Prenatal cocaine exposure and child outcomes: a conference report based on a prospective study from Cleveland.

OBJECTIVE: The study aims to describe developmental outcomes from a longitudinal prospective cohort (Cleveland study) of prenatally cocaine-exposed (CE) infants. METHODS: Two hundred eighteen CE and 197 nonexposed infants were enrolled at birth and followed through mid-adolescence. Birth CE status was determined by interview and biologic measures. Multiple demographic, drug, and environmental correlates were controlled. Standardized, normative, reliable measures of fetal growth, intelligence quotient (IQ), behavior, executive function, and language were given at each age and risk for substance misuse assessed in adolescence. A subset of children received volumetric magnetic resonance imaging (MRI) at 7 years and functional MRI at 14 years. The effect of CE was determined through multiple regression analyses controlling for confounders. RESULTS: Cocaine exposed had significant negative effects on fetal growth, attention, executive function, language, and behavior, while overall IQ was not affected. CE had significant negative effects on perceptual reasoning IQ and visual-motor skills and predicted lower volume of corpus callosum and decreased gray matter in the occipital and parietal lobes. CE children had higher risk for substance misuse. Confounding risk factors had additive effects on developmental outcomes. CONCLUSIONS: Prenatal exposure to cocaine was related to poorer perceptual organization IQ, visual-spatial information processing, attention, language, executive function, and behavior regulation through early adolescence.

Externalizing behavior and substance use related problems at 15 years in prenatally cocaine exposed adolescents.

The effect of prenatal cocaine exposure (PCE) on externalizing behavior and substance use related problems at 15 years of age was examined. Participants consisted of 358 adolescents (183 PCE, 175 non-cocaine exposed (NCE)), primarily African-American and of low socioeconomic status, prospectively enrolled in a longitudinal study from birth. Regression analyses indicated that the amount of PCE was associated with higher externalizing behavioral problems (ß = .15, p = .02). Adolescents with PCE were also 2.8 times (95% CI = 1.38-5.56) more likely to have substance use related problems than their NCE counterparts. No differences between PCE adolescents in non-kinship adoptive/foster care (n = 44) and PCE adolescents in maternal/relative care (n = 139) were found in externalizing behavior or in the likelihood of substance use related problems. Findings demonstrate teratologic effects of PCE persisting into adolescence. PCE is a reliable marker for the potential development of problem behaviors in adolescence, including substance use related problems.

Perceptions of Social-Emotional Learning Among K-12 Teachers in the USA During the COVID-19 Pandemic.

Social-emotional learning (SEL) is the process of acquiring and applying knowledge, skills, and attitudes to achieve long-term relational and emotional goals. Teachers often implement SEL strategies in the classroom; however, shifting to online schooling during the COVID-19 pandemic may have impacted teachers' perceptions of their abilities to implement SEL. This study was designed to identify whether and how teachers' perceptions of SEL changed since the onset of the COVID-19 pandemic. Teachers (N = 637) in the USA completed a demographic questionnaire, the Depression, Anxiety, and Stress Scale (DASS-21), and rated their beliefs about SEL during the pandemic on a modified version of the Comfort and Culture subscales of the Teacher SEL Beliefs Scale. Data were collected between September 2020 and March 2021. Teachers indicated that they felt neutral to comfortable with SEL and that they felt neutral to supported by their school culture for SEL during the pandemic. Lower depression symptoms, greater school poverty, and perceived general support (not specific to SEL) from the administration were associated with higher teacher comfort with SEL. Further, greater general support from the district and colleagues was associated with greater school culture supporting SEL during COVID-19. Results suggest that addressing teachers' internalizing symptoms and fostering a supportive work environment is important in aiding teachers in SEL implementation.

Self-reported mental health outcomes in prenatally cocaine exposed adolescents at 17 years of age.

OBJECTIVE: Adverse developmental effects of prenatal cocaine exposure (PCE) are hypothesized to extend into late adolescence, yet few studies have investigated the association between PCE and late adolescent mental health outcomes. We examined the associations between PCE and self-reported mental health symptoms at age 17, controlling for biologic and environmental confounders. We further explored the potential moderating role of sex and the mediating role of earlier drug use by age 15 in the associations. METHOD: 327 (162 PCE; 165 non-cocaine exposed, NCE) urban adolescents, primarily African Americans, of low socioeconomic status, were prospectively recruited at birth for a longitudinal study and participated in the current study. We administered the Computerized Diagnostic Interview Schedule for Children-IV to assess their mental health symptoms at age 17. Alcohol, tobacco, and marijuana use by age 15 were assessed using biologic samples and self-reports. Confounders included other prenatal drug exposures, caregiving environment, and childhood maltreatment. RESULTS: Although no overall associations between PCE and mental health outcomes were observed, multivariate logistic regression models indicate girls with PCE were 3.60 times (95% CI = 1.45-8.96, p = .006) more likely to have symptoms of oppositional defiance disorder than girls with NCE. This relationship was partially mediated by marijuana use by age 15. CONCLUSION: Continued studies into emerging adulthood will further elucidate the long-term mental health outcomes associated with PCE.

