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Effectiveness of a Home Intervention for Perceived Child Behavioral Problems and Parenting Stress in Children With In Utero Drug Exposure
Arlene M. Butz, RN, ScD;
Margaret Pulsifer, PhD;
Nicole Marano, BS;
Harolyn Belcher, MD;
Mary Kathleen Lears, MPH, MSN;
Richard Royall, PhD
Arch Pediatr Adolesc Med. 2001;155:1029-1037.
ABSTRACT
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Objective To determine if a home-based nurse intervention (INT), focusing on parenting
education/skills and caregiver emotional support, reduces child behavioral
problems and parenting stress in caregivers of in utero drug-exposed children.
Design Randomized clinical trial of a home-based INT.
Settings Two urban hospital newborn nurseries; homes of infants (the term infant
is used interchangeably in this study with the term child to denote those
from birth to the age of 36 months); and a research clinic in Baltimore, Md.
Participants In utero drug-exposed children and their caregivers (N = 100) were examined
when the child was between the ages of 2 and 3 years. Two groups were studied:
standard care (SC) (n = 51) and INT (n = 49).
Intervention A home nurse INT consisting of 16 home visits from birth to the age
of 18 months to provide caregivers with emotional support and parenting education
and to provide health monitoring for the infant.
Main Outcome Measures Scores on the Child Behavior Checklist and the Parenting Stress Index.
Results Significantly more drug-exposed children in the SC group earned t scores indicative of significant emotional or behavioral
problems than did children in the INT group on the Child Behavior Checklist
Total (16 [31%] vs 7 [14%]; P = .04), Externalizing
(19 [37%] vs 8 [16%]; P = .02), and Internalizing
(14 [27%] vs 6 [12%]; P = .05) scales and on the
anxiety-depression subscale (16 [31%] vs 5 [10%]; P
= .009). There was a trend (P = .06) in more caregivers
of children in the SC group reporting higher parenting distress than caregivers
of children in the INT group.
Conclusions In utero drug-exposed children receiving a home-based nurse INT had
significantly fewer behavioral problems than did in utero drug-exposed children
receiving SC (P = .04). Furthermore, those caregivers
receiving the home-based INT reported a trend toward lower total parenting
distress compared with caregivers of children who received SC with no home
visits.
INTRODUCTION
EACH YEAR, approximately 221 000 or 5.6% of US infants are born
to mothers who used illicit drugs during pregnancy.1
In some high-risk urban centers, rates of fetal exposure to illicit drugs
may be as high as 18%, based on maternal self-report and urine toxicology
results, to 31%, based on fetal meconium level.2, 3
These infants have multiple risk factors for compromised growth and intellectual
and social or behavioral development due to in utero drug exposure and a stressful
postnatal environment. Children living with substance-abusing parents are
more likely than others to live in disorganized households, which may include
parental criminal involvement and drug dealing; passive exposure to illicit
drugs; and parents who are ill, absent, depressed, or stressed.4
There is some evidence linking in utero drug exposure to compromised
behavioral outcomes; however, findings of the association between in utero
cocaine exposure only and behavioral problems are not convincing.5 Studies6, 7
of neonatal behavior in cocaine-exposed newborns report a dose-response relationship
between state regulation, as measured by the Brazelton Behavioral Scale, and
prenatal cocaine exposure. Caregivers of children exposed to cocaine reported
their children, at the age of 3 years, to be more aggressive and to show destructive
behavior.8 Teachers of elementary school–aged
children, blinded to cocaine exposure, rated the cocaine-exposed children
as having significantly more attention problems than nonexposed children.9 This was supported by Richardson et al,10
who demonstrated that in utero cocaine-exposed children made more errors of
omission on a continuous performance test, suggesting poorer levels of attention,
and by Chasnoff et al,11 who reported that
cocaine/polydrug exposure had a significant effect on children's behavior,
particularly impulse, frustration, and tension control, at the ages of 4,
5, and 6 years.
