A Rural-Based Study of Developmental Outcomes in Young Children Prenatally Exposed to Cocaine

Abstract

This study was designed to determine if differences in cognitive functioning, as measured by scores on the Mullen Scales of Early Learning (AGS, 1995), persist as developmental outcomes between young rural-based children prenatally exposed to cocaine (n = 32) and young children not prenatally exposed to cocaine (n = 32). The subjects (N = 64) were identified and selected into this study by social and public health caseworkers, Head Start directors and teachers, preschool and early intervention program professionals in the states of Alabama, Georgia, and Mississippi. Subjects were matched according to the following selection criteria: (a) gender, (b) race, (c) age (month and year), (d) maternal marital status (single, married, divorced), (e) maternal age (between 16 and 20) (f) present residence (both parents, mother, father, extended family, foster care), (g) live in communities with less than 2,500 residents, (h) maternal education, and (i) family yearly income. Results from MANCOVA procedures indicated that a significant number of young rural-based children prenatally exposed to cocaine exhibited developmental problems in cognitive functioning related to expressive and receptive language areas, and these cognitive functioning deficits persisted across the length of the study. These findings suggest that there is a possible negative long-term relationship between prenatally cocaine exposure and subsequent deficits in cognitive functioning in this population of young children.

Although the overall population of chronic cocaine users in urban areas is slowly declining, there is renewed concern regarding the vulnerability of individuals who live in rural communities to the spread of illicit substances such as cocaine (U.S. Department of Health and Human Services [HHS], 1999). For example, data analyzed by the National Center on Addiction and Substance Abuse [CASA] (2000) indicate that young children and youth who live in rural America are likelier to use crack cocaine (83%) and cocaine (50%) when compared with urban peers. The reason for these high percentages may be related to the relative ease in obtaining illicit substances in smaller communities. In fact, rural areas are now viewed as a new market away from escalating competition and tougher law enforcement found in urban areas of the United States (Chapman, 2000).

Illicit drug abuse among pregnant teen and young women is also an issue of special concern in rural areas. A study conducted by Skatrud, Bennett, and Loda (1998) found a significantly higher birthrate in rural teenagers between the ages of 15 and 17 (38 per 1,000) when compared to urban teens of the same age (29 per 1000). Another disconcerting finding from a National Institute on Drug Abuse [NIDA] study (1996) suggested that young Americans between the ages of 16-to-25 years of age exhibit the highest rate of cocaine abuse. Unfortunately, this age range is commensurate with the peak childbearing years for females thereby placing their unborn children at serious risk for health and/or developmental problems. Although the actual number of young women who abuse cocaine during their pregnancy has varied considerably, conservative estimates indicate that each year approximately 45,000 infants are born to females who abuse this illicit substance (National Institute on Drug Abuse, 1996).

Another mitigating factor regarding cocaine abuse in rural communities is poverty. The number of Americans living in poverty grew significantly in 2001, swelling to 32.9 million people. This represents nearly one out of every eight people in the United States. The southern region of the U.S. experienced the largest increase in poverty where rates rose to 13.5% from 12.8% (U.S. Census Bureau, 2002). Sadly, individuals who reside in rural America constitute the poorest segment of our society. For example, a study by Shaw (1996) indicated a poverty rate in rural areas was approximately 16%, as opposed to 12% in urban settings. This study also found that many individuals who reside in rural communities live just above the poverty line with the working poor making up 26% of rural residents as opposed to 18% who live in urban settings. Economic marginality often correlates with family stress that can have a devastating impact on a person's decision-making regarding illicit drug and early childbearing.

