Fetal Drug Exposure and Its Possible of the first 11 patients diagnosed with

Fetal Alcohol Syndrome showed that

Implications for Learning in the two had died, one could not be found for
Preschool and School-Age Population follow-up, and eight had shown growth
deficiency and dysmorphic features
(Streissguth, Clarren, & Jones, 1985). Of
Don C. Van Dyke and Alison A. Fox those eight patients, four were of bor-
derline intelligence and needed some
For the past 5 years there has been an exponential increase in the use of cocaine,remedial teaching, and the other four
phenylcyclidine hydrochloride (PCP), and other central nervous system (CNS) ac-were severely intellectually handicapped
and needed complete out-of-home care
tive drugs, A significant amount of this accelerated usage is in sexually active females,
resulting in some urban hospitals reporting positive drug screens in over 16% of (Streissguth et al., 1985).
the infants born on their busy obstetrical service. There is a growing body of dataA significant number of children who
showing that fetal exposure to cocaine, phenylcyclidine hydrochloride (PCP), and were diagnosed with fetal alcohol ex-
other CNS-active drugs results in infants and children with abnormal brain wave posure in the 1970s are having learning
patterns, short-term neurologic signs, depression of interactive behavior, and poor problems, behavioral problems, and at-
organizational responses to environmental stimuli. Whether such neurologic find- deficits in the 1980s. Educational
tention
ings will translate into a significant number of children with learning and behavioral evaluations of such children by Gold and
problems needs to be the focus of long-term longitudinal studies of children with Sherry (1984) suggested that maternal
fetal drug exposure to cocaine, PCP, and other CNS-active drugs. alcohol consumption causes behaviors in
children that result in the diagnosis of
learning disability (hyperactivity, short

S ince the escalation in the use of illic- Angeles area have reported as many as attention span, and emotional lability).
it drugs during the 1960s and 1970s, 10 to 15 new referrals per month for Recent reports indicate that hyperactivity
drug abuse has emerged as a major prob- children with a history of fetal drug ex- and distractibility are major handicaps in
lem in the United States (MacDonald, posure to PCP, heroin, and/or cocaine. the school careers of these children (Spohr
1987). Recent surveys indicate that be- During their pregnancies, mothers are & Steinhausen, 1987).
tween 20% and 40% of high school stu- reporting usage of PCP, cocaine, or
dents use alcohol or drugs excessively multiple other drugs. Surveys published
(Donovan & Jessor, 1978; Johnston, between 1967 and 1982 indicate that be- COCAINE
O'Malley, & Bachman, 1986; Kandel, tween three and six drugs were taken by
1986; Radial, Guess, Hubbard, & Maisto, pregnant women; the most commonly In the 1980s, there has been an in-
1982). This may be a conservative esti- used were alcohol, iron, and tobacco, crease in the use of cocaine for all socio-
mate. It has also been reported that 75% and the most frequently abused were economic classes, races, ages, and sexes
of patients seeking to obtain substance tobacco, alcohol, marijuana, heroin, and (Gold, 1987). Cocaine now surpasses
abuse treatment were previously uniden- cocaine (Goldman, 1980; Hill & Klein- heroin as America's leading street drug
tified by health care providers (Singer, berg, 1984; Nora, Nora, Somerville, Hill, (Tarr & Macklin, 1987). In the late 1980s,
Petchers, & Anglin, 1987). & McNamara, 1967). Some of the women "crack," a relatively pure and inexpensive
The County of Los Angeles Depart- surveyed reported taking 10 or more form of cocaine, emerged on the drug
ment of Health Services reported that medications during their pregnancy scene (Gold, 1987).
from April to June 1987, the drugs most (Bleyer, An, Lange, & Raisz, 1970; Hill, In some urban areas, cocaine is the
involved with overdosage were hallucino- 1973; Peckham & King, 1963). This ar- number one illicit drug used by women
gens, followed by cocaine and PCP/ ticle will review the hazards that com- of childbearing age (Adams & Durrell,
"angel dust" (Schulze, 1987). Epidemio- monly abused substances such as al- 1984; Pollin, 1985; Wish, Anderson,
logical studies of drug usage in the United cohol, cocaine, and PCP present to the Miller, & Johnson, 1984). In San Fran-
States have shown that, between 1976 unborn child. Professionals in programs cisco, officials have noted an alarming
and 1986, visits to the emergency room that evaluate and/or provide services to increase in the number of babies born to
for cocaine abuse increased more than these children need to be aware of the cocaine-addicted mothers. In San Fran-
fifteenfold (Colliver, 1987; National In- possible deficits in cognitive, social, and cisco County Hospital, 16% of the chil-
stitute on Drug Abuse, 1987). behavioral development consequent to dren born at that hospital were born to
With an increase in abuse, there is also such fetal drug exposure. cocaine-addicted mothers (American
an increase in fetal exposure, since most Academy of Pediatrics, 1988). With the
of the abusers are young, many are fe- increased use of cocaine, there is a grow-
male, and some are pregnant. The full ALCOHOL ing concern about the long-term effects
extent of the problem may be even of this drug on the fetus and the neonate.
greater than previously thought. Re- The first review of reported cases of Some neurochemical studies on cocaine
gional centers responsible for develop- Fetal Alcohol Syndrome was by Clarren in utero suggest that, if it is present dur-
mental evaluations on children in the Los and Smith (1978). A 10-year follow-up ing gestation, it may affect developing