Parenting skills and stress are suggested to play a significant role
in determining whether a child has a behavior problem.9
Evidence indicates that levels of parenting stress were higher as reported
by mothers compared with foster mothers of drug-exposed children, and by a
comparison group of non–drug-exposed mothers of a similar socioeconomic
status.12
Data are conflicting for what constitutes effective parent educational
interventions (INTs) addressing child behavioral problems and parenting stress
in substance-abusing families with children. Because of the shortage of drug
treatment programs for pregnant and parenting women with children,13, 14 other types of treatment strategies,
including home-based INTs, have been evaluated. Increased maternal-infant
communication and lower continued drug use were demonstrated in polydrug-dependent
adolescent mothers who received an educational, vocational, and infant day
care INT.14 In a clinical trial15
of a home INT program for drug-using women with newborns, the home-visited
group provided marginally more stimulation to their children, yet child-related
stress was not influenced by the INT. No difference was seen in the quality
of home stimulation for high-risk infants (maternal homelessness or mental
illness) who received a home visit (HV) or a case management INT compared
with standard clinic care.16
Home INTs have been reported to reduce child behavioral problems in
unmarried teenaged mothers and their children17, 18
and in infants with failure to thrive.19 Nurse-visited
low-income children displayed fewer behavioral problems with toilet training
and extreme shyness as preschoolers than their counterparts who did not receive
HVs.20 Parenting stress was reduced during
the second year of follow-up in low-income families receiving HVs by paraprofessionals
in the Hawaii Healthy Start Program.21 Cautious
optimism is indicated for positive child outcomes following home-based INTs
for many high-risk groups, including low-income mothers, drug-dependent mothers,
and mothers with less than a high school education.15
This study determines if a home-based nurse INT, focusing on parenting
education/skills and caregiver emotional support, reduces child behavioral
problems and parenting stress in caregivers of in utero drug-exposed children.
We hypothesized that a nurse HV INT aimed at increasing parenting skills would
decrease the rate of child behavioral problems and the level of parenting
stress in families with drug-exposed children.
PARTICIPANTS AND METHODS
STUDY DESIGN
This randomized clinical trial, designed to examine the effectiveness
of a home nurse INT for in utero drug-exposed infants (the term infant is
used interchangeably in this study with the term child to denote those from
birth to the age of 36 months), recruited infants born to mothers who used
cocaine and/or opiates. The design was intent-to-treat in that families randomized
to the INT were included in the INT group regardless of the number of HVs
they received. After informed consent was obtained, mother-infant dyads were
randomized into the INT or standard care (SC) groups by selecting an envelope
with a computer-generated random number. Subjects with odd numbers were assigned
to the INT group, and those with even numbers were assigned to the SC group.
INTERVENTION
The home INT consisted of 16 home nurse visits from birth to the age
of 18 months, with more frequent visits during the infant's first 6 months
of life. Home visits were conducted by 2 pediatric nurse specialists (PNSs)
who were community health nurses experienced in conducting HVs with inner-city
populations and specifically trained and supervised in basic pediatric assessment
skills for in utero drug-exposed infants. Ongoing supervision of the PNSs
by a pediatric nurse practitioner (A.M.B.) was conducted on a monthly basis
to ensure the integrity of the INT delivered to each infant in the INT group
and for quality assurance purposes. The pediatric nurse practitioner was available
to the PNSs by beeper 24 hours a day for immediate problems. The PNSs established
a caring relationship with the caregiver, provided emotional support, modeled
positive parent-child interactions, and provided health monitoring of the
infant. Parenting information was provided, and specific skills were taught
to the mother or caregiver to enhance maternal-infant interaction. The parent
educational component of the home INT was based on the Hawaii Early Learning
Profile22 and the Carolina preschool curriculum.23 The Hawaii Early Learning Profile curriculum includes
activity sheets illustrating for the parent step-by-step instructions for
several hundred developmental skills. The Carolina preschool curriculum for
high-risk infants is based on effectiveness teaching principles for young
children (providing choices and building learning experiences into daily routines).