The importance of the postnatal environments and infant/child development cannot be overstated (Delaney-Black, Covington, & Ostrea, 1996; Griffith, 1992; Lester, 1998). Unfortunately, the effort to earn a living can contribute to maternal/ infant bonding difficulties (Gustavsson & MacEachron, 1997). These behaviors, coupled with the mother's continued use of cocaine could increase rates of maternal passivity, neglect, and abuse; each of these factors can serve as major impediments to their children attaining developmental milestones (Lewit, 1993; Mayfield & Chapman, 1998). A recent USGAO (1997) report indicated that many children who were exposed to cocaine live in poverty, and are at additional risk for experiencing serious physiological and developmental consequences as a result of these environments (e.g., lead poisoning). This combination of physiological and environmental risk factors often place many of these young children at substantial risk for the development of multiple, long-term difficulties (Lester, 1998). Research investigating the initial and long-term effects of prenatal cocaine exposure on both mothers and their exposed children began in earnest during the mid-1980s (Chapman, 2000). Results from numerous studies indicate that the primary initial effects of cocaine on pregnant females include vasoconstriction, increases in blood pressure, and respiratory rate problems (Chasnoff, Griffith, Freier, & Murray 1992; Bateman, Ng, Hansen, & Heagarty, 1993; Oro & Dixon, 1987). Needless to say, these effects place the developing fetus at increased risk for a variety of complications, including premature birth. However, the long-term effects of prenatal cocaine exposure on the physiological, cognitive, and behavioral development of exposed newborns and developing infants has focused primarily on the first 12 months of life, and findings from research have been mixed.

Despite the mixed results regarding the impact of prenatal cocaine exposure on development infants and young children, an emerging focus of recent investigations has centered on a link between cocaine and subtle, long-term contextual difficulties (Chapman, 2000; Delaney-Black et al., 2000; Lester, LaGasse, & Seifer, 1998; Singer, Arendt, Minnes, Salvator, Siegel, and Lewis, 2001; Trad, 1992). These researchers hypothesize that the effects of prenatal cocaine exposure may not be evident in infants during the first months or year of life, but emerge in later years as the young child develops and matures. To illustrate, Malakoff, Mayes, and Schottenfeld (1994) investigated 21 young children (age range = 29-70 months) whose mothers attended cocaine/drug treatment programs. Findings revealed that 60% of these young children exhibited cognitive deficits related to language development, and these deficits appear to increase with the child's age.

In order to ascertain the effects of prenatal cocaine exposure on the full context of development, there is a need for research beyond the first 12-months of life. Furthermore, Chapman (2000) suggested that the majority of investigations concerning the impact of prenatal cocaine exposure on developing infants and children have been conducted primarily in public medical facilities and/ or drug treatment programs located in large metropolitan areas and not in rural areas of the United States. As Toufexis (1991) noted, cocaine is an "equal opportunity drug," and its use crosses all socioeconomic and ethnic groups. Within this context, the purpose of this study was to determine whether children who had been prenatally exposed to cocaine would exhibit a difference from non-exposed children in areas of cognitive functioning. Specifically, this study sought to answer the following question: Are there developmental delays in cognitive development in rural-based children who were prenatally exposed to cocaine when compared to non-exposed children?

Method

Participants

Public health nurses/caseworkers, Head Start directors and teachers, preschool and early intervention program professionals in the states of Alabama, Georgia, and Mississippi screened agency/ program data and records for young children who might serve as potential participants in this study. These professionals screened data for young children with documentation of prenatal cocaine exposure. The documentation method included: (a) infant urine toxicology report indicating positive cocaine exposure with (b) the mother admitting to cocaine use, and/or report of mother's cocaine use by agency/program professionals. These same agencies and programs screened their data and records and recommended young children who were not prenatally exposed to cocaine for potential participation in this study. Once it was ascertained that a young child met study selection criteria, permission was requested from parents/legal guardians to release to the primary investigator names of the potential participants. This step was initiated in order to receive names of prospective participants without breaching confidentiality. The primary investigator scheduled an initial information session with each prospective family/guardians of children exposed and non-exposed to cocaine, and the study was explained in detail. After giving permission for their children to participate, parents/ guardians who met study criteria received a copy of the Informed Consent Statement.

