Children of Mothers with Serious Substance Abuse Problems

Children of Mothers with Serious Substance Abuse Problems

Children of Mothers with Serious Substance Abuse Problems

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This study examines the life circumstances and experiences of 4084

children affected by maternal addiction to alcohol or other drugs. The

paper will address the characteristics of their caregivers, the multiple risk

factors faced by these children, their health and development, and their

school performance. Data were collected from mothers at intake into 50

publicly funded residential substance abuse treatment programs for

pregnant and parenting women. Findings from this study suggest that

children whose mothers abuse alcohol or other drugs confront a high

level of risk and are at increased vulnerability for physical, academic,

and socioemotional problems. Children affected by maternal addiction

are in need of long-term supportive services.

Key Words: Substance abuse; Children; Risk factors; Mothers.

Although there are few reliable estimates of the numbers of children

in the United States whose mothers are addicted to alcohol or other drugs,

the information available suggests the number may be shockingly high.

Researchers estimate that up to 15% of all American women between 15

and 44 years old abuse alcohol or illicit drugs (1). Results from the

combined 2000 and 2001 National Household Survey on Drug Abuse

(NHSDA) indicate 3.7% of pregnant women reported using illicit drugs in

the prior month (2). Also based on the NHSDA, it has been estimated that

10% of children (more than 7 million) have at least one parent who is

dependent on alcohol or illicit drugs and that 6% have at least one parent

who is in need of treatment for illicit drug use (3). These estimates suggest

that millions of children currently are being reared in environments

characterized by maternal addiction.

Children of substance abusing parents are widely considered at high

risk for a range of biological, developmental, and behavioral problems,

including for developing substance abuse problems of their own. However,

while much has been written about possible risks that parental substance

abuse poses to children, there is almost no systematic documentation of the

life circumstances of these children. Further documentation of the life

experiences of such children is critically needed for both policy makers and

those involved in planning health and human services. Although studies

examining the effects of prenatal exposure to drugs and alcohol on the

health and early developmental course of children are making clearer the

biologic vulnerability of children born to addicted mothers, comparatively

little attention has been given to the postnatal environmental factors that

may negatively impact children’s development. The broader literature on

risk exposure suggests that the accumulation of postnatal environmental risk

744 Conners et al.

conditions may combine with prenatal exposure to alcohol or other drugs

(AOD) in both an additive and an interactive fashion, dramatically in-

creasing total vulnerability to developmental problems.

The limited research on families affected by parental addiction consists

mostly of case studies or studies involving very small samples. Thus, there

is reason to be concerned about generalizability. Moreover, studies of

chemically dependent families have focused most commonly on intact

families with an alcoholic father (4). To what extent the impact of paternal

alcoholism on children may be similar to that of maternal substance ad-

diction is unknown.

The purpose of this study is to offer some insight into the life

circumstances and experiences of a large group of children affected by

maternal addiction, children whose mothers’ addiction is severe enough to

warrant their admission to long-term residential facilities for pregnant and

parenting women and their children. This paper will address the following

questions about this group of children: 1) Who is acting as the primary

caregiver for these children? What strengths and/or challenges do these

caregivers have that would affect their ability to provide for the physical

and emotional needs of the children in their care? 2) What percentage of

children operate under multiple risk factors known to lead to poor out-

comes? 3) What physical or developmental problems do these children

experience? 4) How do these children perform in school?

METHOD

Procedure

Our study relies on data collected on women and children served by the

Residential Women and Children (RWC)/Pregnant and Postpartum Women

(PPW) programs. The Substance Abuse and Mental Health Services

Administration/Center for Substance Abuse Treatment (CSAT) funded the

projects from 1993 to 2000. Each RWC/PPW project developed residential

substance abuse treatment programs for women, including pregnant and

postpartum women and their infants and children, and participated in a

national cross-site evaluation.

The national evaluation collected data from 50 (26 RWC and 24

PPW) projects from 1996 to 2000. These programs were diverse in many

ways. Some targeted clients from specific racial or ethnic groups, while

others served diverse clienteles. The RWC/PPW projects were located

across all regions of the country, with the largest numbers of programs in

the Northeast. While most programs were located in urban areas, others

Children of Substance Abusing Mothers 745

were located in suburban neighborhoods or rural areas, with a few on

Indian reservations.