The PNS tailored the type of educational information provided to the mother
or caregiver at each visit according to the needs of the mother. The mean
number of HVs received by children in the INT group and their caregivers was
12.8 (SD, 3.2; range, 1-20), of the 16 scheduled visits, with nearly 90% of
the families receiving 9 or more visits and 86% of the families receiving
10 or more visits. Additional details of the home nurse program can be found
elsewhere.24
All children were examined for growth, development, and behavioral outcomes
every 6 months from birth through the age of 36 months. The emotional/behavioral
problems detected in this sample of children by the age of 36 months are reported
herein. The study was approved by the institutional review boards of The Johns
Hopkins Medical Institutions and the Bayview Medical Institution, Baltimore,
Md. From December 1, 1994, to January 31, 1997, 204 singleton newborns born
to cocaine- and/or opiate-using mothers were recruited with their mothers
from 2 urban hospitals into the ongoing home nurse clinical trial.
SAMPLE
Drug-Exposed Study Population
Eligibility for enrollment was based on maternal delivery of a neonate
at 1 of 2 urban hospitals, maternal age between 19 and 40 years, and maternal
use of cocaine and/or opiates during the index pregnancy. Adolescent and older
mothers were excluded because cost constraints for the larger study precluded
development of multiple age-specific INTs. To reduce confounding with child
behavioral and developmental outcomes, infants were excluded if they (1) were
younger than 35 weeks' gestational age; (2) required admission to the neonatal
intensive care unit for longer than 24 hours; (3) were discharged directly
into nonkinship foster care; or (4) were born to mothers with a major psychiatric
diagnosis, including schizophrenia and other psychotic disorders. Maternal
human immunodeficiency virus status was recorded when known.
Eligible mother-infant dyads were identified by postpartum staff based
on (1) medical record documentation of maternal self-report of prenatal cocaine
and/or opiate use or any positive prenatal urine toxicology screen results
and/or (2) a positive maternal urine toxicology screen result obtained during
labor or a positive infant urine toxicology screen result obtained within
24 hours of birth. Mothers who received no prenatal care were included only
if a positive urine toxicology screen result was obtained at the time of delivery
of the neonate. The standard of care at the 2 study hospitals included performing
urine toxicology screens on all women being delivered of a neonate at these
sites. If a maternal toxicology screen was not performed before delivery of
the neonate, an infant urine toxicology screen was performed in more than
90% of the cases. Concomitant alcohol and nicotine use was recorded. Type
of fetal drug exposure, based on maternal self-report and toxicology screen
results, was classified into 3 groups based on exposure to cocaine and opiates:
cocaine only, opiate only (heroin and/or methadone), and cocaine plus opiate.
Information was elicited on use of other drugs, including marijuana, barbiturates,
and amphetamines; however, we based our analysis on cocaine and/or opiate
use and controlled for in utero alcohol and nicotine exposure in the analyses.
Eligible mothers were informed of the study by 1 of 2 research nurses
and invited to participate. After the study was explained to the mother and
informed consent was obtained, a structured interview was conducted by trained
interviewers to determine demographic information and prenatal and lifetime
drug, alcohol, and tobacco use by the mother. For the latter, the Addiction
Severity Index,25 previously validated in male
veteran alcoholics and male and female drug-dependent populations, was used.
The Addiction Severity Index provides assessment of alcohol and other drug
use and severity ratings of multiple problems associated with alcohol- and
other drug–dependent persons. The Addiction Severity Index has been
extensively used in homeless substance abusers,26
rural substance abusers,27 urban outpatient
female substance abuse clinic patients in the United States,28
and Dutch drug-dependent persons.29 A certificate
of confidentiality was obtained from the National Institute on Drug Abuse,
Bethesda, Md, assuring participants that no personal information would be
shared with anyone outside the study team. Participants were informed of their
risk that any detection of child abuse or neglect by study personnel would
be reported. The timing of prenatal cocaine and/or opiate use was based on
(1) self-report by trimester of use and (2) urine toxicology screen results
obtained during labor by nursing staff.