From a pool of possible participants, 32 matched pairs of young children (N = 64) were formed. Pairing of cocaine-exposed (Group I) and non-exposed (Group II) participants was based on both sets of participants having exact matches on nine variables. These variables were (a) gender, (b) race, (c) age (month and year), (d) maternal marital status (single, married, divorced), (c) maternal age (between 16 and 20), (f) present residence (both parents, mother, father, extended family, foster care), (g) live in communities with less than 2,500 residents, (h) maternal education, and (i) family yearly income. The majority of matched-paired participants were female (67%) with an ethnic composite of African-American (50%), Caucasian (31%), and Hispanic-American (19%). Regarding present residence, 56% of participants were residing with a single mother, 13% were living with extended family, and none of these two combined groups of participants (69%) were living with their male parent or foster care. The remaining 31% of participants were residing with both natural parents. All mothers were between the ages of 16 and 20 with 38% never married, 19% were married, and 43% were divorced. All study participants lived in rural settings (under 2,500), and a large number (78%) did not complete high school. All family groups lived below the poverty line according to federal guidelines.

Instrument

The Mullen Scales of Early Learning (MSEL) (American Guidance Service [AGS], 1995) was the assessment instrument employed in this study. The MSEL measures cognitive functioning for infants and preschool children from birth to 68 months of age. The instrument identifies a child's strengths and weaknesses through assessing early intellectual development and readiness for school. Test-retest reliability ranged from .83 to .99, indicating excellent reliability across time. Interscorer reliability estimates ranged from .98 to .99, indicating the results are comparable across examiners. The four cognitive constructs, Visual Reception, Fine Motor, Receptive Language, and Expressive Language, arc clearly defined and identified and are established in a conceptual framework. Internal consistency was measured to provide empirical support for the four constructs. Regarding content validity, the content of the tasks within each domain is very specific and the purpose for which the test is to be used is evident. Validity designed studies were created by the author in which independent and dependent variables were obtained and used to establish evidence of criterion-related validity. The MSEL has a strong theoretical base in neurocievelopment and intrasensory/ intersensory learning.

The MSEL consist of a Gross Motor Scale (GMS) and four cognitive scales: Visual Reception Scale (VRS), Fine Motor Scale (FMS), Receptive Language Scale (RLS), and Expressive Language Scale (ELS). The Gross Motor Scale (GMS) measures central motor control and mobility in a number of developmental positions. As children over the age of 39 months generally become more secure and coordinated in the gross motor skills, the MSEL does not define developmental stages on the Gross Motor Scale (GMS) for children beyond the age of 39 months, 30 days. As the age of participants in this study ranged from 24 month, 0 days to 55 month, 30 days, the GMS was not used as part of assessment procedures or analyses in this study.

The Fine Motor Scale (FMS) measures visual-motor abilities (unilateral/bilateral manipulation and writing readiness). The FMS reflects the expressive (output) side of visual organization. The Fine Motor items involve visual discrimination and motor control. The Visual Reception Scale (VRS) assesses performance in processing visual patterns (visual organization skills). The primary ability areas covered by the VRS are visual discrimination and visual memory. These abilities involve visual organization, visual sequencing, and visual spatial awareness, including concepts of position, shape, and size. The Receptive Language Scale (RLS) measures the ability to process linguistic input. The primary ability areas covered in this Scale are auditory comprehension and auditory memory. These abilities involve auditory organization, sequencing, and use of spatial concepts. The last scale, Expressive Language Scale (ELS) measures the ability to use language productively. The primary ability areas covered in the scale are speaking ability and language formation, including the ability to verbalize concepts. Each of the five scales yields a test age score.

Procedure

The study employed a quasi-experimental, non-equivalent group design, and was conducted in three states located in the southeast region of the United States. Primary assessment procedures took place during a 6-month span (June, 2002 through November, 2002); participant age range = 24 months to 57 months. Each assessment procedure (N = 64) was administered by the primary investigator. Participants were assessed during the morning hours in their place of residence. The MSEL four scales (VRS, FMS, RLS, ELS) took 20 to 45 minutes to complete. No attrition occurred during the 6-month course of the study.

Several design procedures were employed to enhance the validity and reliability of the study and to decrease systematic error by controlling confounding variables. First, participants were exact matches on the nine variables previously described. Second, interscorer reliability estimates were obtained via the employment of an alternating role system. The primary investigator administered and scored the MSEL, and an external evaluator also scored MSEL performance independently. The mean interscorer agreement was 98.6. Third, assessments were scheduled during the same day and month for each corresponding matched participant in the study.

