aged 8–10 years. PCE, environmental risk, sex, neonatal health, other prenatal exposures, and foster care history were examined as predictors of externalizing problems. Results Multiple regression analyses indicated that PCE, environmental risk, and male sex explained significant variance in externalizing problems in late childhood. Models varied by source of information. PCE predicted externalizing problems for child laboratory behavior and interacted with sex because males with PCE reported more externalizing problems. PCE did not predict caregiver or teacher ratings of externalizing problems. Conclusions The effect of PCE on externalizing problems may persist into late childhood. The findings highlight the potential importance of including child-based measures of externalizing problems in studies of prenatal exposure.
doi:10.1093/jpepsy/jss117
PMCID: PMC3604825  PMID: 23248347
environmental risk; externalizing problems; prenatal cocaine exposure; sex differences
3.  Predicting Caregiver-Reported Behavior Problems in Cocaine-Exposed Children at 3 Years 
Predictors of caregiver-reported behavior problems for 3-year-olds with prenatal cocaine exposure (PCE) and matched controls were examined using structural equation modeling. We tested whether PCE had a direct effect on child behavior problems in a model that included other prenatal drug exposure, child sex, caregiver depression, and the quality of the child’s home environment. The sample (N = 256) was drawn from a longitudinal, prospective study of children of (predominantly crack) cocaine-using women and controls matched on race, socioeconomic status, parity, and pregnancy risk. Child Behavior Problems was modeled as a latent variable composed of the 48-item Conners’ Parent Report Scale Conduct Problem and Impulsive-Hyperactive scales and the Eyberg Child Behavior Inventory Intensity scale. Caregiver depression was the only significant predictor of Child Behavior Problems. Mean levels of caregiver self-reported depression and reported child behavior problems did not differ between groups. Mean depression scores were well above the recommended clinical cutoff while mean child behavior problems scores were within normal limits. The model explained 21% of the variance in caregiver-reported child behavior problems in our sample of rural African American, low SES youngsters. Non-maternal caregivers of cocaine-exposed children had significantly lower mean depression scores and mean child behavior problems ratings for 2 of 3 scales used in the study compared to biological mothers of children with PCE and controls. For all groups, much larger proportions of children were rated as having clinically significant behavior problems than would be expected based on the prevalence of behavior problems in the general population.
PMCID: PMC3150578  PMID: 16682870
4.  Self-Reported Adolescent Behavioral Adjustment: Effects of Prenatal Cocaine Exposure 
Purpose
To assess the direct effects of prenatal cocaine exposure (PCE) on adolescent internalizing, externalizing and attention problems, controlling for confounding drug and environmental factors.
Method
At 12 and 15 years of age, 371 adolescents (189 PCE, 182 non-cocaine exposed (NCE)), primarily African-American and of low socioeconomic status, participating in a longitudinal, prospective study from birth were assessed for behavioral adjustment using the Youth Self-Report (YSR).
Results
Longitudinal mixed model analyses indicated that PCE was associated with greater externalizing behavioral problems at ages 12 and 15 and more attention problems at age 15, after controlling for confounders. PCE effects were not found for internalizing behaviors. PCE adolescents in adoptive/foster care reported more externalizing and attention problems than PCE adolescents in biological mother/relative care at age 12 or NCE adolescents at both ages. No PCE by gender interaction was found. Prenatal marijuana exposure, home environment, parental attachment and monitoring, family conflict, and violence exposure were also significant predictors of adolescent behavioral adjustment.
Conclusions
Prenatal cocaine exposure is a risk factor for poor behavioral adjustment in adolescence.
doi:10.1016/j.jadohealth.2013.12.032
PMCID: PMC4108526  PMID: 24581794
Prenatal cocaine; behavior; attention; adolescents
5.  Caregiver and self-report of mental health symptoms in 9-year old children with prenatal cocaine exposure 
Neurotoxicology and teratology  2011;33(5):582-591.
Objective
To assess the effect of prenatal cocaine exposure on mental health symptoms in 9-year old children controlling for potential confounders.
Methods
332 children (170 prenatally cocaine-exposed (PCE), 162 non cocaine-exposed (NCE) were assessed using self (Dominic Interactive; DI) and caregiver report (Child Behavior Checklist; CBCL).