Self-report
The Addiction Severity Index and additional drug use questions elicited
information on frequency, use by trimester, and route of use of alcohol, nicotine,
marijuana, cocaine, heroin, tranquilizers, barbiturates, and other illicit
substances during and before pregnancy and type, if any, of drug treatment
received before or during the pregnancy. Questions were designed to elicit
general patterns of use by each trimester of the pregnancy, asking about behavior
in a typical week, frequency of use for each substance in a day, and cost
of use of each substance per week. When mothers reported a change in type
of drug use during the pregnancy, the trimester during which the change in
use occurred was recorded. For each trimester, type of drug use was recorded
and coded (ie, cocaine only, opiate plus cocaine, or opiate only). Nicotine
use was also recorded by trimester of use.
Toxicology Screens
Maternal urine specimens (30 mL) were collected by labor and delivery
nursing staff and sent to the hospital laboratory for toxicology screening.
Each urine sample was tested using thin-layer chromatography for the following
substances: cocaine, opiates, barbiturates, and cannabinoids. Infant toxicology
screens were performed within 24 hours of birth for those infants in whom
a maternal toxicology screen was not obtained.
OUTPATIENT FOLLOW-UP
After informed consent was obtained from the caregiver at each visit,
the drug-exposed children were examined by research staff without knowledge
of type of in utero drug exposure; health and development and behavioral characteristics
were evaluated every 6 months from birth to the age of 36 months. Objective
standardized measures of child emotional/behavioral problems (Child Behavior
Checklist [CBCL]) and parenting stress (Parenting Stress Index [PSI]) were
administered to caregivers when the children were between the ages of 2 and
3 years. To improve completion and comprehension of the 2 measures, each instrument
was read aloud to all caregivers by one research staff member who was masked
to study group. This was done because the average caregiver's reading level
in this sample was previously evaluated to be at a fourth- to fifth-grade
level. Neither group had a greater familiarity with the interviewer administering
the CBCL or the PSI.
MEASURES
Child Behavior and Emotional Functioning
The CBCL is a written parent report measure designed to assess behavioral/emotional
problems in children.30 The CBCL takes approximately
15 minutes to complete. The CBCL for ages 2 to 3 years (100 items) yields
normalized t scores (mean, 50; SD, 10) that assess
behavioral problems in several specific areas. These scores are also combined
into 3 global scores: an Internalizing score for emotional problems, an Externalizing
score for behavioral problems, and a Total problem score. Higher scores indicate
greater emotional/behavioral problems, with t scores
of 60 or greater denoting clinically significant problems.30
Parental Stress
The PSI–Short Form (PSI-SF) is a written parental report measure
of the magnitude of stress in a parent-child system, and is completed by a
parent or other caregiver.31 The PSI-SF consists
of 36 items and takes about 15 minutes to complete. Parental stress is assessed
in 3 areas, each of which receives a subscale score: difficult child (child's
adaptability, manageability, and temperament), parental distress (self-perception
of competence in the parenting role, restrictions in life outside of the family,
and external and spousal support), and parent-child dysfunctional interaction
(degree to which the parent lacks satisfaction from interaction with the child
and the child falls short of parental expectations).31
The PSI-SF yields percentile scores for the 3 subscales, and for Total Stress.
Scores above the 90th percentile are generally considered indicative of significant
stress. Percentile scores were converted to standard scores (mean, 100; SD,
15) for data analysis purposes in this study.
Item analysis was conducted on one item from the PSI-SF (item 22). In
this item, caregivers are asked to evaluate their parenting skills. The parent
is asked to endorse 1 of 5 responses to the following statement: "I feel that
I am: (1) not very good at being a parent, (2) a person who has some trouble
being a parent, (3) an average parent, (4) a better than average parent, or
(5) a very good parent." Caregiver responses were recorded on this Likert
scale item for each caregiver completing the PSI-SF.