Results

The independent variable was group membership (i.e., Group 1 = cocaine exposed children; Group II = non-cocaine exposed children). Dependent variables (DVs) were levels of cognitive functioning as measured by the MSEL: Visual Reception Scale (VRS), Receptive Language Scale (RLS), Expressive Language Scale (ELS), and Fine Motor Scale (FMS). To further decrease the potential relationship between age and the four DVs, and to control for the effects of the extraneous variable by partitioning out the variation attributed to this variable, "age" was employed as the covariant in the analyses.

To determine if cognitive functioning of young children prenatally exposed to cocaine significantly differed from those of non-exposed children, data from assessment procedures were subjected to the SPSS computer program (SPSS Inc., 1999). Multiple analyses of covariance (MANCOVA) statistical procedures for "group" and covariant "age" were conducted. Table 1 displays the mean MSEL t-scores and standard deviations for assessment data on the DVs for the two groups. A preliminary analysis evaluating the MANCOVA test assumptions of assessment data indicated linearity, homogeneity-of-slopes, and the homogeneity of variance-covariance assumptions were met satisfactorily. Significant differences were found between the two groups on the dependent measures, Wilkes' 1 = .843, F(4, 58) = 3.37, p

Discussion

The primary question posed in this study was whether or not there were developmental delays in cognitive development in rural-based children who were prenatally exposed to cocaine and live in rural communities when compared to non-exposed children? Analysis of assessment data indicated that group membership had a significant effect on measures of cognitive functioning pertaining to expressive and receptive language skills between Group I (prenatally exposed to cocaine) and Group II (non-exposed), and "age" had no significant effect between groups in these cognitive skill areas. Further analysis of assessment data indicated that a total of 8 participants (25% of Group I) were identified with negative cognitive functioning relative to expressive/ receptive language. No study participant in Group II exhibited negative cognitive functioning related to any of the four DV.

These findings are supported by existing data from several previous studies (Arendt, R.; Angelopoulos, J.; Salvator, A., & Singer, L., 1999; Chapman, 2000; Johnson et al., 1997; Kleigman et al., 1994; Martin, J. C., Barr, H. M., Martin, D.C., & Streissguth, A. P., 1996) that suggested a relationship between prenatal cocaine exposure and a cluster of developmental indicators (i.e., abnormal cognitive development). For example, Johnson and colleagues (1997) investigated the relationship between prenatal exposure, the environment, and language development. A matched sample of 24 drug exposed (cocaine) children were assessed and found to exhibit lower expressive and receptive skills than the non-exposed sample. In addition, Chapman (2000) investigated if differences in cognitive development exist between young children prenatally exposed to cocaine and a non-exposed sample (N = 112) employing the Bayley Scales of Infant Development (Psychological Corporation, 1993) and the MSEL. Results indicated that the sample of infants and toddlers prenatally exposed to cocaine exhibited developmental areas of concern on the Bayley's mental development index (MDI) and deficits in cognitive functioning (e.g., expressive and receptive language) on the MSEL.

When one considers the critical nature of language acquisition and future cognitive, social and emotional development, results from this study are particularly disconcerting. Language is a complex phenomenon, and is inextricably linked to cognitive development. This processing chain of language acquisition depends on the ability to perceive, to organize, to associate, and respond to complex stimuli, and coincides with other learning, is the primary basis of other learning, and consists of numerous, interrelated components (Delaney-Black et al., 2000). Consequently, problems in one or more language components may have subtle and significant long-term effects on other developmental areas. For example, young children who exhibit cognitive functioning deficits in expressive skills may have the content and social skills necessary for communication, but have a faulty auditory memory and/or auditory discrimination abilities which causes a child to exhibit a lack of appropriate sounds, words, or grammatical morphemes necessary to complete their communication process.