Examining the Role of Language in Play Among Children With and Without Developmental Disabilities.

Purpose Play is a critical aspect of children's development, and researchers have long argued that symbolic deficits in play may be diagnostic of developmental disabilities. This study examined whether deficits in play emerge as a function of developmental disabilities and whether our perceptions of play are colored by differences in language and behavioral presentations. Method Ninety-three children participated in this study (typically developing [TD]; n = 23, developmental language disorders [DLD]; n = 24, attention-deficit/hyperactivity disorder [ADHD]; n = 26, and autism spectrum disorder [ASD]; n = 20). Children were videotaped engaging in free-play. Children's symbolic play (imagination, organization, elaboration, and comfort) was scored under conditions of both audible language and no audible language to assess diagnostic group differences in play and whether audible language impacted raters' perception of play. Results Significant differences in play were evident across diagnostic groups. The presence of language did not alter play ratings for the TD group, but differences were found among the other diagnostic groups. When language was audible, children with DLD and ASD (but not ADHD) were scored poorly on play compared to their TD peers. When language was not audible, children with DLD were perceived to play better than when language was audible. Conversely, children with ADHD showed organizational deficits when language was not available to support their play. Finally, children with ASD demonstrated poor play performance regardless of whether language was audible or not. Conclusions Language affects our understanding of play skills in some young children. Parents, researchers, and clinicians must be careful not to underestimate or overestimate play based on language presentation. Differential skills in language have the potential to unduly influence our perceptions of play for children with developmental disabilities.

Using Telehealth to address disparities in cognitive, language, and emotion regulation problems in young children: A case illustration using the INvesT model.

Over the past decade, there has been a rise in the prevalence of developmental disabilities. Early diagnosis and access to healthcare services are essential for children with developmental delays to optimize development. For families living in poverty, accessing specialized assessment/intervention services for children with developmental disabilities is often a formidable task. In this study, we provide preliminary evidence for the implementation of a developmental risk assessment screening questionnaire using a telehealth format to address the gap in access to services in a community clinic serving a low-income urban neighborhood. Ninety-seven caregivers of children between 12 months and 7 years of age participated in this study. Caregivers completed the risk assessment screening questionnaire using an iPad that was available to them at the clinic. Results showed that while only 11% of caregivers indicated they were initially concerned about their child's overall development, completion of the focused risk assessment resulted in a completely different picture. Fifty percent of caregivers reported that their child had three or more concerns in at least one area of development that would warrant further evaluation. Alerting both families and professionals to these concerns as early as possible may position the family and child to receive the much-needed services that have the potential to mitigate more serious developmental problems. This article discusses the promising role that Telehealth can play in providing screening services for all families, but especially low-income urban households.

Development and validation of the Affect in Play Scale-brief rating version (APS-BR).

The Affect in Play Scale (APS; Russ, 1987, 2004) is one of few reliable, standardized measures of pretend play, yet the fact that it requires videotaping and extensive training to score compromises its clinical utility. In this study, we developed and validated a brief rating version (APS-BR) that does not require videotaping. Construct validity was established by comparing scores from the original APS and the APS-BR using an existing data set of videotaped play (n = 46). We examined associations between scores on the APS-BR and theoretically relevant measures of divergent thinking and emotional memories. Scores on the APS-BR related strongly to those on the APS, and the pattern of correlations for each scale and relevant criterion measures was similar in strength and direction, supporting the APS-BR as an alternate form of the APS. In addition, we completed a pilot study to examine the efficacy of using the APS-BR in its intended in vivo format (n = 28). Results from both studies suggest that the APS-BR is a promising brief measure of children's pretend play that can be substituted for the APS in clinical and research settings.

Interactive Block Games for Assessing Children's Cognitive Skills: Design and Preliminary Evaluation.