STATISTICAL ANALYSIS
Frequency distribution and the mean and SD of the CBCL and the PSI scores
were examined. Using  2 analysis and t
test analysis, we examined initially for differences between the respondents
and nonrespondents for child sex, race or ethnicity, gestational age, type
of in utero alcohol and other drug exposure and maternal age, educational
level, and marital status. Using an analysis of variance and 2
analysis, we determined if there were differences in CBCL and PSI Total and
subscale scores by group status, that is, SC or INT, and by dose of INT or
number of HVs. Based on the number of HVs received, children were categorized
into "high HVs" (received  9 HVs [90th percentile]) or "low HVs" (received  8
HVs [10th percentile]). The cutoff of 8 or fewer HVs was based on the frequency
of HVs received by the families. Using stepwise multiple logistic regression,
several models were tested to identify variables that could predict risk of
child emotional/behavioral problem, that is, earning a score of 60 or greater
on the Total CBCL. Candidate predictor variables in the regression models
included group status (SC or INT) or number of HVs, caregiver type, biological
mother's age, educational level, marital status, and child sex. These variables
were selected for inclusion in the models based on the bivariate analyses
and theoretical considerations. Odds ratios and corresponding 95% confidence
intervals are presented for those predictors that remained in the model at
the .05 significance level. Spearman  rank correlations were conducted
to determine if there was an association between Total CBCL scores and Total
PSI-SF and subscale scores. Statistical analyses were performed using the
Statistical Package for the Social Sciences.32
All reported P values used 2-tailed tests of significance.
RESULTS
SOCIODEMOGRAPHIC CHARACTERISTICS BY RETENTION STATUS
As seen in Figure 1, 248 mother-infant
dyads were eligible for participation in the study between December 1, 1994,
and January 31, 1997. Of these dyads, 233 (94%) were approached for enrollment
into the study; 15 mothers left or were discharged from the hospital before
consent could be obtained. Of the 233 mothers approached for enrollment, 204
(88%) consented. Of the 29 mothers who refused to participate, most (26 of
29 or 90%) denied drug use or feared disclosure of their drug use to family
members. This group did not differ significantly from the study group for
maternal age, race, type of drug use, and amount of prenatal care. Between
birth and the age of 36 months, 1 infant died, 6 infants moved out of the
study area, 14 caregivers refused to bring the child to the clinic for follow-up
examinations, and 66 infants could not be located. Children lost to follow-up
or not retained (n = 87) were significantly less likely to be in the care
of their biological mother than the retained children (n = 117) (P<.01), but were comparable for sex, race, gestational age, and
type of in utero drug exposure and maternal age, educational level, and marital
status (Table 1). Data for 100
children and caregivers who were examined to assess emotional/behavioral problems
and who have complete data on the CBCL and PSI measures are presented herein.
In addition to the examination of the child for emotional/behavioral problems,
caregivers were examined to assess their level of parenting stress when the
child was aged 2 to 4 years.
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Figure 1. Subject recruitment and retention
flow diagram from birth to age 36 months. SIDS indicates sudden infant death
syndrome; CBCL, Child Behavior Checklist; and PSI, Parenting Stress Index.
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Table 1. Sociodemographic and Health Characteristics by Respondent
Status*
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SOCIODEMOGRAPHIC CHARACTERISTICS BY GROUP STATUS
For the total sample, most infants were African American, full term,
and exposed in utero primarily to nicotine, followed by cocaine plus opiates,
opiate only, and cocaine only (Table 2).
Daily prenatal alcohol use was reported by 9% of mothers, with 28% reporting
occasional alcohol use (<1 time per week). Most mothers reported no alcohol
use during the pregnancy. The mean age of the mothers was 28.5 years, and
the mothers were primarily single and had less than a high school education.
More than two thirds of the infants were residing with their mother at the
age of 36 months; however, most mothers reported continued postnatal drug
use. One third of the mothers reported continued alcohol use during the follow-up
period. As seen in Table 2, there
were no significant differences between the SC and INT groups, with the exception
of more female children randomized to the INT group.
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Table 2. Sociodemographic and Health Characteristics by Group Status*
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There were no significant differences between children receiving a high
number of HVs and those receiving a low number of HVs for prenatal maternal
smoking or alcohol use; maternal marital status, educational level, and age;
infant sex, race, gestational age, and type of in utero drug exposure; and
continued postnatal maternal drug use. Caregiver type at the age of 36 months
was significantly different by number of HVs, with children in foster care
more likely to receive more HVs (P = .01). The lost
to follow-up rates were comparable (SC group, 59 of 108 children or 55%; and
INT group, 58 of 96 children or 60%).