Results
Higher levels of PCE were associated with caregiver report of clinically elevated aggressive and delinquent behavior. With each increased unit of PCE, children were 1.3 times more likely to be rated as aggressive (OR=1.30, 95% CI: 1.02–1.67, p<0.04). For each increased unit of PCE, girls were 2 times more likely to be rated as having delinquent behavior (OR=2.08, 95% CI: 1.46–2.96, p<0.0001). PCE status was also associated with increased odds of delinquent behavior (OR=2.41; 95% CI: 1.16–4.97, p=0.02), primarily due to the increased risk among girls with PCE. While girls with PCE status were 7 times more likely than NCE girls to have delinquent behaviors (OR=7.42; 95% CI: 2.03–27.11, p<0.002) boys with PCE did not demonstrate increased risk (OR=0.98; 95% CI: 0.36–2.65, p>0.97). Foster or adoptive parents were more likely to rate their PCE children as having more thought problems, inattention, delinquent behavior, aggression, externalizing and overall problems (p<0.05) than biologic mothers or relative caregivers. Higher 2nd trimester tobacco exposure was associated with increased odds of caregiver reported anxiety (OR=1.73; 95% CI 1.06–2.81, p<0.03) and marijuana exposure increased the odds of thought problems (OR=1.68; 95% CI 1.01–2.79, p<0.05). Children with PCE self-reported fewer symptoms of oppositional defiant disorder (ODD) compared to NCE children (OR=0.44, 95% CI: 0.21–0.92, p<0.03). Greater tobacco exposure was associated with increased odds of child reported ODD (OR=1.24; 95% CI 1.03–1.78, p<0.03).
Conclusion
Higher PCE was associated with disruptive behaviors including aggression and delinquent behavior among girls by caregiver report, but not child report. These findings highlight the need for early behavioral assessment using multiple informants in multi-risk children.
doi:10.1016/j.ntt.2011.03.002
PMCID: PMC3595600  PMID: 21764256
Prenatal cocaine exposure; Mental health; Child Behavior Checklist; Dominic Interactive; Tobacco; Neurobehavioral teratology
6.  Children Who Witness Violence, and Parent Report of Children’s Behavior 
Objectives
To examine how much distress children report in response to violence that they have witnessed and how this is associated with parental reports of children’s behavior.
Methods
As part of a study of in utero exposure to cocaine, children completed the Levonn interview for assessing children’s symptoms of distress in response to witnessing violence. The children’s care givers completed the Exposure to Violence Interview (EVI), a caretaker-report measure of the child’s exposure to violent events during the last 12 months. The EVI was analyzed as a 3-level variable: no exposure, low exposure, and high exposure. The caregivers also completed the Children’s Behavior Checklist (CBCL).
Results
Of 94 six-year-old children, 58% had no exposure to violence, 36% had low exposure to violence, and 6% had high exposure to violence, according to caretaker reports. The children’s median ±SD Levonn score was 64 (SD ± 19.3). The mean (SD ± CBCL total T-score was 53 (SD ± 10.2). In multiple regression analyses with gender, low and high exposure on EVI, Levonn, and prenatal cocaine exposure status as predictors, the Levonn score explained 4.8% of total variance in children’s CBCL internalizing scores, 9.1% of the total variance in CBCL externalizing score, and 12.2% of the total variance in CBCL total score (P = .04, P = .004, and P <.001, respectively).
Conclusions
After accounting for the caretaker’s report of the level of the child’s exposure to violence, the child’s own report significantly increased the amount of variance in predicting child behavior problems with the CBCL. These findings indicate that clinicians and researchers should elicit children’s own accounts of exposure to violence in addition to the caretakers’ when attempting to understand children’s behavior.
PMCID: PMC2366171  PMID: 12144371
7.  Serial Pediatric Symptom Checklist Screening in Children with Prenatal Drug Exposure 
Objective
To examine screening results obtained by serial annual behavioral assessment of children with prenatal drug exposure.
Method
The Maternal Lifestyle Study enrolled children with prenatal cocaine exposure (PCE) at birth for longitudinal assessments of developmental, behavioral, and health outcomes. At 8, 9, 10, 11, and 12 years of age, caregivers rated participants on the Pediatric Symptom Checklist (PSC). Serial PSC results were compared to an established broad-based behavioral measure at 9, 11, and 13 years. PSC results were analyzed for 1,081 children who had at least 2 annual screens during the 5-year time span. Most subjects (87%) had 4 or more annual screens rated by the same caregiver (80%). PSC scores (and Positive screens) over time were compared at different time points for those with and without PCE. Covariates, including demographic factors and exposures to certain other substances, were controlled.
Results
Children with PCE had significantly higher scores overall, with more Positive screens for behavior problems than children without PCE. Children with PCE had more externalizing behavior problems. Children exposed to tobacco pre- and post-natally also showed higher PSC scores. Over time, PSC scores differed slightly from the 8-year scores, without clear directional trend. Earlier PSC results predicted later behavioral outcomes.
Conclusion
Findings of increased total PSC scores and Positive PSC screens for behavioral concerns in this group of children with prenatal substance exposure support the growing body of evidence that additional attention to identification of mental health problems may be warranted in this high-risk group.
doi:10.1097/DBP.0b013e318208ee3c
PMCID: PMC3069136  PMID: 21200328
Behavior disorder; child behavior; mental health; screening; prenatal cocaine exposure; Pediatric Symptom Checklist
8.  Prenatal cocaine exposure: Effects on mother- and teacher-rated behavior problems and growth in school-age children 
Neurotoxicology and teratology  2010;33(1):69-77.