Each RWC/PPW project collected and submitted a standard set of

client- and child-level data on a quarterly basis. Programs used software

provided by CSAT’s cross-site contractor to transmit data to a central

location for processing and analysis. All programs involved in the cross-site

study were required to send staff to a conference where they were trained in

the procedures of the study and in the administration of the data collection

instruments. Due to possible staff turnover, further training also was offered

at later grantee conferences and during site visits.

Instruments

This paper uses data collected from families at intake into treatment.

The data collection instruments were developed by CSAT staff and their

cross-site contractor, with extensive input from experts in the field. The

team reviewed relevant literature from the field of substance abuse treat-

ment and prevention, as well as existing data collection tools, and de-

veloped two intake instruments: one for women entering treatment and one

for their children. Both intake instruments were designed to be administered

to the mother by a trained staff member (usually the counselor or intake

coordinator) during the first week after treatment entry.

The intake instrument for women entering treatment was designed to

collect information about individual, familial, and social factors believed to

affect women’s retention in substance abuse treatment and the probability

of successful completion of treatment. Parts of the instrument were modeled

after the Addiction Severity Index (ASI), a widely used semi-structured

interview, which is designed to gather information about aspects of a

client’s life that may contribute to their substance abuse problem (5). Like

the ASI, the cross-site instrument covered areas such as past treatment

history, income and employment, physical and mental health symptoms,

family history of mental health and substance abuse problems, abuse his-

tory, legal involvement, and past and current AOD use.

The team also reviewed literature on substance abuse prevention and

factors influencing children’s early experimentation with drugs or alcohol.

Based on this review, an instrument was developed to collect information

about children entering treatment with their mothers. This instrument

covered areas such as prenatal exposure to alcohol and other drugs, child

custody and living situation, father involvement, physical health problems,

performance in school, and experimentation with tobacco, drugs, or alcohol

(for older children).

746 Conners et al.

Physical and Developmental Problems

One goal of the present study is to describe various physical health

conditions and developmental delays experienced by children who enrolled

in treatment with their mothers. These data were obtained through mother-

report at intake into treatment. As it is unlikely that certain conditions

would be diagnosed in very young children, we developed minimum age

criteria for each condition in consultation with a developmental pediatri-

cian. Only those children meeting the age criteria were included in the

analyses describing the prevalence of various conditions in this sample. The

age criteria were not designed to reflect the minimum age at which a child

Table 1. Sample description.

Description of mothers (n = 2746)

Race

African American 46.3%

White 31.6%

Hispanic 9.7%

Native American 6.9%

Multiracial 2.1%

Alaskan Native 1.5%

Other 1.8%

Marital status

Single 59.8%

Married 13.0%

Separated 13.3%

Divorced 12.1%

Widowed 1.8%

Pregnant 22.1%

Mean age 30.6 (SD = 6.1)

Description of children (n = 4084)

Male 49.0%

Female 51%

Mean age 3.8 years (SD = 3.4)

Child placement Legal custody Living situation

Mother 67.1% 45.8%

Father 0.9% 4.1%

Mother and father 12.8% 9.0%

Grandparent 2.1% 13.3%

Other relative 0.8% 6.0%

State 13.8% 15.9%

Other 2.5% 5.7%

Children of Substance Abusing Mothers 747

could experience a condition but rather the age by which it is reasonably

likely that a diagnosis would be made (i.e., some conditions such as

learning delays would likely go undiagnosed until school entry).

Sample

Of the 4520 children who entered treatment during the cross-site study

period, 4084 are included in these analyses, along with their 2746 mothers.

Four hundred and thirty-six children were excluded due to missing data. As

shown in Table 1, nearly half of the mothers in this sample were African

American, and they ranged in age from 16 to 54 years. Children ranged in

age from newborn to 17 years of age. The majority of children were in the

legal custody of their mother (67.1%) or mother and father (12.8%) at intake

into treatment. However, for many children, there was a discrepancy between

the person(s) holding legal custody of the child, and the person(s) who

actually cared for the child prior to admission. For example, while few

grandparents or other relatives had legal custody of the children, 13.3% lived

with their grandparents or relatives in the 30 days prior to admission.