CHILD EMOTIONAL/BEHAVIORAL PROBLEMS
Overall, the total sample did not demonstrate serious perceived emotional/behavioral
problems at the age of 30 months (CBCL Total mean t
score, 49.5; SD, 10.76), although 23% (23/100) of all children showed clinically
significant perceived emotional/behavioral problems,
defined as earning a CBCL Total t score of 60 or
greater. As seen in Table 3, mean t scores for the subscale "withdrawn" were significantly
higher in the SC group compared with the INT group. No significant differences
were noted by group status for Total, Internalizing, and Externalizing scales
and the anxiety-depression, sleep, somatization, aggression, and destruction
subscales.
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Table 3. CBCL Total Score and Subscale Normalized t Score Results by Group Status*
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Based on 2 analysis and scoring 60 or greater on CBCL
scales or subscales, significantly more children in the SC group earned t scores indicative of significant perceived emotional
or behavioral problems on the Total (P = .04), Externalizing
(P = .02), and Internalizing (P = .05) scales and on the anxiety-depression (P = .009) subscale than did children in the INT group (Figure 2). Of the 51 children in the SC group, 16 (31%) earned CBCL
Total t scores of 60 or greater, compared with only
7 (14%) of the 49 children in the INT group. Almost one quarter (23% [23/100])
of all children earned CBCL Total t scores of 60
or greater. More than one third (19 [37%]) of the SC group earned scores indicative
of an externalizing behavior problem (ie, is defiant, hits others, or is easily
frustrated) in contrast to 8 (16%) of the INT group. Anxiety-depression problems
were reported by 16 (31%) of the children in the SC group compared with 5
(10%) of the children in the INT group (P = .009).
There was no significant difference by category of number of HVs (low vs high)
or by continued maternal alcohol and other drug use for CBCL Total and all
subscales scores.
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Figure 2. Percentage of children with emotional/behavioral problems, defined as a Child Behavior Checklist
(CBCL) t score of 60 or greater, by group status.
The asterisk denotes P.05; the dagger, P<.01.
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PARENTING STRESS
Overall mean parenting stress scores were not elevated across all children
(PSI-SF Total standard score mean, 96.9; SD, 19.3). As seen in Table 4, there was a trend in caregivers of children in the SC group
reporting a significantly higher mean on the parent distress subscale compared
with caregivers of children in the INT group. Based on scoring at the 90th
percentile or higher or a standard score of 119 or greater, indicative of
high levels of parenting stress, there was no significant difference in Total
Stress scores or dysfunctional parent-child interaction, difficult child,
or parental distress subscale scores between the 2 groups. Almost one fifth
(19%) of all caregivers in this study reported dysfunctional parent-child
interactions. There was no significant difference by category of number of
HVs (low vs high), continued maternal alcohol and other drug use for Total
Stress, and all subscales.
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Table 4. PSI Total and Subscale Standard Scores by Group Status*
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Most caregivers rated their parenting skills as very good based on item
analysis of their self-rating of parenting skills (Table 5). There were no significant differences in parental skill
rating between the 2 groups (23 = 4.13, P = .25). Categorizing reports of parenting skills into 2 classifications
(trouble being a parent or average parent vs better than average or very good
at being a parent) also revealed no significant difference between the 2 groups
(21 = .05, P = .81). Caregiver
rating was not associated with high parenting stress (PSI-SF) scores in that
most caregivers with high Total PSI-SF scores (90th percentile) rated
themselves as very good parents (P = .76). Last,
caregiver ratings were not associated with mean CBCL Total scores.
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Table 5. Caregiver Evaluation of Parenting Skills by Group Status
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PREDICTORS OF A PERCEIVED CHILD EMOTIONAL/BEHAVIORAL PROBLEM
Using multiple logistic regression to predict the risk of perceived
child emotional/behavioral problem, that is, earning 60 or greater on the
CBCL Total scale, the only significant covariate was maternal age (odds ratio,
1.14; 95% confidence interval, 1.01-1.23; P = .04),
while controlling for group status (SC or INT), maternal educational level,
prenatal alcohol use, continued maternal drug use, and child sex. Similar
models adding prenatal smoking, type of in utero drug exposure, type of caregiver
at the age of 36 months, continued maternal alcohol and/or other drug use,
and number of completed HVs as covariates did not change maternal age as the
only significant covariate.
