Ethical Issues in Working with Prenatally Drug-Affected Children
Mary Bellis Williams, Ph.D.
Prenatally drug-affected children are those affected by the drugs ingested by their mothers during pregnancy. My work has been primarily with babies, children, and young adults whose mothers took cocaine or crack or methamphetamines during pregnancy. While these drugs can affect a developing fetus at any point, including causing fetal death, my focus has been on the effects of the drugs on the developing brain of the fetus that can profoundly affect behavior, learning, and socialization once the child is born.
Typically, if a pregnant woman ingests crack, meth, or cocaine at the end of the first trimester and start of the second trimester of pregnancy when the prefrontal cortex of the brain is forming, the drugs can harm the normal development of the brain. These strong stimulant drugs are drawn to the dopamine-rich areas of the brain (making users high); they cross the placental barrier and enter the fetus, and since the prefrontal cortex is a dopamine-rich area even in formation, the drugs disrupt the neurons that make up that part of the brain.
Why is this important? The prefrontal cortex is called the Executive Function of the brain, as it governs reasoning, judgment, decision-making, self-control, relationships with others, and a host of other important tasks. Damage to this part of the brain can and does result in children without self-control, unable to recognize or control their moods or rages, unable to bond with caregivers, thus further hampering any appropriate social development. They cannot understand cause and effect or logical consequences, have difficulty remembering past consequences, and cannot generalize from events and use them in their learning and their responses to new situations. It is typical that they cannot make sense out of their experiences and that they lack empathy because they cannot learn by watching and cannot “read” the emotions of others by their facial expressions and body language. They have no sense of personal space and thus can alarm others. They cannot form friendships. They cannot calm themselves, and their own anger or tantrum has no logical origin and only serves to intensify their mood to violence. They lack conscience and remorse.
There are many more problems for affected children: sleep difficulties, mostly because they cannot establish routines in their lives; eating problems (some are afraid of new food!); very serious attention problems that affect them academically as well as socially; and the inability to calm themselves.
They do not grow out of these problems, and as they grow older and are in school and more is expected of them year by year, they are unable to respond to these expectations so they fall farther behind. If a child cannot understand cause and effect, how is she ever able to understand and answer questions about the causes of the Civil War? If a child cannot understand human behavior and emotions, how can he possibly answer questions about the motives of a character in a story? If a child cannot connect new learning to old learning, how can she learn the cumulative and sequential methods of mathematics? If he’s unable to have insights, how can he understand science in the laboratory setting, or understand his classmates’ behavior?
Intellectually, they are not damaged, at least according to the usual diagnostic and school standards of administering IQ tests to decide who’s normal. They remain within the normal IQ spread with the median dropped by only 5 points to 95 from the normal 100. However, they cannot reason, cannot understand consequences, and cannot connect new learning to old learning. It is as though their whole brain filing system for new information is harmed. Many learn to cope in ways that make their behaviors and reasoning seem normal for a short while to a casual observer, but the basic building blocks of thinking and reasoning are deeply flawed and incomplete.
This damage is on a continuum from only a little damage to profound and pervasive damage.
There are interventions which can help form new neural connections and build appropriate and almost normal behaviors and responses. The more these correct behaviors are practiced, the more fluent they become, and eventually the individual is able to build on the new foundations and reason and behave more appropriately. Many of the interventions are those used effectively with intensive therapy interventions with children with autism: focusing attention, shaping behavior including social behavior, etc.
Working with prenatally drug-affected individuals has several ethical considerations:
Mary Bellis Williams, Ph.D.
Prenatally drug-affected children are those affected by the drugs ingested by their mothers during pregnancy. My work has been primarily with babies, children, and young adults whose mothers took cocaine or crack or methamphetamines during pregnancy. While these drugs can affect a developing fetus at any point, including causing fetal death, my focus has been on the effects of the drugs on the developing brain of the fetus that can profoundly affect behavior, learning, and socialization once the child is born.
Typically, if a pregnant woman ingests crack, meth, or cocaine at the end of the first trimester and start of the second trimester of pregnancy when the prefrontal cortex of the brain is forming, the drugs can harm the normal development of the brain. These strong stimulant drugs are drawn to the dopamine-rich areas of the brain (making users high); they cross the placental barrier and enter the fetus, and since the prefrontal cortex is a dopamine-rich area even in formation, the drugs disrupt the neurons that make up that part of the brain.
Why is this important? The prefrontal cortex is called the Executive Function of the brain, as it governs reasoning, judgment, decision-making, self-control, relationships with others, and a host of other important tasks. Damage to this part of the brain can and does result in children without self-control, unable to recognize or control their moods or rages, unable to bond with caregivers, thus further hampering any appropriate social development. They cannot understand cause and effect or logical consequences, have difficulty remembering past consequences, and cannot generalize from events and use them in their learning and their responses to new situations. It is typical that they cannot make sense out of their experiences and that they lack empathy because they cannot learn by watching and cannot “read” the emotions of others by their facial expressions and body language. They have no sense of personal space and thus can alarm others. They cannot form friendships. They cannot calm themselves, and their own anger or tantrum has no logical origin and only serves to intensify their mood to violence. They lack conscience and remorse.
There are many more problems for affected children: sleep difficulties, mostly because they cannot establish routines in their lives; eating problems (some are afraid of new food!); very serious attention problems that affect them academically as well as socially; and the inability to calm themselves.
They do not grow out of these problems, and as they grow older and are in school and more is expected of them year by year, they are unable to respond to these expectations so they fall farther behind. If a child cannot understand cause and effect, how is she ever able to understand and answer questions about the causes of the Civil War? If a child cannot understand human behavior and emotions, how can he possibly answer questions about the motives of a character in a story? If a child cannot connect new learning to old learning, how can she learn the cumulative and sequential methods of mathematics? If he’s unable to have insights, how can he understand science in the laboratory setting, or understand his classmates’ behavior?
Intellectually, they are not damaged, at least according to the usual diagnostic and school standards of administering IQ tests to decide who’s normal. They remain within the normal IQ spread with the median dropped by only 5 points to 95 from the normal 100. However, they cannot reason, cannot understand consequences, and cannot connect new learning to old learning. It is as though their whole brain filing system for new information is harmed. Many learn to cope in ways that make their behaviors and reasoning seem normal for a short while to a casual observer, but the basic building blocks of thinking and reasoning are deeply flawed and incomplete.
This damage is on a continuum from only a little damage to profound and pervasive damage.
There are interventions which can help form new neural connections and build appropriate and almost normal behaviors and responses. The more these correct behaviors are practiced, the more fluent they become, and eventually the individual is able to build on the new foundations and reason and behave more appropriately. Many of the interventions are those used effectively with intensive therapy interventions with children with autism: focusing attention, shaping behavior including social behavior, etc.
Working with prenatally drug-affected individuals has several ethical considerations:
- Is it appropriate to make a clinical judgment that a person is, in fact, prenatally drug-affected? Is this a diagnosis of doom, and/or a judgment upon their mothers? Should this make a difference?
- Is it right to do therapeutic interventions with them, without their informed consent? Without any idea of consequences, can they give informed consent?
- Is it ethical to impose upon the damaged individual some societal vision of behavior?
- Since prenatal drug syndrome or effect is not in the Diagnostic and Statistical Manual, should or could affected individuals be held to the same legal standards as others? Many are already in prison for violent crimes.