As receptive language domains represent the input system of our language acquisition and learning abilities, young children who exhibit these deficits may experience a number of problems in such areas as visual memory, visual reception and/or auditory comprehension. To illustrate, these deficits can make reading for comprehension difficult and can result in confusion sorting out words with multiple meanings and difficulties understanding mathematical terms. As problem solving is an essential higher order part of learning, these young children may be at-risk for difficulties verbalizing the steps or formalizing strategies to solve problems. Additionally, reading and writing are two of the highest levels of language abilities; however, these areas are dependent on the efficient development and functioning of all lower-level language functions. Any underlying weakness in early language attainment and refinement can cause significant problems in developing these higher skills areas.

Language is also a social behavior that forms the basic underpinning for social learning. It is of major concern that a significant number of rural-based participants in the Group 1 are at-risk for exhibiting cognitive deficits that could lead to language problems from within a social context. Among others, these children may experience problems in varying their language to match the individual they are communicating with or the context in which it is occurring, maintaining a topic during conversation, taking turns during a conversation, recognizing when a listener is not understanding and take action to clarify, and be a considerate speaker and listener (Bos & Vaughn, 2002). It is noteworthy that problems in using language appropriately can seriously impede development of social and peer relationships (Friend & Bursuck, 1999).

There are a number of factors that may have compromised the results of this study, and these must be considered as limitations. Although participants were matched on nine variables, the sample consisted of young children within rural communities in the southeastern region of the United States, and selection was not random. Also, the overrepresentation of participants who were African American, Hispanic, females, and living in the lower economic strata must be taken into consideration when interpreting the findings. Age was the only covariant used in the analysis. Other equally important variables such as number of siblings and parenting styles were not considered in the analyses. Additionally, the manner in which maternal cocaine use was routed (smoked or inhaled) could not be determined represents an additional limitation of the study. Finally, the period(s) during pregnancy in which the mother used cocaine was not investigated (i.e., during one or more of the three trimesters of pregnancy) must also be considered as a limitation of the study. Consequently, results from this study are not generalizable to all young children prenatally exposed to cocaine.

Despite these limitations, the results provide an impetus for replication and additional research. The key finding was a relationship between prenatal cocaine exposure and at-risk-status children for negative development in cognitive functioning related to receptive and expressive language skills. Given the potential importance of this finding, a number of recommendations should be considered. The first recommendation is related to a larger sample size. This would increase the probability that results could be generalized to other groups of young children with similar characteristics. There is also a critical need to investigate young children from varied cultural and socioeconomic backgrounds, and follow-up data collection with the same sample and their subsequent developmental patterns across time employing language specific assessment instruments. Research from within a variety of environments, including stable home conditions, focused on identifying various contributing factors that may attenuate or exacerbate the numerous risks factors associated with young children and cocaine exposure would be valuable. Clearly, it is important that the relationship of all areas of development and prenatal cocaine exposure be investigated to ascertain if developmental problems persist across time.

In conclusion, the cognitive component of language acquisition is one the most complex learning task children accomplish during their lifetimes. The developmental contexts of language acquisition are predictable and most children will progress successfully through diverse stages of language learning. However, findings from this study suggest that many rural-based children prenatally exposed to cocaine are at-risk for failure to develop cognitive functioning related to adequate development of language skills. Failure to develop these skills can impact attainment of language competencies needed to cope with language learning demands such as those required of formal teaching and literacy development. This can affect all areas of their cognitive, social, and emotional development throughout a child's life.

Acknowledgment

This study was partially supported by a research grant from the College of Education, The University of Alabama. The author would like to thank Mr. Thomas Cook, Ms. Betty Dobbs, Ms. Jane Otten, Ms. Kitty Petrone, Ms. Sybil Steele, Mr. Hank Wilcox, and Drs. Judy Giesen, and Lou Anne Worthington for their assistance, comments and suggestions regarding this study. Always close to my heart, the author gratefully and lovingly acknowledges the children who participated in this study and their families.

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J. Keith Chapman, Ph.D.

Department of Interdisciplinary Teacher Education

Programs in Special Education

College of Education

The University of Alabama

Tuscaloosa, Alabama

35487

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