ASSOCIATION OF PERCEIVED EMOTIONAL/BEHAVIORAL PROBLEMS AND PARENTING
STRESS
The CBCL Total t score and the PSI-SF Total
standard score were highly correlated (Spearman = 0.42, P = .001). All clinical subscales of the PSI-SF were highly correlated
with the CBCL Total t score: parental distress (Spearman
= 0.29, P = .02), parent-child dysfunctional interaction
(Spearman = 0.26, P = .04), and difficult child
(Spearman = 0.46, P<.001).
COMMENT
Caregivers of in utero drug-exposed children receiving a home-based
nurse INT reported significantly fewer perceived specific behavioral problems
in their children compared with caregivers of drug-exposed children receiving
SC with no HVs. Specifically, the home nurse INT was effective in reducing
perceived externalizing and internalizing behavioral problems, most noticeably
in problems related to anxiety, depression, aggression, and being withdrawn.
More than one third (19 [37%]) of the children receiving SC were reported
to have externalizing behavioral problems, including defiant behavior, low
frustration tolerance, and aggressive behavior. This is in contrast to 8 (16%)
of the children receiving the home nurse INT. Our data are consistent with
previous reports11 that found that children
prenatally exposed to cocaine and other drugs had significantly higher scores
on the Internalizing and Externalizing domains and the CBCL Total scale. Although
children were observed up to the age of 36 months in this study, Olds et al 18 report data from a 15-year follow-up of a home-based
nurse INT on children's behavior. Infants born to unmarried adolescents who
received nurse visits prenatally and postnatally later reported fewer behavioral
problems related to the use of alcohol and other drugs at the age of 15 years.18
Although the home-based nurse INT was not associated with a significant
decrease in total parenting stress scores, a trend was noted in a decrease
in mean parental distress scores in the INT group. These results are most
likely due to the effect of the INT in fostering and improving the quality
of the mother-child interaction during the crucial early years,33
as suggested by the long-term follow-up data of Olds et al.18
Parental distress is influenced by parenting skills and by the parent's own
needs and coping strategies,34, 35
and is potentially the most direct way to affect child development and behavior.36
Caregivers who reported high parenting stress levels were more likely
to report significant behavioral problems in their child. Although the directionality
of the relationship cannot be determined (ie, does having a child with behavioral
problems increase parenting stress or does high parenting stress result in
children with emotional/behavioral problems?), caregivers of children with
in utero drug exposure did report high levels of parenting stress. Almost
1 of 4 caregivers (23%) reported significant child behavioral problems in
their child, indicating that this is a significant stress on these families.
The PSI measures multiple domains to assess stress in the parent-child
system. One item includes the caregivers' perception of themselves as a parent,
with lower parental rating generally being associated with higher parenting
stress. Despite reporting parenting stress, most drug-exposed caregivers in
this study believed they were and rated themselves as being good to very good
parents. Possible explanations for this discrepancy are offered. First, the
caregivers may be in denial of the less than optimal level of their parenting
skills, really believing their parenting abilities are good or very good.
Second, it may well be that caregivers with substance abuse in this study
are competent parents despite a high level of parenting stress.
These findings must be interpreted with caution. First, the sample size
is small, with a 49% follow-up rate at one particular follow-up time point,
reflecting the difficulty in retaining these families in longitudinal studies.
Although the nonretained infants may reflect the more "at-risk infants," based
on birth and maternal sociodemographic data, these infants were not significantly
different from the infants receiving follow-up visits. Although we attempted
to adjust statistically for some potential biases in our data, there may be
other confounders that biased our sample in unknown ways, such as "multiple
caregiving." Some families use multiple caregivers (biological mother, aunts,
and grandmother) to raise the child, yet our data are based on one caregiver's
perception of the child's behavior and this caregiver's level of parenting
stress. In addition, one other confounding factor was continued postnatal
maternal substance abuse. Based on self-report of ongoing drug use, approximately
two thirds of the biological mothers reported continued drug use during the
36-month follow-up. Last, child behavior and parenting stress self-report
measures were read aloud to all caregivers. This may have resulted in underreporting
of behavioral problems and parenting stress because of social desirability.
