Validation of the 4P's Plus screen for substance use in pregnancy validation of the 4P's Plus.

OBJECTIVE: The purpose of this study is to validate the 4P's Plus screen for substance use in pregnancy. STUDY DESIGN: A total of 228 pregnant women enrolled in prenatal care underwent screening with the 4P's Plus and received a follow-up clinical assessment for substance use. Statistical analyses regarding reliability, sensitivity, specificity, and positive and negative predictive validity of the 4Ps Plus were conducted. RESULT: The overall reliability for the five-item measure was 0.62. Seventy-four (32.5%) of the women had a positive screen. Sensitivity and specificity were very good, at 87 and 76%, respectively. Positive predictive validity was low (36%), but negative predictive validity was quite high (97%). Of the 31 women who had a positive clinical assessment, 45% were using less than 1 day per week. CONCLUSION: The 4P's Plus reliably and effectively screens pregnant women for risk of substance use, including those women typically missed by other perinatal screening methodologies.

Screening for substance use in pregnancy: a practical approach for the primary care physician.

Our goal was to identify risk factors for substance use during pregnancy for primary care physicians so that we could assess a woman's risk of alcohol or illicit drug use. Participants were 2002 Medicaid-eligible pregnant women with < or =2 visits to prenatal care clinics in South Carolina and Washington State. Structured interviews were used to collect data. Logistic regressions and classification and regression trees identified predictors for pregnant women at high risk for substance use. Approximately 9% of the sample reported current use of either drugs or alcohol or both. Past use of alcohol or cigarettes, including during the month before pregnancy, most differentiated current drug or alcohol users from current nonusers. Our analysis suggests that primary care physicians can ask 3 questions in the context of a prenatal health evaluation to target women for referral to a full clinical assessment for drug and alcohol use.

Perinatal substance abuse treatment. Findings from focus groups with clients and providers.

Thirty-three focus groups were conducted with pregnant women in substance abuse treatment and their providers in order to identify factors in women's lives that facilitate and hamper their treatment process and successful program components to address the needs of this high-risk population. The focus groups were conducted as part of a larger evaluation of demonstrations funded by the Health Care Financing Administration. From the 88 women in the focus groups we received a picture of their troubled lives and the events that led to their participation in the programs. The women had difficult childhoods, and currently had weak support networks and difficult relationships with male partners, many of whom were substance abusers. Most had children, which complicated getting into and staying in treatment. However, fear of losing custody of children was a major motivator for treatment. Important components of successful programs included: (a) the development of interorganizational linkages between various governmental agencies, especially child protection systems, prenatal care providers, and substance abuse treatment agencies and providers; (b) outreach and systems for identifying pregnant substance abusers through provider education and routine screening; and (c) intensive case management, necessary to link women to the many services they needed in order to obtain treatment, such as child care, transportation, and housing.

Prenatal exposure to cocaine and other drugs. Outcome at four to six years.

In a longitudinal, prospective study, 95 children born to mothers who used cocaine and other drugs during pregnancy and 75 matched, nonexposed children born to mothers who had no evidence of alcohol or illicit substance use during pregnancy were evaluated for cognitive and behavioral outcome at 6 years of age. Prenatal exposure to cocaine and other drugs had no direct effect on the child's cognitive outcome (measured as IQ), but it had an indirect effect as mediated through the home environment. However, prenatal exposure to cocaine and other drugs did have a direct effect on the child's behavioral characteristics at 4-6 years of age, with the home environment having little impact. This study helps us to understand the fragile interaction of biological and environmental factors affecting the cognitive and behavioral development of children prenatally exposed to cocaine and other drugs.

Three-year outcome of children exposed prenatally to drugs.

