The Future of Children, Princeton - Brookings: Providing research and analysis to promote effective policies and programs for children.

In this, the fourth issue of The Future of Children, we introduce Revisiting the Issues as a regular feature of the journal. In the Spring 1991 issue of The Future of Children, which addresses the subject of drug-exposed infants, the impact of the drug epidemic on the already overloaded substitute care system was described. Particularly disturbing was the large number of drug-exposed infants being admitted to foster care. But in considering the possibilities for placement in out-of-home care for the infants and children, McCullough stated that the drug epidemic had not had a dramatic impact on adoption services because adoption was rarely chosen for those infants and children who were drug-exposed or whose parents were drug-dependent. Furthermore, as described by Richard Barth, articles in the lay press about difficulties in parenting drug-exposed infants and children deterred many potential adoptive parents.

In this issue of the journal, Barth presents the results of a study on the outcome, two years after placement, of 320 children who were considered drug-exposed prenatally and compares them with 456 non-drug-exposed children adopted in the same period (1988–1989). A third group, from the total cohort, consisted of 620 children whose drug exposure was unknown. Data were collected from state records and from a detailed questionnaire completed by the adoptive parents. Two years after placement, when the children averaged 5.2 years of age in the drug-exposed group and 4.85 years in the non-drug-exposed group, no differences were found between the groups in the children's behavior, temperament, health, or school adjustment. Likewise, parent satisfaction was high in the two groups, with no differences found.

Barth recognizes and describes the possible methodological problems with this study. However, he points out that the sample size of the children is the largest yet reported for any adoption study and that the failure to find any statistically significant differences among the groups is striking.

Although this study is still in its early stages and clearly more follow-up research is needed, the results thus far are very encouraging. They are in accord with other information in the medical literature supporting the idea that, unless the infant has been seriously damaged, the environment is the most important factor in determining good outcome.¹

After nearly a decade of decline, the number of children in foster care in the United States has grown. Sharp increases in the number of prenatally drug-exposed children in need of homes is believed to be responsible for this growth. Across the country, infants (under 2 years of age) are entering foster care in record numbers, and this is largely the result of drug exposure. For example, in New York, Illinois, and Michigan, the number of infant admissions to foster care more than doubled between 1984 and 1989, and exceeded 15 per 1,000 births.² Many of these infants should be candidates for adoption because drug involvement is a poor predictor of reunification with their birthfamilies; yet, they remain in foster care far longer than older children.³ For example, in California, the elapsed time until 30% of infants have left foster care is 18 months; for children placed at 1 to 6 years of age, 30% have left foster care by the time they are 9 months old.³

Uncertainty about the appropriateness of adoption for drug-exposed children is partly to blame for the failure of adoption to provide an exit for young children in foster care. Concerns about the adoption of drug-affected babies are surfacing across the nation and focus on both the children and the adoptive parents. Concerns about the parents include fear that they will not be able to manage the care of drug-exposed babies: "(their) parents need special training; they need respite; they have trouble dealing with medical professionals who themselves do not understand the needs/problems of drug-exposed infants" and "homes are difficult to secure for these infants . . . they are often difficult to comfort, cry excessively or have medical problems which require monitoring and frequent doctor or hospital visits."⁴

The pessimism about adoption of drug-exposed children is captured by Charlotte McCullough's analysis: "Adoption is rarely the option chosen for drug-exposed infants or for young children of drug-dependent parents. There are many barriers to adoption. Termination of parental rights is usually contested, and although the process can theoretically take place in 18 months, in reality it usually takes 3 years. The infants become toddlers or older and the prospective parents become frustrated with the prolonged process. In addition, potential adoptive parents are fearful of the long-term effects of drug exposure and the possible need for expensive medical, educational, and psychological care."⁵

Journalistic accounts further fuel concerns about adoption of drug-exposed children. Blakeslee concludes that parents who adopt drug-exposed babies often find that rearing them is vastly more difficult than experts predicted. Parents she interviewed stated that the children are often hyperactive, have difficulty getting along with peers, and have explosive tendencies. She reports that half of the members of a Southern California support group for adoptive parents of drug-exposed children are planning to return custody of their children to the child welfare agency. Yet her report does describe the potential for drug-exposed children to thrive; one parent described her child as one who "should have been one of the worst. She is one of the best."⁶ However, another journalistic account describes the death by battering of a drug-exposed infant when the woman who was her foster mother and had planned to adopt her became exhausted and enraged.⁷

Leading experts cannot agree on outcomes of drug-exposed children. In a presentation to an adoption conference, Howard indicated that the more data she gathers the more deviance she sees. She predicted that these children are apt to wear out caregivers quickly, both physically and emotionally. She indicated a possible need for orphanages as an alternative for drug-using parents who decide to take their child home to care for them.⁸ Barry Zuckerman, on the other hand, emphasizes that "the mere presence, or even the degree, of a biologic insult are poor predictors of developmental outcome. Rather, children's development can best be understood by the dynamic interplay between the environment and the child, so that the child is shaped by the environment and the environment is actively modified by the child."⁹

These concerns are leading some to believe that, without drastic alternatives like orphanages, prenatally drug-exposed children will experience the dual hardships of the physical effects of drug exposure and the transience and vulnerability of living in a drug-dominated family. Yet orphanages are often an unacceptable alternative because of the associated cost and the possibility of developmental delay or damage.¹⁰ Where feasible, adoption represents a more humane, less costly, lifetime investment in these vulnerable children. There have been a few calls for a more affirmative adoption response. Kroll suggested that drug-exposed infants are "similar to other groups of disabled children—children who are successfully adopted as long as appropriate family preparation and follow-up support are in place."¹¹ Yet even this assessment assumes that drug exposure is a "new disability"; the data upon which these hopeful comments stand are no stronger than those of their pessimistic counterparts. Because of the lack of agreement, we conducted a study on the outcome of a cohort of drug-exposed children who were adopted and on the experience of their adoptive parents during the two years following placement.