RESULTS

Description of Caregivers

Mothers

The mothers faced many challenges that could limit their ability to

provide for their child’s physical and/or emotional needs: chronic drug use,

few financial resources, unstable housing, familial history of abuse, legal

problems, problems with physical and mental health conditions, and lack of

social support from family and friends. The vast majority of women were

chronic drug users, with an average of 15.9 [standard deviation (SD) = 6.7]

years of AOD use prior to treatment entry. Most women had been in

treatment before (85.9%). Crack/powder cocaine was the most commonly

used primary substance of abuse (50.4%), followed by alcohol (13.0%),

amphetamines (11.1%), and heroin (8.8%). Most women were unemployed

(88.9%), lacked a high school degree or GED (51.7%), and relied on public

assistance as a source of financial support (70.6%). Thirty-two percent had

been homeless in the two years prior to entering treatment.

The women had a variety of legal problems that brought them into

contact with the criminal justice and/or the child protective services

systems. Two-thirds (66.4%) of the women had been arrested, and over half

748 Conners et al.

(52.0%) were involved with the criminal justice system at the time of

admission. The majority had become involved with the child protective

service system (54.7%), and 41.8% had a child removed from their care by

someone in the child welfare system.

Histories of victimization as well as mental and physical health

problems were common among these women. More than half of the women

reported a history of abuse by their parents (57.4%) and nearly three-fourths

(73.6%) reported being a victim of abuse by someone other than a parent.

Physical health problems were reported by 66.9% of women, and 58.1%

reported a mental health problem. The most commonly reported physical

health problems were respiratory problems (24.1%), sexually transmitted

diseases (13.4%), and other gynecological problems (11.9%). The most

commonly reported mental health problems were depression (40.1%),

psychological trauma (10.7%), and bipolar disorder (6.7%). One-fourth

(29.8%) of women reported at least one attempted suicide.

There is some evidence to suggest that most women lacked social

support from nondrug involved family, friends, or partners. Many women

had a relationship with a partner, and nearly one-third (31.9%) lived with a

spouse or partner in the year prior to treatment entry. Of those women with

a spouse or partner, 44.5% reported that their partner got drunk frequently,

and 57.5% reported that their partner used drugs other than alcohol. Only

25.2% of women reported receiving any financial support from their partner

for their children. Three-fourths of women (79.3%) reported that their

family members were involved in alcohol or drug related activities, and

42.9% reported having fewer than two friends that did not use drugs.

Fathers

Relatively few children had a relationship with their father (either

biological or stepfather). Mothers reported that 30.6% of children never saw

their father in the year prior to treatment entry, and an additional 15.5%

percent saw them only once or twice. As to the nature of their child’s

relationship with their father, 31.4% of the children were reported as

having ‘‘no relationship’’ with their father, 17.8% a ‘‘distant’’ or ‘‘poor’’

relationship, and 50.8% had an ‘‘adequate,’’ ‘‘friendly,’’ or ‘‘close’’ rela-

tionship. According to mothers’ reports, 51.0% of fathers used illegal drugs.

Only 13% of mothers reported receiving child support.

Grandparents

Thirteen percent of children lived with a grandparent prior to treatment

entry. Information about the history of the maternal grandparents was

Children of Substance Abusing Mothers 749

collected at admission to treatment, and reports from mother bring into

question the grandparents’ ability to adequately parent their grandchild. For

children living with a grandparent, the low level of father involvement in

this sample suggests it would likely be the maternal grandparent.

For the children living with their grandparents prior to admission,

32.4% of the grandmothers and 54.0% of the grandfathers were described

as having gotten drunk ‘‘sometimes,’’ ‘‘often,’’ or ‘‘very often’’ when the

mother was a child. Furthermore, 18.3% of these grandmothers and 23.5%

of grandfathers reportedly used other drugs. Nearly one-fourth (23.1%) of

grandfathers and 7.9% of grandmothers spent time in jail or prison. A

substantial portion of women in treatment reported they were physically

abused by their mother (25.5%) and father (28.1%). A smaller number

reported sexual abuse by their mother (2.7%) or father (13.2%). Finally,

59.0% of mothers reported witnessing violence at home while growing up.