OBJECTIVE: To evaluate the 3-year behavioral and developmental outcome of children prenatally exposed to maternal substances of abuse. METHOD: Ninety-three children exposed prenatally to cocaine and other drugs taken by the mother during pregnancy (Group 1), 24 polydrug/noncocaine exposed children (Group 2), and 25 nonexposed children (Group 3) were evaluated at 3 years of age as part of a longitudinal prospective study of the impact of intrauterine substance exposure on long-term outcome. The Stanford-Binet Intelligence Scale: Fourth Edition(SBIS) was administered by examiners blinded to the exposure background of the children, and a pediatrician performed a complete medical evaluation on all the children. The children's primary caregiver completed the Achenbach Child Behavior Checklist. Stepwise multiple regression procedures were used to determine the factors that best predicted 3-year growth, intelligence, and behavior. RESULTS: Groups 1 and 2 differed from Group 3 on head circumference. Group 1 scored lower than Group 3 on SBIS Verbal Reasoning. Group 2 scored Slower than Group 3 on SBIS Abstract/Visual Reasoning. Cocaine exposure predicted poor verbal reasoning. Marijuana exposure predicted poor abstract/visual reasoning. Examiner rating predicted intellectual outcome and caregiver ratings. Caregivers rated exposed children as more aggressive than nonexposed. CONCLUSION: Contrary to information in the popular media, not all substance-exposed children suffer the same poor prognosis. In fact, generalizations about the fate of drug-exposed children must await additional research into the outcome of the broader population of drug-exposed children, examining the roles of maternal and environmental factors across a variety of geographic locations and socioeconomic levels.

Outcome of children prenatally exposed to cocaine and other drugs: a path analysis of three-year data.

OBJECTIVE: Cocaine and other drug use during pregnancy continues to be a major health concern. With increasing use of cocaine by women of childbearing age, large numbers of children have been exposed to this and other substances in utero. Currently, very little information regarding the long-term developmental implications of cocaine/polydrug exposure exists. The purpose of this study is to present 3-year cognitive and behavioral data on infants exposed to cocaine and other drugs during gestation. METHODS: The subjects and controls in this study are currently enrolled in a longitudinal, prospective evaluation. At 3 years of age, 92 children exposed to cocaine and other drugs, 25 children exposed to multiple drugs but no cocaine, and 45 drug-free controls were evaluated using the Stanford-Binet Intelligence Scale (fourth edition), the Child Behavioral Checklist, the Home Screening Questionnaire, and a Summative Perseverance Scale. The data were analyzed using an a priori model and path analytic procedures. RESULTS: The results indicate that prenatal drug exposure has significant direct and indirect effects on 3-year cognitive functioning as measured on the Stanford-Binet scale. The fit indices indicated that overall, the hypothesized model accurately reflected the actual data. CONCLUSIONS: The findings of the study provide specific evidence elucidating the nature of long-term developmental risk associated with intrauterine drug exposure. Drug exposure was found to have a direct effect on cognitive ability at 3 years of age. However, the effects of drug exposure are also mediated indirectly through head circumference, home environment, and level of perseverance at a task. Future explorations should continue to utilize path analysis techniques to further clarify the ramifications of drug exposure on the development of the growing child.

Motor assessment of cocaine/polydrug exposed infants at age 4 months.

Fifty nondrug-exposed infants and 74 cocaine/polydrug-exposed infants were evaluated on the Movement Assessment of Infants (MAI). The test provides an assessment of risk for motor dysfunction at age 4 months. There was a significant difference in total risk scores between the two groups of infants with cocaine-exposed infants having higher total risk scores (p less than .0001). Categorical risk scores revealed significant differences between the infants in muscle tone, primitive reflexes, and volitional movement with cocaine-exposed infants scoring more poorly in each category (p less than .0001). The groups scored differently on 11 of the 49 MAI items in those categories. Placement of infants within previously established ranges of risk scores (0-7 = no risk; 8-13 questionable risk; greater than 13 = high risk) revealed a significant difference in distribution between the two groups (p less than .0001). Earlier studies of the effects of intrauterine drug exposure have not revealed significant differences in motor development. The MAI demonstrated differential assessments of risk for motor dysfunction between cocaine-exposed and nondrug-exposed infants.