In this longitudinal study of prenatal cocaine exposure (PCE), school-age physical and cognitive development and behavioral characteristics were examined, while controlling for other factors that affect child development. At this follow-up phase, children were on average 7.2 years old, and their caregivers were 33.7 years old, had 12.5 years of education, and 48% were African American. During the first trimester, 20% of the women were frequent cocaine users (≥ 1 line/day). First trimester cocaine exposure predicted decreased weight and height at 7 years. There was no significant relationship between PCE and the cognitive and neuropsychological measures. Third trimester cocaine use predicted more total and externalizing behavior problems on the Child Behavior Checklist [3] and the Teacher Report Form [4], and increased activity, inattention, and impulsivity on the Routh Activity [67] and SNAP scales [55]. Children who were exposed to cocaine throughout pregnancy had more mother- and teacher-rated behavior problems compared to children of women who stopped using early in pregnancy or who never used cocaine prenatally. These detrimental effects of PCE on behavior are consistent with other reports in the literature and with the hypothesis that PCE affects development through changes in neurotransmitter systems. These school-age behaviors may be precursors of later adolescent behavior problems.
doi:10.1016/j.ntt.2010.06.003
PMCID: PMC3026056  PMID: 20600846
prenatal cocaine exposure; school age; growth; cognitive development; behavior problems
9.  Externalizing Behavior Problems Among Polydrug Cocaine-exposed Children: Indirect Pathways via Maternal Harshness and Self-Regulation in Early Childhood 
This study examined direct and indirect associations between prenatal cocaine exposure (CE) and children’s externalizing problems in kindergarten via higher maternal harshness and lower self-regulation in early childhood. Other environmental risk variables such as child exposure to community violence and experience of hunger were used as additional predictors. The sample consisted of 216 mother-infant dyads recruited at delivery from local area hospitals (116 cocaine-exposed, 100 non-exposed). Maternal harshness was coded from observations of mother-toddler interactions at 2 years of age, and children’s self-regulation was measured at 3 years of age using several laboratory paradigms. Maternal reports of externalizing behavior problems were obtained at both time points and at kindergarten. Teacher reports were obtained and classroom observations of externalizing behaviors were conducted in the kindergarten classroom. Results indicated significant indirect associations between CE and maternal reports of externalizing problems via higher maternal harshness at 2 years and higher externalizing problems at 3 years of child age. A second indirect path from CE to externalizing problems in the school setting via higher maternal harshness at 2 years and lower self-regulation at 3 years was also significant. There were significant associations between community violence exposure and maternal reports of externalizing problems, and between hunger and externalizing problems in the school setting. Results highlight the role of parenting and self-regulation in early childhood as critical process variables in the indirect association between CE and externalizing behavior problems in kindergarten.
doi:10.1037/a0032632
PMCID: PMC4174429  PMID: 23647157
Cocaine; Prenatal Exposure; Behavior Problems; Parenting; Self-Regulation
10.  Prenatal cocaine exposure and trajectories of externalizing behavior problems in early childhood: Examining the role of maternal negative affect 
Development and psychopathology  2014;26(2):515-528.
This study examined the association between prenatal cocaine exposure (PCE) and developmental trajectories of externalizing behavior problems from 18 to 54 months of child age. A hypothesized indirect association between PCE and externalizing trajectories via maternal negative affect was also examined. Caregiving environmental risk and child sex were evaluated as moderators. This study consisted of 196 mother-child dyads recruited at delivery from local area hospitals (107 cocaine exposed, 89 non-exposed) and assessed at 7 time points across the toddler to preschool periods. Results revealed no direct associations between PCE and externalizing behavior problem trajectories. However, results did indicate that PCE shared a significant indirect relationship with externalizing behavior problem trajectories via higher levels of maternal negative affect. The association between PCE and externalizing problem trajectories was also moderated by caregiving environmental risk such that PCE children in high-risk caregiving environments did not experience the well documented normative decline in externalizing behavior problems beginning at around three years of age. This study suggests potential pathways to externalizing behavior problems among high-risk children.
doi:10.1017/S0954579414000091
PMCID: PMC3981877  PMID: 24622033
Cocaine; Behavior Problems; Prenatal Substance Exposure; Trajectory; Externalizing
11.  Comparison of 12-Year-Old Children with Prenatal Exposure to Cocaine and Non-Exposed Controls on Caregiver Ratings of Executive Function 
Journal of youth and adolescence  2013;43(1):10.1007/s10964-013-9927-3.