Risk Index

Table 2 shows the comparison of an 11-item risk index with national

estimates. The risk index comprises factors that research has shown to be

Table 2. Percentage of children with risk factors (n = 3529).

Children in

treatment National

Homeless in past two years 28.2 NA*

Poor quality father relationship 49.0 NA*

Not living in two parent home 90.9 31y

Maternal use of AOD while pregnant 61.6 3.7 (drugs)z

12.9 (alcohol)z

Maternal use of cigarettes while pregnant 69.8 19.8z

Placed in NICU at birth 18.6 NA*

Low income status 91.3 17y

Mother involved with child

protective services

56.6 NA*

Maternal mental illness 58.3 21%x

Low maternal education 52.2 18%y

Minority status 77.2 30.9k

Mean no. of risk factors per child (of 11) 6.5 (SD = 1.7)

*Not Available—no reliable estimates could be obtained. ySource. Annie E. Casey Foundation (6). zSource. Substance Abuse and Mental Health Services Administration (2). xSource. Nicholson et al. (7). kSource. US Census Bureau (8).

750 Conners et al.

associated with poor physical, academic, or socioemotional outcomes for

children. With few exceptions (homelessness and child placed in Neonatal

Intensive Care Unit (NICU) at birth), each risk factor was present for at

least half of the children in this sample. The most common risk factors

were the family’s low-income status and the child not living in a two-

parent home. To assess the extent to which children were exposed to

multiple risks, we summed the number of risk factors present for each

child. On average, children in this sample were faced with 6.5 (SD = 1.7)

risk factors. The median number of risk factors was 6. Where it was

possible to make comparisons with children nationally, each risk factor was

at least twice as common for children in this sample.

Physical and Developmental Problems

Table 3 compares the prevalence of various physical health prob-

lems and developmental delays in the children in this sample (as reported

by mothers at intake into treatment) with children nationally. For many

conditions, there was very little difference between the two groups of

children. However, compared with children nationally, children in this

sample were more than twice as likely to have asthma, three times as

likely to have hearing problems, and seven times as likely to have vi-

sion problems.

Table 3. Percentage of children with physical and developmental problems.

Condition (minimum age*) Children in treatment National

Asthma (6 mo) 14.8% 6.2%y

Fetal alcohol syndrome (3 y) 0.3% 0.03–0.22%z

Hearing problems (3 y) 2.4% 0.7%x

Vision problems (3 y) 5.2% 0.7%x

Mental retardation (6 y) 0.8% 0.9%x

Learning disorder (7 y) 7.1% 5.2%x

Motor skills disorder (7 y) 1.4% 2.1%x

Communication disorder (3 y) 3.8% 2.1%x

Attention deficit disorder (7 y) 8.4% 4–12%k

*Analyses were restricted to children meeting minimum age requirement. Age

requirements were designed to reflect age by which child would likely have been

diagnosed with a condition. ySource. US Dept of Health and Human Services (9). zSource. Center for Disease Control and Prevention (10). xSource. US Census Bureau (11). kSource. Brown et al. (12).

Children of Substance Abusing Mothers 751

School Performance

Analyses of the children’s school performance were limited to the 905

children in first grade or above. According to the mother’s report, 81.9% of

school age children were at the right grade level for their age, and 90.5%

had successfully completed the last academic year. Mothers reported that

17.0% of children received some special instruction service (remedial

education, special education classes) in the 6 months prior to treatment entry.

For children enrolled in school, their mothers reported on their school

behavior at the end of each quarter. For children on whom quarterly data

are available during the school year (605), 24.4% of mothers reported

having been contacted by the school during the quarter because of the

behavior of their child. Another 10.9% reported that their child had a

serious argument or fight with their teacher.

DISCUSSION

Results from this study indicate that, on average, children affected by

maternal addiction confront a high level of risk. From the time of their

conception and continuing throughout childhood, their environment has

been characterized by an accumulation of factors known to place children at

increased vulnerability for physical, academic, and socioemotional pro-

blems. The majority of these children experienced prenatal exposure to

alcohol, other drugs, and cigarette smoke, and nearly a quarter of these

children had health problems at birth. After birth, the life course tends to be

littered with obstacles to success, such as low income status, low maternal

education, maternal mental illness, instability in caregivers, residential in-

stability, child abuse and neglect, little father involvement, and experiences

in foster care.