160 Journal of Learning Disabilities

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fetal neuroreceptor-neurotransmitter sys-
tems. This could have significant impact
on the developing nervous system (Perry,
Pesavento, Kussie, LPPrichard, & Schnoll,
1984), and some believe that fetal and
neonatal growth retardation may result
in long-term neurologic and mental mor-
bidity. In some of these cases, the cen-
tral nervous system symptoms may be
limited to the first months of age (Le
Blanc, Parekh, Naso, & Glass, 1987), but
there is a growing body of evidence that
neurological and behavioral abnormali-
ties are a reflection of intrauterine neuro-
logical insult, which may become evident
later and can be manifested by poor
organization, reading problems, and dif-
ficulties in acquiring satisfactory mathe-
matical skills (Hill & Tennyson, 1986).
A recent 1-year study of 40 infants born
to cocaine-addicted mothers at Beth
Israel Medical Center in New York
found that "the babies were smaller than
most newborns, had abnormal brain
wave patterns, and showed short-term
neurologic signs such as irritability and
poor caretaker interaction" (Kandall,
1988, p. 12).
A study using the Brazelton Neonatal
Behavioral Assessment Scale revealed
that infants exposed to cocaine showed
significant depression of interactive be-
havior and poor organization responses
to environmental stimuli (Chasnoff,
Burns, Schnoll, & Burns, 1985). A more
recent study, by Bingol, Fuchs, Diaz,
Stone, and Gromisch (1987), concluded
that cocaine use in humans significantly
reduces the weight of the fetus, increases
the stillbirth rate related to abruptio
placentae, and is associated with a higher
malformation rate. In addition, mothers
who are multidrug users (cocaine plus
other drugs) have children with the most
adverse outcomes. Specifically, infants
with combined exposure to narcotics and
cocaine, or narcotics and methampheta-
mines, have been shown to have the
worst outcomes, with significantly in-
creased incidence of growth retardation
and other growth abnormalities (Oro &
Dixon, 1987).
A study of 39 newborns with intrau-
terine exposure to cocaine found 34 to
have signs of CNS irritability, such as in-
creased muscle tone, tremors, and irri-
tability in the first week of life (Dober-
czak, Shanzer, Senie, & Kandall, 1988).
Volume 23, Number 3, March 1990
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Seventeen of these newborns had abnor- ing smooth approximate digital-thumb
mal electroencephalograms (EEGs) dur- grasp, and tended to approach objects in
ing the first week, which continued to be a palmar fashion.
present (in a few) on follow-up at 8 days, In a study by Pinkert (1985), infants
19 days, 3 months, and one at 12 months exposed to PCP were found to demon-
(Doberczak et al., 1988). A study by Dix- strate more lability of state and poorer
on, Coen, and Crutchfield (1987) showed consolability than all other groups of
abnormal visual evoked responses (VERs) drug-exposed neonates. Neurobehavioral
and EEGs in 11 of 12 newborns with co- changes in these children clearly differen-
caine detected in their urine, with VER tiated them from other drug-exposed
abnormalities still detected in some in- children (Chasnoff, 1985). A study by
fants at 4 and 6 months of life. The Strauss, Modanlou, and Bosu (1986) re-
growing body of evidence by multiple in- ported neonatal symptoms of jitteriness,
vestigators demonstrates that the initial hypertonicity, and vomiting in infants
abnormalities noted in these children with fetal exposure to PCP. In some
deserve careful long-term follow-up. urban hospitals the frequency of drug ex-
These studies strongly suggest that co- posure in neonates is so high that a drug
caine usage has influenced the neurologic screen is a routine order in newborn
behavior of the newborn as well as the nurseries and neonatal units. Despite the
outcome of pregnancy. increasing awareness of the side effects
of PCP, a recent nationwide survey
showed that approximately 6% of high
PHENYLCYCLIDINE school seniors in the northeastern and
HYDROCHLORIDE (PCP) western regions of the United States have
taken PCP (Johnston, O'Malley, & Bach-
PCP ("angel dust") has become a fa- man, 1985).
vorite street drug in the last few years Animal studies of PCP provide further
(Schwartz, Hoffmann, Smith, Hayden, documentation of its deleterious effects.
& Riddile, 1987). A review of a drug PCP exposure during gestation has been
bulletin from the County of Los Angeles shown to adversely affect the develop-
Department of Health shows that PCP ment of behavioral reflexes in mice
is second only to hallucinogens in cases (Nicholas & Schreiber, 1983). When
of drug overdose (Schulze, 1987). It is given in very high prenatal doses, PCP
claimed that the unique neurobehavioral induced birth defects in a significant
changes of PCP infants during the neo- number of rats; when given in nontera-
natal period clearly differentiated them togenetic dosages it produced alterations
from children who were exposed to in postnatal behavioral development
opiates or cocaine (Howard, 1986). Chil- (Jordan, Young, Dinwiddie, & Harry,
dren with fetal exposure to PCP appear 1979).
extremely tremulous, are sensitive to
touch and environmental sounds, and