Background: This paper presents design and results from preliminary evaluation of Tangible Geometric Games (TAG-Games) for cognitive assessment in young children. The TAG-Games technology employs a set of sensor-integrated cube blocks, called SIG-Blocks, and graphical user interfaces for test administration and real-time performance monitoring. TAG-Games were administered to children from 4 to 8 years of age for evaluating preliminary efficacy of this new technology-based approach. Methods: Five different sets of SIG-Blocks comprised of geometric shapes, segmented human faces, segmented animal faces, emoticons, and colors, were used for three types of TAG-Games, including Assembly, Shape Matching, and Sequence Memory. Computational task difficulty measures were defined for each game and used to generate items with varying difficulty. For preliminary evaluation, TAG-Games were tested on 40 children. To explore the clinical utility of the information assessed by TAG-Games, three subtests of the age-appropriate Wechsler tests (i.e., Block Design, Matrix Reasoning, and Picture Concept) were also administered. Results: Internal consistency of TAG-Games was evaluated by the split-half reliability test. Weak to moderate correlations between Assembly and Block Design, Shape Matching and Matrix Reasoning, and Sequence Memory and Picture Concept were found. The computational measure of task complexity for each TAG-Game showed a significant correlation with participants' performance. In addition, age-correlations on TAG-Game scores were found, implying its potential use for assessing children's cognitive skills autonomously.

Blood lead levels and longitudinal language outcomes in children from 4 to 12 years.

OBJECTIVES: In this study, the authors aimed to examine the association of a range of blood lead levels on language skills assessed at 4, 6, 10 and 12 years of age using a prospective longitudinal design controlling for potential confounding variables including maternal vocabulary, caregiver's psychological distress and symptomatology, child's race and prenatal drug exposure. METHODS: The participants (N = 278) were a subsample of a large longitudinal study that examined the association of prenatal drug exposure on children who were followed prospectively from birth and assessed for receptive and expressive language skills at 4, 6, 10 and 12 years of age. Blood lead levels were determined at 4-years of age by atomic absorption spectrometry. A mixed model approach with restricted maximum likelihood procedures was used to assess the association of lead on language outcomes. RESULTS: Longitudinal mixed model analyses suggested a negative effect of lead exposure on both receptive and expressive language, with the adverse outcomes of lead exposure appearing to become more prominent at 10 and 12 years. Higher caregiver vocabulary was positively associated with child's language scores whereas caregiver psychological distress appeared to negatively affect language scores. Prenatal drug exposure was not related to the effects of lead on language skills. CONCLUSIONS: These findings suggest that elevated blood lead levels occurring early in life may be associated with poorer language skills at older ages. A language rich environment may minimize the negative influence of early lead exposure on language skills, with psychological distress seemingly exacerbating the negative outcome.

Impact of Multiple Daily Clinical Pharmacist-Enforced Assessments on Time in Target Sedation Range.

OBJECTIVES: Incorporation of a single daily assessment by a clinical pharmacist to improve adherence with a sedation protocol is associated with reduced duration of mechanical ventilation and intensive care unit (ICU) length of stay (LOS). We test the feasibility of incorporating a clinical pharmacist into more frequent sedation assessments and observed whether there are any potential differences in the sedatives administered. METHODS: Prospective, quasi-experimental, pilot study of patients admitted to the medical ICU. Patients were included in the analysis if ≥18 years of age within the first 24 hours of initiation of mechanical ventilation. Our primary intent was to test the clinical feasibility surrounding more frequent sedation assessments by a clinical pharmacist by evaluating potential differences in time in target sedation range and sedative administration. Exploratory efficacy end points included time in target sedation range (0 to -2) using the Richmond Agitation Sedation Scale (RASS) and sedative exposure. Patients were assigned to receive either 3 assessments with a clinical pharmacist per day (intervention) or a single assessment by a clinical pharmacist per day (standard of care). During the assessments, clinical pharmacists participated in the RASS administration and made dosing adjustments according to an established sedation protocol. MAIN RESULTS: Seventeen patients were enrolled (n = 6 intervention group, n = 11 standard of care). Duration of mechanical ventilation was similar in the 2 groups (intervention 100.0 hours [52.5-197.5] vs control 76.0 hours [46.0-201.0], P = .95), but patients in the intervention group exhibited a greater percentage time in the target RASS range (intervention 76.0% [53.7-81.5%] vs control 45.2% [35.3-67.0], P = .11) that was not statistically significant. Patients in the intervention group received less fentanyl per day (820.9 µg [227.3-1579.4] vs 1997 µg [1648.2-2477.2], P = .02) than in the control group. CONCLUSION: Incorporating a clinical pharmacist into more frequent daily sedation assessments was associated with a reduction in fentanyl administration. There were no observed differences in time in target sedation range or reduction in duration of mechanical ventilation.

Methylphenidate in the treatment of children and adolescents with bipolar disorder and attention-deficit/hyperactivity disorder.