Of the 11 risk factors examined in this study, 2 factors (low income

status and not living in a 2-parent home) were present for almost all of the

children, and all but 3 risk factors were present for more than half of the

children in the sample. Furthermore, where national data are available for

comparative purposes, children in this sample were at least twice as likely

to be exposed to a given risk factor than children nationally. These com-

parisons with national samples are somewhat imprecise, in that such esti-

mates are difficult to obtain, and the present sample is not comparable with

national samples on factors such as race or income (although if they were

comparable, they would not be ‘‘at-risk’’). While any particular comparison

may be inexact, the overall pattern still suggests that children whose

mothers abuse AOD are far more likely to be exposed to a variety of risk

752 Conners et al.

factors compared with other children. Clearly, when a mother’s addiction

has progressed to the point that she seeks treatment in a long-term

residential facility, her children are highly likely to have been living in

poverty and to have been exposed to an array of other risks.

Each of these risks has been shown to be related to negative outcomes

for children. However, more important than the impact of these risk factors

individually, is the accumulation of these factors in the life of a child.

There is ample evidence to suggest that for most children, a single risk

factor will not result in a major developmental problem. Rather, it is the

buildup of risk factors that poses the greatest threat to the child. In one of

the earliest studies of the effects of cumulative risk, Rutter (13) examined

six risk factors (severe marital distress, low socioeconomic status (SES),

paternal criminality, large family size/overcrowding, maternal mental

illness, and child placement in foster care) and their relation to psychiatric

disorders in 10-year-old children. He found that only 2% of children in

families with zero or one risk factor exhibited psychiatric problems,

compared with 20% of children in families with four or more risks.

Similarly, results from the Rochester Longitudinal study suggest that high

numbers of environmental risks (maternal mental illness and anxiety,

rigidity in parenting attitudes, few positive maternal interactions, unskilled

occupation, low education, minority status, single parenthood, stressful life

events, and large family size) are related to lower IQ scores and increased

socioemotional problems in four-year-old children. Each risk factor resulted

in an average four point drop in the child’s IQ, and children with no

environmental risks scored more than 30 points higher than children with

eight or nine risk factors (14). Likewise, results from the Canadian National

Longitudinal Study of Children and Youth showed that children of ages 6–

10 years old exposed to four or more risk factors have a rate of behavioral

problems that is five times higher than for children without multiple risks

(15). These results are of particular concern considering that of the eleven

risk factors assessed in the present study, the mean number experienced by

children of mothers with addictions was 6.5. Only 4% of children were

exposed to fewer than four risk factors.

In one of the few studies addressing both the effects of cumulative

environmental risk and prenatal substance exposure on young children’s

development, Carta and others (16) followed 278 infants, toddlers, and

preschool children, and periodically tested their general development. A

cumulative environmental risk index was created by summing five factors

(low income, single parent with no caregiving support, family size > 5,

caregiver did not complete high school, minority status). They found that

while both prenatal drug exposure and cumulative environmental risk

predicted children’s developmental level and rate of growth, environmental

Children of Substance Abusing Mothers 753

risk accounted for more variance in developmental trajectories than prenatal

drug exposure. Over time, the effects of environmental risk outweighed the

adverse consequences of prenatal substance exposure. Their findings

confirm the importance of examining the range of risk factors in children’s

environments that are associated with maternal substance abuse.

In addition to high levels of exposure to risks, another challenging

aspect of the lives of these children is that they appear to have limited

opportunities to develop the kinds of skills and relationships that might

serve as buffers against risk. Given the instability in their lives, there is a

decreased likelihood that they will be able to acquire good skills for

emotional regulation and social interaction, to form stable and supportive

relationships with caring adults, and to access the kinds of consistent

stimulating encounters that facilitate knowledge and bolster achievement. In

effect, it is less likely that they will develop the kinds of personal assets

needed to protect them against the risk conditions they face (17).

These data also highlight the intergenerational nature of substance

abuse and related problems. A substantial fraction of this group of mothers

came from homes where substance abuse, family conflict, and physical and/

or sexual abuse were common. Their children appear to be reliving their

mothers’ childhood experiences, and, without intervention, there is little

reason to believe that this group of children will be able to avoid the

problems that their mothers faced.