Differences in caregiver reported executive function in 12-year-old children who were prenatally exposed to cocaine (PCE) compared to children who were not prenatally exposed to cocaine (NCE) were assessed. One hundred and sixty-nine PCE and 169 NCE, primarily African-American, low socioeconomic status children participated in a prospective longitudinal study. The Behavior Rating Inventory of Executive Function (BRIEF) Parent Form was administered. Two broadband BRIEF scores (Behavioral Regulation Index (BRI) and Metacognition Index (MI)) and a summary Global Executive Composite (GEC) were computed. Multiple and logistic regression analyses were used to assess the effects of amount of PCE on executive function, controlling for covariates including caregiver (rater) psychological distress, child’s gender and other prenatal drug exposure variables. After adjustment for covariates, amount of PCE was associated with the GEC and two MI subscales, Plan/Organize and Monitor, with heavier exposure associated with more problems of executive function. An amount of PCE by gender interaction revealed amount of PCE effects in other remaining subscales of the MI (Initiate, Working Memory, and Organization of Materials) only among girls. Head circumference did not mediate the effects of cocaine on outcomes. Higher current caregiver psychological distress levels were independently associated with poorer ratings on the executive function scales. Assessment and targeted interventions to improve metacognitive processes are recommended for girls who were prenatally exposed to cocaine.
doi:10.1007/s10964-013-9927-3
PMCID: PMC3715590  PMID: 23423839
Executive Function; Prenatal; Cocaine; BRIEF; Parental Rating
12.  Child Behavior Problems: Role of Cocaine Use, Parenting and Child Exposure to Violence 
Psychology of violence  2014;4(3):266-280.
Objective
Studies examining the association between prenatal cocaine exposure (PCE) and child behavior problems have yielded mixed results, suggesting a need to identify additional mediating and moderating influences. We hypothesized that the relation between PCE and behavior problems at kindergarten would be mediated/moderated by child exposure to violence; and that maternal warmth/sensitivity and harshness would moderate the association between violence exposure and behavior problems.
Methods
Participants consisted of 216 (116 cocaine-exposed, 100 non-cocaine exposed (NCE) mother-child dyads participating in an ongoing longitudinal study of PCE.
Results
Results yielded no direct or mediated/moderated association between PCE and child behavior problems, and no significant interaction effects between PCE and parenting quality. However, higher exposure to violence in kindergarten was significantly associated with higher child behavior problems. This association was moderated by maternal warmth/sensitivity and harshness. High maternal warmth/sensitivity buffered the association between violence exposure and behavior problems while high maternal harshness exacerbated this association.
Conclusion
This study highlights the role of violence exposure in the development of behavior problems among high-risk children, and emphasizes the significance of parenting quality in buffering or exacerbating this risk among these children. Implications for prevention include targeting the potential role of maternal warmth/sensitivity as a protective influence among children exposed to violence.
doi:10.1037/a0036157
PMCID: PMC4193800  PMID: 25313345
community and family violence; cocaine exposure; child; behavior problems; parenting
13.  Effects of prenatal cocaine exposure on child behavior and growth at 10 years of age 
Neurotoxicology and teratology  2013;0:10.1016/j.ntt.2013.08.001.
We examined physical growth and behavioral outcomes in 226 10-year-old children who were participants in a longitudinal study of prenatal cocaine exposure (PCE), while controlling for other factors that affect development. During the first trimester, 42% of the women used cocaine, with use declining across pregnancy. At the 10-year follow-up, the caregivers were 37 years old, had 12.8 years of education, and 50% were African American. First trimester cocaine exposure predicted decreased weight, height, and head circumference at 10 years. First trimester cocaine use also predicted maternal ratings of less sociability on the EAS Temperament Survey and more withdrawn behavior problems on the Child Behavior Checklist, more anxious/depressed behaviors on the Teacher Report Form, and more self-reported depressive symptoms on the Children’s Depression Inventory. In addition, exposure to violence mediated the effect of PCE on child and teacher reports of depressive symptoms, but not of maternal reports of sociability and withdrawn behaviors. These behaviors may be precursors of later psychiatric problems.
doi:10.1016/j.ntt.2013.08.001
PMCID: PMC3844023  PMID: 23981277
prenatal cocaine exposure; growth; behavior problems; depression
14.  A Review of the Effects of Prenatal Cocaine Exposure Among School-Aged Children abstract 
Pediatrics  2010;125(3):554-565.
CONTEXT
Studies through 6 years have shown no long-term direct effects of prenatal cocaine exposure (PCE) on children’s physical growth, developmental test scores, or language outcomes. Little is known about the effects of PCE among school-aged children aged 6 years and older.
OBJECTIVE
We reviewed articles from studies that examined the effects of PCE on growth, cognitive ability, academic functioning, and brain structure and function among school-aged children.
METHODS
Articles were obtained by searching PubMed, Medline, TOXNET, and PsycInfo databases from January 1980 to December 2008 with the terms “prenatal cocaine exposure,” “cocaine,” “drug exposure,” “substance exposure,” “maternal drug use,” “polysubstance,” “children,” “adolescent,” “in utero,” “pregnancy,” “development,” and “behavior.” Criteria for inclusion were (1) empirical research on children aged 6 years and older prenatally exposed to cocaine, (2) peer-reviewed English-language journal, (3) comparison group, (4) longitudinal follow-up or historical prospective design, (5) masked assessment, (6) exclusion of subjects with serious medical disabilities, and (7) studies that reported nonredundant findings for samples used in multiple investigations. Thirty-two unique studies met the criteria. Each article was independently abstracted by 2 authors to obtain sample composition, methods of PCE assessment, study design, comparison groups, dependent variables, covariates, and results.