This step was taken because the average reading level of the sample was assessed
to be at the fourth- to fifth-grade level. Despite this procedure, caregivers
reported a significant degree of overall behavioral problems and parenting
stress.
Several clinical implications can be derived from these data. Interventions
for high-risk parents must respect the caregivers' perception of their parenting
abilities while promoting an expanded repertoire of parenting skills. Observation
of parent-child interaction during health supervision visits may aid in determining
the level of parental distress rather than the caregiver admission of stress
during a clinic visit. In one study,37 systematic
observation of maternal behavior by clinicians during health supervision visits
of infants was found to be effective in predicting subsequent behavioral problems.
In that study, clinical observation of the mother-child interaction when the
child was aged 8 months was strongly associated with behavior problem status
when the child was aged 36 months. In addition to observation, modeling appropriate
interactions and stimulating child interaction with the caregiver during an
episode of problem behavior demonstrates behavior modification techniques
for the parent to use at home.
In summary, in utero drug-exposed infants receiving a home-based nurse
INT had significantly fewer perceived behavioral problems compared with infants
receiving SC with no home INT. These findings suggest that more aggressive
and intensive home-based INT services (more visits over a longer duration)
may have a greater impact on perceived behavioral problems and parenting stress.
More intensive home-based INTs should be considered as a treatment option
with drug-using mothers and their children. Additional studies that address
expanded home-based INTs are needed to investigate how to reduce parenting
stress and perceived child behavioral problems in these families.
AUTHOR INFORMATION
What This Study Adds
Infants with in utero drug exposure have multiple risk factors for compromised
growth and intellectual and social or behavioral development secondary to
in utero drug exposure and a stressful postnatal environment. Previous clinical
trials of home-based INTs indicate cautious success in reducing child behavioral
problems in unmarried teenaged mothers and their children and in infants with
failure to thrive. This study was conducted to determine if a home-based nurse
INT focusing on parenting educational skills and caregiver emotional support
reduces child behavioral problems and parenting stress in caregivers of in
utero drug-exposed children.
In utero drug-exposed infants receiving a home-based nurse INT had significantly
fewer perceived behavioral problems compared with infants receiving SC with
no home INT. We suggest that more aggressive and intensive home-based INT
services (more HVs over a longer duration) may have a greater impact on perceived
behavioral problems and parenting stress and should be considered as a treatment
option for drug-using mothers and their children. In addition, observation
of a parent-child interaction with modeling of appropriate interactions and
stimulating a child interaction with the caregiver during well-child visits
provides the caregiver with behavior modification techniques to use at home.
Accepted for publication April 19, 2001.
This study was supported by grant NR03442 from the National Institute
of Nursing Research, National Institutes of Health, Bethesda, Md.
Presented at the Pediatric Academic Societies and the American Academy
of Pediatrics Joint Meeting, Boston, Mass, May 13, 2000.
We thank the staff of the General Clinical Research Center for their
help in recruiting families; Beth Lang for her help in tracking the families;
Mary Leppert, MD, for her thoughtful review; and, most important, the families
and children who participated in this study.
From the Departments of Pediatrics (Drs Butz and Belcher) and Psychiatry
(Dr Pulsifer), The Johns Hopkins University School of Medicine, Institutional
Research Department, Loyola College, Baltimore (Ms Marano), The Kennedy Krieger
Institute, Baltimore (Dr Belcher), and the Schools of Nursing (Ms Lears) and
Public Health (Dr Royall), The Johns Hopkins University, Baltimore, Md.
Corresponding author and reprints: Arlene M. Butz, RN, ScD, Department
of Pediatrics, The Johns Hopkins University School of Medicine, 600 N Wolfe
St, Room CMSC-144, Baltimore, MD 21287-3144 (e-mail: abutz{at}jhmi.edu).
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