Infants and Children in Context. Tara L. Kuther

to violence are controlled, suggesting that the postnatal environment contributes to children’s adjustment (Buckingham-Howes et al., 2013).

      Opioids

      Prenatal exposure to opioids—a class of drugs that includes the illegal drugs heroin and synthetic opioids such as fentanyl, as well as pain relievers available legally by prescription, such as oxycodone, morphine, and others—poses serious risks to development. Newborns exposed to opioids prenatally may show signs of addiction and withdrawal symptoms, including tremors, irritability, abnormal crying, disturbed sleep, and impaired motor control (Gupta, 2017; Raffaeli et al., 2017). Prenatal exposure to opioids is associated with low birthweight, smaller head circumference, and altered brain development in newborns (Monnelly et al., 2018; Nørgaard, Nielsson, & Heide-Jørgensen, 2015; Towers et al., 2019). Children exposed to opioids prenatally tend to show difficulty with attention, managing arousal, learning, and inhibitory control (Bazinet et al., 2016; Levine & Woodward, 2018). They perform more poorly than their peers on tasks measuring executive functioning (such as planning) in preschool (Konijnenberg & Melinder, 2015), score lower in measures of intelligence in late childhood (Nygaard, Moe, Slinning, & Walhovd, 2015), and show reduced volume and a smaller cortical surface area in adolescence (Nygaard et al., 2018; Sirnes et al., 2017).

      The challenge of determining the effects of prenatal exposure to illegal drugs is that most infants exposed to opioids or cocaine are also exposed to other substances, including tobacco, alcohol, and marijuana, making it difficult to isolate the effect of each drug on prenatal development. We must be cautious in interpreting findings about illicit drug use and the effects on prenatal development because many other contextual factors often co-occur with parental substance use and also pose risks for development. These risks include poverty, malnutrition, inconsistent parenting, stress, and diminished parental responsiveness (Smith et al., 2016). For example, parents who abuse drugs tend to provide poorer quality care, a home environment less conducive to cognitive development, and parent–child interaction that is less sensitive and positive than the environments provided by other parents (Hatzis, Dawe, Harnett, & Barlow, 2017). Children raised by substance-abusing parents are at risk for being subjected to overly harsh discipline and lack of supervision as well as disruptions in care due to factors such as parental incarceration, inability to care for a child, and even death (e.g., from a drug overdose or violence).

      Applying Developmental Science

      Maternal Drug Use While Pregnant

      We have seen that exposure to teratogens such as drugs and alcohol adversely affects the developing fetus. Is maternal substance use fetal abuse? For many states, the answer is yes. Although laws are generally intended to promote health and protect fetuses, some developmental scientists and policy analysts argue that state laws are punitive because they potentially threaten women with involuntary treatment or protective custody during pregnancy (Seiler, 2016). As of 2017, 34 states had laws related to reporting of alcohol consumption during pregnancy (Alcohol Policy Information System, 2018). One-half of states classify controlled substance use during pregnancy as child abuse, which may lead to removing the infant from parental custody or even terminating parental rights (Guttmacher Institute, 2018). In some cases, these consequences have been extended to include alcohol abuse and dependence (Paltrow & Flavin, 2013; Seiler, 2016).

      Both the American College of Obstetricians and Gynecologists (2011) and the American Medical Association (2014) argue that criminal sanctions for maternal drug use are ineffective because they increase the risk of harm by discouraging prenatal and postnatal care and undermining the physician–patient relationship. Such policies can cause women to develop a mistrust in medical professionals that ultimately harms their care if they become reluctant to seek medical care for themselves and their children. Others argue that these policies are discriminatory toward women of color and those in low socioeconomic status brackets because low-income African American and Hispanic women are disproportionately tested and tried for substance use (Paltrow & Flavin, 2013). For example, a study of one California county with universal screening policies requiring drug and alcohol testing for all pregnant women found that although Black and White women showed similar rates of drug and alcohol use, Black women were four times more likely than White women to be reported to child protective services after delivery (Roberts & Nuru-Jeter, 2012).

      Moreover, some experts argue that mandatory drug testing violates women’s rights because they are treated differently under the law compared with men because of their sex and pregnancy status (Hui, Angelotta, & Fisher, 2017). Punitive approaches to maternal substance use that favor criminal charges over substance abuse treatment may pit the interdependent interests of the mother and fetus against each other. Some argue that there is no evidence that punitive measures improve maternal or fetal outcomes. Instead, fetal outcomes as supported by substance abuse treatment that rewards abstention, invests in family and community supports, and promotes contact with health care and social support services hold the most promise (Bada et al., 2012; Hui et al., 2017).

      What Do You Think?

      1 In your view, is substance use during pregnancy a form of abuse? Why or why not?

      2 What do you think could be done to reduce the prevalence of substance use by pregnant women?

      Maternal alcohol and substance use harms prenatal development. Is it abuse?

      ©iStockphoto.com/vchal

      At the same time, quality care can lessen the long-term impact of prenatal exposure to substances (Calhoun, Conner, Miller, & Messina, 2015). Some evidence suggests, for example, that developmental differences in exposed infants are reduced and often disappear when medical and environmental factors are considered (Behnke & Smith, 2013). Disentangling the long-term effects of prenatal exposure to substances, subsequent parenting, and contextual factors is challenging. Researchers and health care providers who construct interventions must address the contextual and parenting-related risk factors to improve the developmental outlook for children exposed to drugs prenatally. The accompanying Applying Developmental Science feature examines the difficulties of addressing maternal drug use in the legal system.

      Maternal Illness

      Depending on the type and when it occurs, an illness experienced by the mother during pregnancy can have devastating consequences for the developing fetus. For example, rubella (German measles) prior to the 11th week of pregnancy can cause a variety of defects, including blindness, deafness, heart defects, and brain damage, but after the first trimester, adverse consequences become less likely (Bouthry et al., 2014). Other illnesses have varying effects on the fetus. For example, chicken pox can produce birth defects affecting the arms, legs, eyes, and brain; mumps can increase the risk of miscarriage (Mehta, 2016; Webster et al., 2018). In addition to posing risks to development, some sexually transmitted infections, such as syphilis, can be transmitted to the fetus during pregnancy (Tsimis & Sheffield, 2017). Others, such as gonorrhea, genital herpes, and HIV, can be transmitted as the child passes through the birth canal during birth or through bodily fluids after birth. Since some diseases, such as mumps and rubella, can be prevented with vaccinations, it is important for women who are considering becoming pregnant to discuss their immunization status with their health care provider.

      Some illnesses with teratogenic effects, such as the mosquito-borne Zika virus, are not well understood. Children born to women infected with the Zika virus are at greater risk of microencephaly, reduced head size (Prakalapakorn, Meaney-Delman, Honein, & Rasmussen, 2017). They may also show a pattern of defects now known as congenital Zika syndrome, which includes severe microcephaly characterized by partial skull collapse, damage to the back of the eye, and body deformities, including joints and muscles with restricted range of motion (Centers for Disease Control and Prevention, 2017d; Moore, 2017).

      Environmental Hazards

      Prenatal