RESULTS
Associations between PCE and growth, cognitive ability, academic achievement, and language functioning were small and attenuated by environmental variables. PCE had significant negative associations with sustained attention and behavioral self-regulation, even with covariate control. Although emerging evidence suggests PCE-related alterations in brain structure and function, interpretation is limited by methodologic inconsistencies.
CONCLUSIONS
Consistent with findings among preschool-aged children, environmental variables play a key role in moderating and explaining the effects of PCE on school-aged children’s functioning. After controlling for these effects, PCE-related impairments are reliably reported in sustained attention and behavioral self-regulation among school-aged children. Pediatrics 2010;125:554–565
doi:10.1542/peds.2009-0637
PMCID: PMC3150504  PMID: 20142293
cocaine; maternal exposure; prenatal exposure delayed effects; attention; behavior; growth; language; adolescent development
15.  Prenatal cocaine exposure: An examination of childhood externalizing and internalizing behavior problems at age 7 years 
SUMMARY
Aim
This study examines the relationship between prenatal cocaine exposure and parent-reported child behavior problems at age 7 years.
Methods
Data are from 407 African-American children (210 cocaine-exposed, 197 non-cocaine-exposed) enrolled prospectively at birth in a longitudinal study on the neurodevelopmental consequences of in utero exposure to cocaine. Prenatal cocaine exposure was assessed at delivery through maternal self-report and bioassays (maternal and infant urine and infant meconium). The Achenbach Child Behavior Checklist (CBCL), a measure of childhood externalizing and internalizing behavior problems, was completed by the child’s current primary caregiver during an assessment visit scheduled when the child was seven years old.
Results
Structural equation and GLM/GEE models disclosed no association linking prenatal cocaine exposure status or level of cocaine exposure to child behavior (CBCL Externalizing and Internalizing scores or the eight CBCL sub-scale scores).
Conclusions
This evidence, based on standardized ratings by the current primary caregiver, fails to support hypothesized cocaine-associated behavioral problems in school-aged children with in utero cocaine exposure. A next step in this line of research is to secure standardized ratings from other informants (e.g., teachers, youth self-report).
PMCID: PMC2641031  PMID: 16584100
cocaine; prenatal exposure; child behavior
16.  Externalizing Behavior and Substance Use Related Problems at 15 Years in Prenatally Cocaine Exposed Adolescents 
Journal of adolescence  2014;37(3):269-279.
The effect of prenatal cocaine exposure (PCE) on externalizing behavior and substance use related problems at 15 years of age was examined. Participants consisted of 358 adolescents (183 PCE, 175 non-cocaine exposed (NCE)), primarily African-American and of low socioeconomic status, prospectively enrolled in a longitudinal study from birth. Regression analyses indicated that the amount of PCE was associated with higher externalizing behavioral problems (β=.15, p=.02). Adolescents with PCE were also 2.8 times (95% CI=1.38–5.56) more likely to have substance use related problems than their NCE counterparts. No differences between PCE adolescents in non-kinship adoptive or foster care (n=44) and PCE adolescents in maternal/relative care (n=139) were found in externalizing behavior or in the likelihood of substance use related problems. Findings demonstrate teratologic effects of PCE persisting into adolescence. PCE is a reliable marker for the potential development of problem behaviors in adolescence, including substance use related problems.
doi:10.1016/j.adolescence.2014.01.004
PMCID: PMC3980446  PMID: 24636687
Prenatal cocaine exposure; externalizing behavior; substance use; parental monitoring; violence exposure
17.  Importance of Stability of Early Living Arrangements on Behavior Outcomes of Children With and Without Prenatal Drug Exposure 
Objective:
We evaluated whether living arrangements of children with or without prenatal drug exposure would be associated with their behavior outcomes and adaptive functioning.
Methods:
1388 children with or without prenatal cocaine or opiate exposure were enrolled in a longitudinal cohort study at one month of age, were seen at intervals, tracked over time for their living situation, and evaluated for behavior problems and adaptive functioning at three years of age. Child Behavior Check List and Vineland Adaptive Behavior Scales (VABS) were administered. Using multiple regression models, we determined the factors that would predict behavior problems and adaptive functioning.
Results:
1,092 children were evaluated. Total and externalizing behavior problems T scores of children in relative care were lower (better) than those in parental; externalizing behavior scores were lower than those in non-relative care (p<0.05). Total behavior problem scores increased 2.3 and 1.3 points respectively with each move/year and each year of Child Protective Services’ involvement. Compared to children in non-relative care, those in parental or relative care had higher (better) scores in the VABS total composite (p<0.023), communication (p<0.045), and daily living (p<0.001). Each caretaker change was associated with a decrease of 2.65 and 2.19 points respectively in communication and daily living scores.