Cocaine/polydrug use in pregnancy: two-year follow-up.

The impact of cocaine on pregnancy and neonatal outcome has been well documented over the past few years, but little information regarding long-term outcome of the passively exposed infants has been available. In the present study, the 2-year growth and developmental outcome for three groups of infants is presented: group 1 infants exposed to cocaine and usually marijuana and/or alcohol (n = 106), group 2 infants exposed to marijuana and/or alcohol but no cocaine (n = 45), and group 3 infants exposed to no drugs during pregnancy. All three groups were similar in racial and demographic characteristics and received prenatal care through a comprehensive drug treatment and follow-up program for addicted pregnant women and their infants. The group 1 infants demonstrated significant decreases in birth weight, length, and head circumference, but by a year of age had caught up in mean length and weight compared with control infants. The group 2 infants exhibited only decreased head circumference at birth. Head size in the two drug-exposed groups remained significantly smaller than in control infants through 2 years of age. On the Bayley Scales of Infant Development, mean developmental scores of the two groups of drug-exposed infants did not vary significantly from the control group, although an increased proportion of group 1 and 2 infants scored greater than two standard deviations below the standardized mean score on both the Mental Developmental Index and the Psychomotor Developmental Index compared with the control infants. Cocaine exposure was found to be the single best predictor of head circumference.(ABSTRACT TRUNCATED AT 250 WORDS)

Doppler umbilical velocimetry in women with polydrug abuse including cocaine.

Doppler umbilical artery velocimetry was performed in 40 chemically dependent women. The mean S/D ratio was 2.7 with 15/66 values greater than or equal to 3.0. No cases of absent or reverse end-diastolic flow were noted. The mean S/D ratio in women with positive toxicologies for cocaine use was not statistically elevated compared to women with negative screens (2.8 versus 2.7, P = 0.51). In this study an S/D ratio greater than or equal to 3.0 had a sensitivity of 40% for identifying intrauterine growth retardation with a positive predictive value of 20%.

Cocaine and pregnancy: clinical and methodologic issues.

Although many of the clinical studies of cocaine use in pregnancy completed thus far have suffered from the methodologic issues discussed here, they have been of great value in defining key risk factors and general clinical outcome. With the information now available, it appears safe to conclude that placental dysfunction due to cocaine's vasoconstrictive activity increases risk for intrauterine growth retardation and prematurity; fetal disruption due to acute cocaine-induced vascular compromise places the fetus at risk for structural anomalies; and neurotoxicity due to cocaine's action at the postsynaptic junction places the infant at risk for neurobehavioral abnormalities. There are now needed more sophisticated analytic techniques that can consider the additive and interactive effects of demographic and lifestyle characteristics that place the cocaine-using pregnant woman and her child at risk.

The prevalence of substance abuse in patients with suspected preterm labor.

Premature labor is a recognized complication of substance abuse in pregnancy. However, the prevalence of substance abuse in patients first seen with symptoms of preterm labor and who deny use of illicit drugs is unknown. Between July 1, 1988, and December 15, 1988, 141 patients first seen at Northwestern Memorial Hospital in suspected preterm labor and a comparison group of 108 uncomplicated laboring term patients had urine toxicology screening performed to detect substance abuse. Positive urine toxicology screenings were found in 24 of 141 (17.0%) patients with suspected preterm labor and in 3 of 108 (2.8%) patients in the comparison group. The most common substance identified was cocaine (14/24 and 1/3, respectively). Of those patients in suspected preterm labor, 22 of 86 (25.6%) clinic patients had positive urine toxicology screenings as did 2 of 55 (3.6%) private patients. On the basis of our observations, we recommend that patients admitted in possible preterm labor be encouraged to submit to screening for substance abuse so that appropriate counseling and prenatal and neonatal care become available for these high-risk patients.