OBJECTIVE: To examine the short-term efficacy of methylphenidate in the treatment of youths with bipolar disorder (BD) and comorbid attention deficit/hyperactivity disorder (ADHD). METHOD: A 4-week double-blind, placebo-controlled trial in youths ages 5 to 17 years was conducted. Subjects met DSM-IV criteria for bipolar disorder and ADHD, were currently receiving a stable dose of at least one thymoleptic, and while euthymic continued to have clinically significant symptoms of ADHD. Patients received 1 week each of placebo, methylphenidate 5 mg twice daily, methylphenidate 10 mg twice daily, and methylphenidate 15 mg twice daily using a crossover design. Subjects were randomly assigned to receive one of six possible dosing orders. At study's end, and before the blind being broken, a "best dose week" for each subject was determined. The primary outcome measure was the total score on the parent-completed ADHD Rating Scale-IV. RESULTS: Sixteen patients, with a mean age of 10.43 (SD 3.14) years completed the trial. Lower scores during best dose treatment compared to the week of placebo treatment were found on the ADHD Rating Scale-IV (p < .05), suggesting a therapeutic benefit. A large effect size (Cohen's d = 0.90) was found for methylphenidate. Treatment was generally well tolerated. CONCLUSIONS: Euthymic youths with bipolar disorder and ADHD may benefit from short-term concomitant treatment with methylphenidate.

Developmental and subtype differences in behavioral assets and problems in children diagnosed with ADHD.

OBJECTIVE: Developmental and subtype differences in behavioral assets and problems were examined in 318 children newly diagnosed with ADHD. METHOD: Three age groups were compared: 4 to 6.9 years (n = 95), 7 to 9.9 years (n = 136), and 10 to 15 years (n = 87); with two subtypes examined: inattentive (n = 151), and hyperactive/combined (n = 167). Data on assets and problems were obtained from parental questionnaires. Analyses were conducted for the assets and problems data with subtype and age as between group factors. RESULTS: Younger children had more problems with hyperactivity, and the eldest group had more externalizing problems. The hyperactive/combined subtype exhibited more problems than the inattentive subtype. Also the younger group had more assets than the eldest group. CONCLUSION: Children who possessed greater assets had fewer behavioral problems, with assessment of assets and problems important in the diagnosis of ADHD.

Factor structure of coping: two studies of mothers with high levels of life stress.

Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were used to investigate the factor structure of coping in mothers with high levels of life stress. In Study 1, EFA of the Coping Orientation to Problems Experienced (C. S. Carver, M. F. Scheier, & J. K. Weintraub, 1989) in a sample of mothers of full-term or very low birth weight 2-year-old children yielded 7 reliable coping factors. Each factor accounted for significant variance in at least 1 of 6 outcomes measuring maternal-child well-being. In Study 2, CFA was used to cross-validate the EFA model on the basis of the responses of mothers of 2-year-old children with prenatal polysubstance exposure. CFA results revealed a moderately good fit, confirming the factor structure in a 2nd, independent sample of mothers with high levels of life stress.

Psychometric properties of the Dominic interactive assessment: a computerized self-report for children.

The reliability and validity of the Dominic Interactive (DI) assessment were evaluated. The DI is a computerized self-report measure for children, which assesses symptom presence for seven DSM-IV diagnoses. The participants were 322 children (169 cocaine exposed, 153 non-cocaine exposed) who were recruited at birth for a prospective longitudinal study. At 6 years of age, measures of self-report, parent report, and observational data were collected. Moderate to excellent internal consistencies on the DI were found for the total sample as well as for subsamples based on cocaine status and gender. Concurrent validity correlations between DI scales and the Child Behavior Checklist, Affect in Play Scale, a modified Conners's Teachers Rating Scale, and the Parenting Stress Index were examined. Significant relationships among scales were more apt to be among comparisons that assessed externalizing behaviors. Overall, low correlations were obtained, which are comparable to other studies that evaluate agreement between child and parent report of behaviors.

Executive function in children with prenatal cocaine exposure (12-15years).