Conclusion:
Children’s living arrangements were significantly associated with childhood behavior problems and adaptive functioning. The instability of living situation was also a significant predictor of these outcomes. While family preservation continues to be the goal of the child welfare system, expediting decision toward permanency remains paramount once children are placed in foster care.
doi:10.1097/DBP.0b013e3181644a79
PMCID: PMC3984541  PMID: 18349707
Prenatal cocaine; prenatal opiate; out-of-home-care; child behavior
18.  Socioemotional Effects of Fathers' Incarceration on Low-Income, Urban, School-Aged Children 
Pediatrics  2007;120(3):e678-e685.
OBJECTIVE
The goal was to evaluate whether children of incarcerated fathers are more likely to report or exhibit behavioral symptoms than their equally disadvantaged peers without an incarcerated father.
METHODS
During an ongoing longitudinal study of intrauterine cocaine exposure involving 102 children (50% male and 89% black) from urban, low-income homes, questions regarding incarceration of the child's father were asked of the child's primary caregiver at each visit during school age. Children were administered the Children's Depression Inventory between the ages of 6 and 11 years, and their primary caregivers completed the Child Behavior Checklist. In addition, the children's teachers completed the Teacher Report Form. Children's Depression Inventory, Child Behavior Checklist, and Teacher Report Form data obtained at the oldest available age after the first report of paternal incarceration were analyzed.
RESULTS
In bivariate analyses, children whose fathers were in jail had higher Children's Depression Inventory total scores compared with children without incarcerated fathers, indicating more depressive symptoms. This finding was robust in multivariate analyses after adjustment for children's age, gender, prenatal cocaine and alcohol exposure, and school-age violence exposure. Teachers reported higher Teacher Report Form externalizing scores for children whose fathers were in jail, after adjustment for age, gender, prenatal cocaine and marijuana exposure, and school-age violence exposure.
CONCLUSIONS
Children of incarcerated fathers reported more depressive symptoms and their teachers noted more externalizing behaviors, after controlling for other biopsychosocial risks. Interventions targeted to ameliorate the distress of children with incarcerated fathers should be considered.
doi:10.1542/peds.2006-2166
PMCID: PMC2423929  PMID: 17766508
child depression; externalizing behavior; paternal incarceration; alcohol; marijuana; cocaine
19.  Systematic Review of Prenatal Cocaine Exposure and Adolescent Development 
Pediatrics  2013;131(6):e1917-e1936.
BACKGROUND AND OBJECTIVE:
Previous research found that prenatal cocaine exposure (PCE) may increase children's vulnerability to behavior and cognition problems. Maturational changes in brain and social development make adolescence an ideal time to reexamine associations. The objective was to conduct a systematic review of published studies examining associations between PCE and adolescent development (behavior, cognition/school outcomes, physiologic responses, and brain morphology/functioning).
METHODS:
Articles were obtained from PubMed, PsycInfo, Web of Science, and CINAHL databases through July 2012 with search terms: prenatal drug, substance, or cocaine exposure; adolescence/adolescent; and in utero substance/drug exposure. Criteria for inclusion were nonexposed comparison group, human adolescents aged 11 to 19, peer-reviewed, English-language, and adolescent outcomes.
RESULTS:
Twenty-seven studies representing 9 cohorts met the criteria. Four outcome categories were identified: behavior, cognition/school performance, brain structure/function, and physiologic responses. Eleven examined behavior; 7 found small but significant differences favoring nonexposed adolescents, with small effect sizes. Eight examined cognition/school performance; 6 reported significantly lower scores on language and memory tasks among adolescents with PCE, with varying effect sizes varied. Eight examined brain structure/function and reported morphologic differences with few functional differences. Three examined physiologic responses with discordant findings. Most studies controlled for other prenatal exposures, caregiving environment, and violence exposure; few examined mechanisms.
CONCLUSIONS:
Consistent with findings among younger children, PCE increases the risk for small but significantly less favorable adolescent functioning. Although the clinical importance of differences is often unknown, the caregiving environment and violence exposure pose additional threats. Future research should investigate mechanisms linking PCE with adolescent functioning.
doi:10.1542/peds.2012-0945
PMCID: PMC3666107  PMID: 23713107
prenatal cocaine exposure; adolescent development
20.  Early adolescent cocaine use as determined by hair analysis in a prenatal cocaine exposure cohort 
Neurotoxicology and teratology  2010;33(1):88-99.
Background
Preclinical and other research suggest that youth with prenatal cocaine exposure (PCE) may be at high risk for cocaine use due to both altered brain development and exposure to unhealthy environments.
