Fall 2025 Issue

Substance Use: The Invisible Struggle
By Elizabeth S. Goar
Social Work Today
Vol. 25 No. 4 P. 26

The spotlight on methamphetamine abuse has dimmed as the nation’s attention shifted to the opioid epidemic. Still, the prevalence of newborns with prenatal methamphetamine exposure (PME) remains a serious concern. Yet the lack of urgency around early intervention for these children and limited guidance and support for their families can mean they are saddled with lifelong behavioral, emotional, and learning struggles.

While accurately measuring the incidence of PME is challenging due to variations in reporting, detection methods, and geography, a 2022 JAMA Open Network study found that 1.7 per 1,000 newborns have prenatal exposure. Another study published in 2024 using California data put that figure much higher, documenting methamphetamine use in 3.9 per 1,000 pregnancies, with rates steadily rising in recent years.1,2

Invisible and Inconsistent
For babies with PME, a lack of outward suffering at birth tends to obscure the significant impact prenatal exposure can have on their future development. Unlike babies born with neonatal opioid withdrawal who begin showing immediate and painful symptoms, including agitation, inconsolable crying, diarrhea, sweating, rapid heart rate, etc, babies with PME are often sedate—or not.

As is often the case with PME, there is little consistency in newborn behaviors, according to Barry Lester, PhD, director of Brown University’s Center for the Study of Children at Risk and a leading researcher in the field of neonatal drug exposure and its developmental impacts.

“In our studies, we looked at newborns and found differences between methamphetamine exposed and nonexposed, but they were very similar to cocaine,” he says. “Some babies were hard to rouse, but [others] would show things like jitteriness and tremors that are similar to cocaine [exposure]. There are also regional differences linked to variances in how the drug is manufactured.”

Additionally, biological mothers and their infants don’t always have substances actively present and identifiable at the time of labor and birth. As a result, PME newborns tend to be overlooked unless the mother admits to drug use during pregnancy, which is notoriously unreliable.

“Understandably, mothers also aren’t necessarily always able to give accurate prenatal histories of earlier substance use, given the overwhelming influence of addiction itself and/or other factors that overshadow or impair memory, like trauma. Or they might be hesitant to disclose due to the potential stigma or reactions of hospital or child welfare staff,” says Kendra Morris-Jacobson, MA, program director with the Oregon Post Adoption Resource Center (ORPARC), part of Northwest Resource Associates that has been providing services to Oregon’s foster, adoptive, and guardianship families in the child welfare space.

Because there are few outward physical signs of dependency, up to 90% of meth exposure in newborns goes undetected. It is not until these children approach school age that identifiable cognitive and behavioral issues begin to show. By then, years of potential intervention are lost.

Even when meth dependency is recognized in newborns, there is little guidance on how to approach the management of the effects of their prenatal exposure as they age and mature.3 Adding to the challenge is the reality that drugs, alcohol, and nicotine are rarely used in isolation, says Morris-Jacobson. Her experience is that most drug impacts are significantly underdiagnosed.

“Many people with addictions engage in polysubstance use, even if those other substances aren’t primary. Or engage in polysubstance use accidentally, given how many street drugs are now contaminated or mixed with other drugs. Very little is known about the impacts of most polysubstance combinations, let alone of which there are so many possibilities,” she says.

Devastating Impacts
Given the sizable population of babies born with PME, the impact of exposure is woefully under-researched. What is known is that exposure to methamphetamine during the first and second trimesters can damage the prefrontal cortex, the “executive” region of the brain that regulates decision-making, problem-solving, self-control, and judgment. This damage manifests over time, typically as behavioral and learning issues.

Research by Lester and others from Brown’s Center for the Study of Children at Risk found that children exposed to meth in the womb are also more prone to developing anxiety, depression, and mood disorders.4 These findings were later confirmed by researchers from the National Institute on Drug Abuse, who evaluated children with PME at ages 3 and 5 and compared their findings to those of children with no prenatal exposure.

By age 3, exposed children exhibited symptoms of anxiety, depression, and/or other mood disorders—issues that persisted through age 5. At that age, the children also exhibited attention deficit issues and aggression, leading researchers to compare them to children who had been diagnosed with ADHD. The study also found that heavy prenatal exposure to methamphetamine “was related to attention problems and withdrawn behavior at both ages.”5

Another study surveyed 290 children enrolled in the Infant Development, Environment and Lifestyle (IDEAL) Study at Brown University’s Warren Alpert Medical School. It is the only prospective, longitudinal National Institutes of Health study of PME and child outcome. That research found a strong link between PME and rule-breaking and aggressive behavior, with researchers noting that, if left unaddressed, these issues may exacerbate as the child enters school.

Specifically, the cognitive problems linked with inattention “predict negative externalizing behaviors during childhood, possibly due to the frustration, lack of motivation, and confusion children may experience when compared with their peers. It is also possible that future behavioral problems may result from cognitive problems associated with prenatal methamphetamine exposure,” researchers wrote.6

Exposed children as young as two have less impulse control than their nonexposed peers. They are less able to delay gratification and express frustration when restrained momentarily by their mothers, often through outbursts such as kicking and screaming—all of which are early indicators of what is likely to come in the classroom and with social interactions.