show increased muscle tone and abnor- DISCUSSION
mal eye movements. Developmental
evaluation at 9 months of age on 12 of There is a growing body of knowledge
these infants showed that, although their to indicate that fetal exposure to alcohol,
gross motor and personal/social skills cocaine, and PCP, and possibly other
were appropriate for their age, they CNS-active drugs, may lead to develop-
demonstrated uncoordinated fine motor mental deficits, abnormal neurologic
abilities that appeared to interfere with development, and school/learning prob-
normal development of adaptive be- lems. The strongest evidence for the con-
havior. Their language was also at low nection is between fetal exposure to
normal range. At 18 months and at 2 alcohol and the development of hyperac-
years of age, these infants consistently tivity and learning problems in school-
demonstrated fine motor, adaptive, and age children (Gold, 1987; Spohr & Stein-
language scores in the low normal range. hausen, 1987). The children we have the
These abnormal fine motor movements least information about are those with
were not a variant of normal: The chil- exposures to PCP. It is hoped that lon-
dren had particular difficulty in develop- gitudinal data over the next 3 to 5 years
161
will more clearly define the probability
of these children developing fine motor,
behavior, and school problems. An area
less discussed, but of equal concern, is
the mothers who are experimental poly-
drug users. For example, pregnant
mothers who have taken tripelennamine
and pentazocine ("Ts" and "blues") have
given birth to children who demonstrated
(on the Brazelton Neonatal Assessment
Scale) interactive deficits and withdrawal
similar to those of children with narcotic
exposure (Chasnoff, Hatcher, Burns, &
Schnoll, 1983). Polydrug users, partic-
ularly those women who use multiple
drugs and alcohol, are at significant risk
for having children with future develop-
mental and learning problems.
Fetal alcohol exposure is not a recent
phenomenon; it has been with us for cen-
turies. Now that research in many fields
has demonstrated the negative potential
of fetal alcohol exposure, we can iden-
tify those children we recognized 10 years
ago and help provide them with the in-
terdisciplinary evaluations, medical ser-
vices, and ongoing supportive and educa-
tional programs they need. Of more
recent concern is the exponential increase
in fetal exposure to other potentially
harmful substances such as PCP, co-
caine, and crack. The marked accelera-
tion of their use may produce a signifi-
cant increase in the number of children
with behavioral problems, learning prob-
lems, and attention deficit problems. It
is felt that over the next 3 to 5 years
longitudinal studies need to be conducted
to investigate the possible learning and
behavioral problems of these children.
Particular attention should be paid to
behavioral, cognitive, and perceptual
areas. If such fetal exposure translates in-
to significant numbers of children with
learning and behavioral problems, the
educational system needs to anticipate
providing additional services to meet the
needs of these children.
ABOUT THE AUTHORS
Don C. Van Dyke received his MDfrom the M.S.
Hershey Medical Center, Pennsylvania State Uni-
versity; pediatric residency training at the Geisinger
Medical Center; andfellowship(s) training in Clin-
ical Genetics and Child Development/Rehabilita-
tion at the Children's Hospital of Philadelphia,
University of Pennsylvania. He is an assistant pro-
162
fessor in the Department of Pediatrics, Division of Gold, M.S. (1987). Crack abuse: Its implications
Developmental Disabilities, The University of Iowa
Hospitals and Clinics. Alison A. Fox received her
MS from the University of Pennsylvania, Phila-
delphia. She was on the diagnostic staff of the
Marianne Frostig Center for Educational Therapy,
Pasadena, California. Address: Don C. Van Dyke,
213 University Hospital School, The University of
Iowa Hospitals and Clinics, Iowa City, I A 52242.
AUTHORS'NOTE
We wish to thank Dr. Mark L. Wolraich and Dr.
Joan E. Goodman for critical review of this manu-
script. We are also grateful to Ms. M. Joan Soucek
and Ms. Susan S. Eberly for technical and editorial
assistance.
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MEMORY SKILL INSTRUCTION FOR SCHOOL AGED CHILDREN
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by John Hanson Ph.D.
Volume 23, Number 3, March 1990
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written due to the frustration of teachers
t r y i n g t o find usable memory skill
instruction materials for school aged
children.
The Forgotten R: Remembering attempts
to meet this need by providing:
—a program that can be easily integrated
in the existing curriculum
— an extensive memory skill curriculum
covering verbal, visual and associative
memory skills
— over ]00 classroom activities designed to
enhance a child's knowledge of the skills
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Teaching Resources.
they already use and introduces thirteen
(13) specific memory strategies
Research has s h o w n t h a t d i r e c t
instruction of memory strategy use can
improve retention.
To order your book please enclose your
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163