Methods
Participants are early adolescents who were prospectively enrolled in a longitudinal study of PCE prior to or at birth. Hair samples were collected from the youth at ages 10½ and 12½ (N=263). Samples were analyzed for cocaine and its metabolites using ELISA screening with gas chromatography/mass spectroscopy (GC/MS) confirmation of positive samples. Statistical analyses included comparisons between the hair-positive and hair-negative groups on risk and protective factors chosen a priori as well as hierarchical logistical regression analyses to predict membership in the hair-positive group.
Results
Hair samples were positive for cocaine use for 14% (n=36) of the tested cohort. Exactly half of the hair-positive preteens had a history of PCE. Group comparisons revealed that hair-negative youth had significantly higher IQ scores at age 10½; the hair-positive youth had greater availability of cigarettes, alcohol, and other drugs in the home; caregivers with more alcohol problems and depressive symptoms; less nurturing home environments; and less positive attachment to their primary caregivers and peers. The caregivers of the hair-positive preteens reported that the youth displayed more externalizing and social problems, and the hair-positive youth endorsed more experimentation with cigarettes, alcohol, and/or other drugs. Mental health problems, peer drug use, exposure to violence, and neighborhood characteristics did not differ between the groups. Regression analyses showed that the availability of drugs in the home had the greatest predictive value for hair-positive group membership while higher IQ, more nurturing home environments, and positive attachment to caregivers or peers exerted some protective effect.
Conclusion
The results do not support a direct relationship between PCE and early adolescent experimentation with cocaine. Proximal risk and protective factors—those associated with the home environment and preteens' caregivers—were more closely related to early cocaine use than more distal factors such as neighborhood characteristics. Consistent with theories of adolescent problem behavior, the data demonstrate the complexity of predicting pre-adolescent drug use and identify a number of individual and contextual factors that could serve as important foci for intervention.
doi:10.1016/j.ntt.2010.07.003
PMCID: PMC3675882  PMID: 20647046
Prenatal cocaine exposure; Early adolescents; Hair; Drug testing; Substance abuse
21.  Effects of prenatal cocaine/polydrug exposure on substance use by age 15 
Drug and alcohol dependence  2013;134:201-210.
Objective
Examined effects of prenatal cocaine exposure (PCE) on tobacco, alcohol, marijuana and cocaine use by age 15.
Methods
Adolescent (n = 358; 183 PCE, 175 non-prenatally cocaine exposed; NCE) drug use was assessed using urine, hair, and/or blood spot samples and self-report (Youth Risk Behavior Surveillance System; YRBSS) at ages 12 and 15. Logistic regression assessed effects of PCE on drug use controlling for other drug exposures, environment and blood lead levels (BLL).
Results
Adjusted percentages of drug use (PCE vs. NCE) were: tobacco 35% vs. 26% (p < .04), marijuana 33% vs. 23% (p < .04), alcohol 40% vs. 35% (p < .01), and any drugs 59% vs. 50% (p < .005). PCE adolescents were twice as likely to use tobacco (OR = 2.02, 95% CI = 1.05–3.90, p < .04), 2.2 times more likely to use alcohol (OR = 2.16, 95% CI = 1.21–3.87, p < .01) and 1.8 times more likely to use marijuana (OR = 1.81, 95% CI = 1.02–3.22, p < .04) than NCE adolescents. A race-by-cocaine-exposure interaction (p < .01) indicated PCE non-African American adolescents had greater probability of tobacco use (65%) than NCE non-African American youth (21%). PCE was associated with any drug use (OR = 2.16, CI = 1.26–3.69, p < .005), while higher BLL predicted alcohol use (p < .001). Violence exposure was a predictor of tobacco (p < .002), marijuana (p < .0007) and any drug (p < .04).
Conclusions
PCE and exposure to violence increased the likelihood of tobacco, marijuana or any drug use by age 15, while PCE and higher early BLL predicted alcohol use. Prevention efforts should target high risk groups prior to substance use initiation.
doi:10.1016/j.drugalcdep.2013.09.031
PMCID: PMC3941005  PMID: 24176200
Prenatal cocaine exposure; Adolescent substance use; Violence; Lead
22.  Preschoolers’ Psychosocial Problems: In the Eyes of the Beholder? Adding Teacher Characteristics as Determinants of Discrepant Parent–Teacher Reports 
In this study, we explored informant characteristics as determinants of parent–teacher disagreement on preschoolers’ psychosocial problems. Teacher characteristics were included in the analyses, in addition to child and parent factors. Psychosocial problems of 732 4-year olds from a Norwegian community sample were assessed by parents and teachers (CBCL-TRF). Furthermore, teachers reported on their education, experience and relationship to the child. Parental stress and psychopathology were also measured. Teachers rated children considerably lower than their parents did, especially on internalizing problems. When teachers rated more child problems, this was strongly associated with conflict in the teacher–child relationship, which predicted disagreement more than other factors. The highest agreement was on boys’ externalizing problems. Girls’ behavior was rated much lower by teachers than boys’ behavior compared to parents’ ratings. Possible teacher perception biases are discussed, such as teacher–child conflict, non-identification of internalizing problems, and same-gender child preference.
doi:10.1007/s10578-011-0271-0
PMCID: PMC3332350  PMID: 22080387
Informant; Discrepancy; Disagreement; Psychopathology; Child; Preschool; Psychology; Psychiatry; Child and School Psychology
23.  Infant Neurobehavioral Dysregulation Related to Behavior Problems in Children with Prenatal Substance Exposure 
Pediatrics  2009;124(5):1355-1362.
