Substance Exposed Newborns: Collaborative Approaches to a Complex Issue June 23-24, 2010 Lynne Katz, EDD University of Miami, Department of Psychology

Background  Children who are prenatally exposed to cocaine are at-risk for cognitive, language, and behavioral delays (Lester, et al., 2000)  Regardless of etiology, children who are prenatally exposed to cocaine are an at-risk population who are likely to benefit from early intervention services.

Background  Most of the intervention research for substance-exposed children has focused on the impact of home-based programs (Black, et al., 1994)  The University of Miami’s Linda Ray Intervention Program was designed to examine the impact of three levels of intervention on developmental outcomes for children who are prenatally exposed to cocaine. Multiple cohorts of babies and toddlers have participated since 1991  There is an 80% overlap between these children and the child welfare system

Developmental screenings are mandated for child welfare linked children Child Abuse Prevention and Treatment Act (P.L ) Families are at the table when the Individual Family Support Plan (0-3) and the Individual Education Plan (36 months +) are developed as part of the IDEA Part C and Part B entitlements Opportunities to discuss the child’s special needs and to what degree the family embraces the concept of special needs and services are the first steps

Focus of interventions: What families and the Court can expect The literature tells us the prevailing areas of developmental delay continue to be related to speech and language and social-emotional development We will be using science to inform our interventions Families will be engaged in the process of intervention development from the start and knowledge transfer will be ongoing

Ages & Stages Developmental Screenings in Miami-Dade FL – Children of Substance Abusing Parents enrolled in Dependency Drug Court  200 screenings completed in 2007  Children range from 04 months- 48 months  72-78% children showed delays as compared to the 10-30% expected w/in general population

Comparison How did these children compare to a larger but similar sample? Linda Ray Intervention Center screened 200+ infants & toddlers to compare with the DDC Court sample Areas of delay in both groups primarily social-emotional & language development Delays become more evident approaching 24 months as impact of risk heightens during the expected burst of language

Cognitive Development: Bailey MDI Scores Linda Ray Infant Center Data as of , N=329

Impact on the child, the family and multiple systems: Getting the buy-in  Research informed intervention offers best chance for narrowing or ameliorating developmental delays prior to child entering kindergarten  Opportunities to reduce the stressors related to parenting a child with special needs when intervention and parenting strategies are available to families in one-stop shopping format  Increases chances that child will be ready for school  Makes economic sense across systems of care

Target specific areas for intervention within the domains Joint attention Gestures and early vocalizations Receptive and expressive language Early literacy exposure

Families learn their role in creating language outcomes and the role of the interventionist Research suggests that caregivers that use more complex syntax, a richer vocabulary, and are responsive and sensitive to their children’s signals encourage the development of linguistic capabilities. These factors may be particularly influential for children at-risk for developmental delays where developmentally informed input at home may be lacking.

Techniques:Enhanced Milieu Training (EMT) EMT is intended for toddlers with a vocabulary of greater than 10 words. Relies on environmental arrangement, responsive interaction, and milieu teaching procedures to promote new language forms. Verbal prompts, expansions of utterances, and social consequences are used to increase language use.

EMT Intervention Intervention procedure: Establishing a turn-taking routine with the child. Interrupting the routine so requesting behavior is a solution. Resuming routine when requesting behavior is used and verbally acknowledging/modeling the appropriate form of the communicative behavior. Behaviors and vocalizations become more complex throughout the intervention sessions.

Participants EMT study included: children were identified as having the same primary caregiver from 18 to 36 months (both in home and at the Center) this primary caregiver was the same caregiver who participated in the 24-month interaction N = 89 caregiver-child dyads Data collected at 36 months using the Reynell Developmental Language Scales

Method (continued) At 24 months, the dyads participated in a six-minute play interaction. Interactions were coded for variables examining caregiver speech, responsivity, and directiveness.

Results Lexical richness and adult responsivity were significantly associated with language outcome at 36 months. Number of words and directiveness were not significantly associated with language Informs both discussions for the parenting programs and the work of the interventionist

Discussion Milieu training appears to be valuable to enhancing the pre-linguistic and linguistic abilities of substance- exposed children. This intervention allows the interventionist to work closely with the child’s individual needs. Children are enthusiastic about the naturalistic interaction.

Results (continued) Findings indicated that only lexical richness, not directiveness, independently accounted for a significant amount of the variance in language outcome.

Conclusions These results have critical implications for both the understanding of language development in a high-risk population, as well as the development and implementation of interventions designed to impact the language outcome of young at-risk children.

Priming to enhance language Priming is an acoustic intervention that stimulates and exercises middle ear muscles when the individual is in a calm state with the goal of improving social engagement behaviors (e.g., listening and eye contact). Previous research with the priming stimuli demonstrated improved communication in children with autism (S. Porges, University of Illinois at Chicago).

Linda Ray Children participate in the listening intervention for 40 minutes daily for 1 week. Children listen to adapted Disney music via Mp3 players and headphones created for young children. After the initial 1 week intervention, children listen to music for 10 minute boosters every day for 15 weeks. Embedded into practice when child turns 18 months (pre-empting the 24 months dip)

Overall, our studies have shown that Priming is effective in increasing the language and cognitive ability of cocaine exposed children.

Curriculum components  Language development curriculums and interventions i.e.“Hanen Program: Learning Language and Loving It”  Dependency System Process understanding  Conscious Discipline (Bailey, 2005)  Sensory Integration  Attachment  Parent-Child Relationship building

Food for thought  What does early intervention in your state provide for the target group of babies and toddlers born prenatally exposed?  For those children served, what does outcome data on children leaving Part C look like?  What specific training components are offered to early interventionists about SEN population?  Opportunities for cross-state collaborations exist