PURPOSE: Prenatal exposure to cocaine (PCE) may alter areas of the brain dense with monoamine receptors such as the prefrontal cortex and negatively affect cognitive processes implicated in executive function (EF). This study investigated the effects of PCE on EF at 12 and 15years. METHODS: EF was examined in 189 PCE and 183 non-cocaine exposed (NCE) children who were primarily African American and of low socioeconomic status. Caregivers rated their child on the Behavior Rating Inventory of Executive Function (BRIEF) at ages 12 and 15. The BRIEF includes two summary scales and eight subscales: Behavioral Regulation Index (BRI) (Inhibit, Shift, and Emotion) and Metacognition Index (MI) (Monitor, Working Memory, Plan/Organize, Organization of Materials and Task Completion). Two additional measures were included at age 15 (BRIEF Self-Report and the CANTAB Stockings of Cambridge (SOC)). RESULTS: Girls with PCE were perceived by caregivers to have more behavioral regulation problems at age 12 (p<0.005) and more metacognitive problems at age 12 (p<0.003) than NCE females, but there was no association for males. PCE girls improved in behavioral regulation (p<0.05) and metacognition (p<0.04) from 12 to 15years compared to NCE girls based on caregiver report. By self-report PCE was associated with problems of inhibition (p<0.006). Girls with PCE performed more poorly on number of moves to complete the SOC, requiring planning and problem solving, than NCE girls. CONCLUSION: Prenatally cocaine exposed girls were perceived by caregivers as having problems of behavioral regulation, and by self-report, inhibitory control problems. Girls with PCE also performed more poorly on a task of planning and problem solving at age 15 which corresponded to caregiver report at age 12. Early assessment and remediation of these weaknesses in girls may improve school performance and behavior associated with poor EF.

Prenatal drug exposure and selective attention in preschoolers.

Deficits in sustained attention and impulsivity have previously been demonstrated in preschoolers prenatally exposed to cocaine. We assessed an additional component of attention, selective attention, in a large, poly-substance cocaine-exposed cohort of 4 year olds and their at-risk comparison group. Employing postpartum maternal report and biological assay, we assigned children to overlapping exposed and complementary control groups for maternal use of cocaine, alcohol, marijuana, and cigarettes. Maternal pregnancy use of cocaine and use of cigarettes were both associated with increased commission errors, indicative of inferior selective attention. Severity of maternal use of marijuana during pregnancy was positively correlated with omission errors, suggesting impaired sustained attention. Substance exposure effects were independent of maternal postpartum psychological distress, birth mother cognitive functioning, current caregiver functioning, other substance exposures and child concurrent verbal IQ.

Identification of neurodevelopmental disabilities in underserved children using telehealth (INvesT): Clinical trial study design.

BACKGROUND: Children living in poverty are at high risk for delays in development of language and behavior and they experience a discrepancy in diagnosis and access to intervention services. This gap is partially caused by barriers in access as well as traits that are specific to each child and family. The Identification of Neurodevelopmental Disabilities in Underserved Children using Telehealth (INvesT) trial is a novel intervention approach that was specifically designed to address these barriers. AIMS: The INvesT trial has three primary aims: 1) to reduce the age of identification of neurodevelopmental disability for high-risk, low-income children. 2) To validate the INvesT protocol as a service delivery model that will decrease age of identifications of neurodevelopmental disability for high-risk, low-income children; and 3) to identify important child-specific factors, family-specific factors, and environmental factors that impact feasibility and success of the INvesT trial for high-risk, low-income children. METHODS: The INvesT trial is an open-label, double-blinded, placebo-controlled multi-level study that includes telehealth risk assessment, telehealth screening, traditional full assessment, and follow through to enrollment in early intervention. The trial is conducted in partnership with an urban community health clinic that largely serves a low-income patient population. CONCLUSIONS: The results of the INvesT trial will provide evidence for the use of a telehealth service delivery model to improve access to care for neurodevelopmental disabilities for high-risk, low-income children.

Evaluation of the Duration of Action and Comparative Effectiveness of Lisdexamfetamine Dimesylate and Behavioral Treatment in Youth With ADHD in a Quasi-Naturalistic Setting.

OBJECTIVE: This study compared the relative effects of three treatment conditions: long-acting stimulant medication (MED), behavior modification, and medication/behavioral treatments combined (COM) in children with ADHD. METHOD: A total of 25 children, aged 6 to 12 years, received the three treatment conditions during a 7-week Summer Treatment Program in an alternating treatments design. Counselors completed behavioral ratings from 0.5 to 12.5 hr post dose, and parents completed nighttime ratings. RESULTS: Ratings for SKAMP (Swanson, Kotkin, Agler, M-Flynn, and Pelham) and for following instructions indicated COM and MED improved symptoms over BEH treatment beginning 3 hr post dose (p = .008), with ratings maintained 12.5 hr post dose (p = .001 and .006). Results for frustration tolerance indicated significant improvement in all three conditions until 9 hr post dose. CONCLUSION: MED and COM separated from BEH at 3 hr post dose, and sustained benefit was observed across the day for two of three measures. BEH appears to have an additive effect, extending the duration of frustration tolerance.