OBJECTIVE
To test a developmental model of neurobehavioral dysregulation relating prenatal substance exposure to behavior problems at age 7.
PATIENTS AND METHODS
The sample included 360 cocaine-exposed and 480 unexposed children from lower to lower middle class families of which 78% were African American. Structural equation modeling (SEM) was used to test models whereby prenatal exposure to cocaine and other substances would result in neurobehavioral dysregulation in infancy, which would predict externalizing and internalizing behavior problems in early childhood. SEM models were developed for individual and combined parent and teacher report for externalizing, internalizing, and total problem scores on the Child Behavior Checklist.
RESULTS
The Goodness of Fit Statistics indicated that all of the models met criteria for adequate fit with 7 of the 9 models explaining 18 to 60% of the variance in behavior problems at age 7. The paths in the models indicate that there are direct effects of prenatal substance exposure on 7-year behavior problems as well as indirect effects, including neurobehavioral dysregulation.
CONCLUSIONS
Prenatal substance exposure affects behavior problems at age 7 through two mechanisms. The direct pathway is consistent with a teratogenic effect. Indirect pathways suggest cascading effects where prenatal substance exposure results in neurobehavioral dysregulation manifesting as deviations in later behavioral expression. Developmental models provide an understanding of pathways that describe how prenatal substance exposure affects child outcome and have significant implications for early identification and prevention.
doi:10.1542/peds.2008-2898
PMCID: PMC2874881  PMID: 19822596
Prenatal substance exposure; cocaine; neurobehavioral dysregulation; behavior problems
24.  Dose–Response Effect of Mother–Infant Clinical Home Visiting on Aggressive Behavior Problems in Kindergarten 
Objective
The Objective of this follow-up study was to assess the long-term effects of clinical infant home-visiting services on child outcomes at school entry.
Method
Participants were 63 five-year-olds from low-income families, half of whom were referred to parent–infant home-visiting services during the first 18 months of life due to concerns about the caretaking environment. Families received between 0 and 18 months of weekly home visits based on infant age at entry into the study. At age 5, children were rated by teachers on the Preschool Behavior Questionnaire for behavior problems in the classroom and by parents both on the Simmons Behavior Checklist for behavior problems at home and on the Achenbach Social Competence Items for positive play behaviors with friends.
Results
With initial family risk status and child gender controlled, teacher-rated hostile behavior problems decreased in dose–response relation to the duration of early home-visiting services, which accounted for 15% of the variance in child hostile behavior. Parents' reports of positive play behaviors were positively linearly related to service duration. Parents' reports of behavior problems were less reliably related to service duration than teacher reports.
Conclusions
Early home-visiting services reduced the incidence of aggressive behavior problems among socially at-risk children for up to 3.5 years after the end of services.
PMCID: PMC1896103  PMID: 15167086
aggression; intervention; preschool; conduct disorder; oppositional disorder
25.  Pre-divorce problems in 3-year-olds: a prospective study in boys and girls 
Objective
We examined to what extent internalizing and externalizing problems at age 3 preceded and predicted parental divorce, and if divorce and the time lapse since divorce were related to internalizing and externalizing problems at age 12.
Methods
Parental ratings of internalizing and externalizing problems were collected with the Child Behavior Checklist (CBCL) in a large sample (N = 6,426) of 3-year-old children. All these children were followed through the age of 12 years, at which parents completed the CBCL again, while teachers completed the Teacher’s Report Form. Children whose parents divorced between age 3 and age 12 were compared with children whose families remained intact.
Results
Girls whose parents divorced between ages 3 and 12 already showed more externalizing problems at age 3 than girls whose parents stayed married. Higher levels of externalizing problems in girls at age 3 predicted later parental divorce. Parental reports indicated that 12-year-olds with divorced parents showed more internalizing and externalizing problems than children with married parents. Levels of teacher-reported problems were not different between children with married versus divorced parents. However, children whose parents divorced between ages 3 and 12 showed more teacher-rated internalizing problems at age 12 when the divorce was more recent than when the divorce was less recent. Parental ratings of both internalizing and externalizing problems at age 12 were not associated with the time lapse since divorce.
Conclusion
Externalizing problems in girls precede and predict later parental divorce. Post-divorce problems in children vary by raters, and may depend on the time lapse since divorce.
doi:10.1007/s00127-010-0199-x
PMCID: PMC3056000  PMID: 20213327
Parental divorce; Pre-divorce problems; Internalizing and externalizing problems

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