Spotlight Exclusives

Poverty Is Worse for Children than Gestational Cocaine Exposure

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In the 1980s, cocaine use by expectant mothers reached near epidemic proportions. In Philadelphia, one in six pregnant women had a history of cocaine use or had cocaine in her urine. Users were more likely than non-users to be African American, poor, and to have received scant prenatal care. Deleterious effects of cocaine use on pregnancy were documented, with animal studies suggesting adverse effects on uterine blood flow and fetal oxygenation.

Lay groups and professionals alike prepared for a generation of severely affected newborns. Mariah Blake of the Columbia Journalism Review chronicled some of these stories: including Charles Krauthammer declaring that these children would face a “life of certain suffering, of probable deviance, of permanent inferiority,” and a National Institute on Drug Abuse research psychologist suggesting that “crack was interfering with the central core of what it is to be human.” The public outcry against cocaine-using women was deafening, but little attention was paid to the socioeconomic challenges faced by many of these same women.

What have we learned since then? A 24-year study I led, following more than 200 Philadelphia children, half with gestational cocaine exposure and half without, all from low socioeconomic circumstances, suggests that poverty is more influential on child outcomes than gestational cocaine exposure. And this influence, all negative, begins early.

Developmental evaluations conducted in participants every six months (from six through 30 months of age) showed, surprisingly, that the exposed and non-exposed groups did not differ from each other. Both groups, however, performed poorly when compared with a middle-class group, with deviations noted as early as 12 months of age. At age four, each child was given an IQ test. Once again, the exposed and non-exposed groups were similar (79 and 82, respectively), but both were below average when compared to the standard score of 100.  

Of the 150 low socioeconomic status children tested for IQ, only 32 performed in the average range. What distinguished these “achievers” from those scoring below average? Our research showed that the children with more enriching home environments and positive interactions with their caregiver were more likely to score in the average range. Moreover, children with frequent exposure to violence within the home and/or neighborhood had higher levels of anxiety and depression, lower levels of self-esteem, and were more likely to perform poorly in school than those with lower levels of exposure to violence. Over the years, even more nuanced evaluations analyzing play behavior, problem solving, neurocognitive performance, and stress reactivity have shown no statistical difference between cocaine-exposed and non-exposed groups.

On a more poignant note, more than 90 percent of the children between the ages of eight and ten felt they would most likely go to college or trade school, not use drugs, and not be arrested. By ages 16-18, however, a grimmer reality had emerged. Of the 97 participants evaluated at both time points, more than 30 percent had positive urine drug screens and/or had been adjudicated. And approximately 20 percent had experienced school failure and/or were parents themselves.

For the young people with these troubling outcomes, there were no differences between those with and without gestational cocaine exposure. However, greater exposure to violence and poorer home environments both increased the likelihood of these concerning outcomes.

By age 18, exposed and non-exposed youths had similar rates of academic impairment: 57 percent and 47 percent, respectively, compared with 16 percent in the general population. Exposure to violence, low quality of the early home environment, and changing caregivers were all associated with participant underachievement.

These findings cast serious doubt on the efficacy of current drug policy. The intense scrutiny on women using drugs would be better focused on the much greater number of women and families in socioeconomically challenging circumstances. Unfortunately, poverty is far more difficult to remedy than drug use.

What can be done for our children? Clearly an enriching home environment is a positive force in a child۪s life. Readily accessible parenting classes, an emphasis on literacy, and early intervention services are the foundations for creating such climates, particularly for those parents who may not have had such advantages in their own lives. Moreover, safety from violence beyond the front porch, however difficult to achieve, is also critical to providing such positive environments.

The country currently spends over $40 billion a year fighting the War on Drugs, a sum that would go a long way towards funding the early intervention programs outlined above. With budgets squeezed, now, more than ever, we need to rethink our policy priorities so that they align with the evidence rather than misplaced assumptions.

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Hallam Hurt is a Neonatologist at The Children۪s Hospital of Philadelphia and Professor of Pediatrics at the Perelman School of Medicine at the University of Pennsylvania.

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