In another long-term study that followed hundreds of children since birth, meth-exposed children were found to be more impulsive, responding more rapidly than their nonexposed peers when asked to press a button whenever they saw a picture that was repeatedly flashed on a computer screen. When more pictures were added, exposed children still responded more quickly when the correct image appeared. However, they were unable to screen out distractions and made more mistakes, indicating that their rapid motor response was not indicative of their ability to process the task’s difficulty.7

In summarizing the impact of prenatal exposure on children as they age, educators have noted that they tend to be nonresponsive to visual learning and are often unable to appreciate the concept of playing games with other kids. They frequently fail to recognize and respond appropriately to others’ body language or facial cues, and they cannot fully comprehend cause and effect.

Finally, exposed children seemed to lack a conscience and were unable to show remorse—concepts that typically develop shortly after the first year of life. They were also easily overwhelmed in stimulus-rich situations, which led to behavioral issues. “Becoming more successful in the classroom required instructing the children in settings having intentionally lowered levels of stimuli,” researchers advised.

“The real takeaway message of all of this work is that drugs like methamphetamine and cocaine result in babies being born more vulnerable to other conditions, other insults, than those that are not exposed,” says Lester, who was the principal investigator on the IDEAL study. “The key to their development depends very much on the parenting environment and socio-demographics.”

Children with PME show increased vulnerability and fragility, he says. Without intervention in a positive environment, they’re more likely to develop problems like ADHD, attentional issues, acting out behaviors, or internalized problems such as depression and anxiety.

“If a methamphetamine exposed baby grows up in a really good environment, odds are they’re going to be fine because you can build resistance and recovery and get rid of the fragility in a positive environment,” he says. But “if you put a fragile baby in an adverse environment, they just never recover. They’re much more prone to developmental problems down the road.”

Intervention and Environment
Studies support the idea that a nurturing environment can positively impact development in children exposed to drugs in utero. Researchers studied children born to heroin dependent mothers and adopted at a young age and raised in a “good” environment. They were found to have normal intellectual function despite a high rate of inattention and behavioral problems.8

IDEAL researchers, who studied children up to the age of 7.5, recommended that professionals in various settings, including social work, encourage parents to monitor their child’s development. Parents should also be empowered to advocate for their child when needed by providing them with the necessary knowledge and tools they need to do so.

The challenge, says Brown University’s Lester, is that there is no checklist for social workers, educators, or parents to follow when it comes to knowing what those tools are or what types of intervention will be best for a specific child.

“What you do is treat the symptoms the child has,” he says. “There’s no such thing as a ‘methamphetamine treatment.’” If the child has ADHD, it doesn’t matter if it’s [caused by] the methamphetamine exposure or not. What matters is that the child has an attention deficit, so you do what you would to treat that deficit.

“There’s no magic bullet. It really is a matter of treating the symptoms,” Lester adds. “Involving the support system, the family, is absolutely crucial. Kids with problems can be demanding and put a lot of stress on the family system, and then you have a mismatch between child and parent. But once they understand what’s going on, parents can really become helpers, working and aligning with their child and doing things together. That can also go a long way to reinforcing the parent-child relationship.”

ORPARC’s Morris-Jacobson concurs, noting that PME impacts can be challenging to discern from other factors impacting kids coming into care, including trauma and disrupted attachments.

“PME and drug impacts can mimic and mirror other conditions—or trigger other symptomatology whose roots may lie elsewhere—that look like ADHD, anxiety, learning differences, neurodiversity, etc,” she said. “PME or other drug impacts may not surface more obviously until children are school-aged and social and academic expectations increase. Even then, providers may not make the connection between the early exposure and present-day behaviors or challenges.”

As such, Morris-Jacobson recommends social workers and other child welfare professionals practice “radical and robust early intervention” focused on providing an optimal and healthy, enriched environment when it is likely a child in their care has had some level of prenatal exposure.

“Be diligent in providing a menu of rich, sensory input—guided by the child’s tolerance, of course,” she said, as well as creating early learning opportunities and large and fine motor skill development.

For parents, Morris-Jacobson urges frequent and meaningful interactions such as reading to the child and incorporating activities like music and rhythm, exercise, and movement as often as possible. Additionally, “Be prepared for relentless school advocacy, utilizing supplementary learning options, tutoring, and any other advantages you can access. Watch, monitor, and optimize nutrition—another factor often overlooked in our foster and adoptive children, and impacted by prenatal factors.

“Plan on having to educate—with prudence—as needed, adults who interact with your child. Not all adults can safeguard a child’s history and health details appropriately and responsibly,” she adds.

Ending the Stigma
One of the most impactful actions social workers can take to support children with PME and their families is to work to end the stigma attached to being exposed to methamphetamine or any other drug during pregnancy. Lester notes that some children find themselves bullied or shunned when those around them discover they were born with PME.

“That really does a number on their self-concept,” he says. “[…] One of the best and strongest predictors of good outcomes for these kids is a really strong relationship with somebody. It could be an uncle. It could be a priest. It could be [anyone]. But they need to have that anchor and to get involved in community activities; to get out there in the world, have friends, and not feel isolated.”

The stigma can also create hostility toward the mother or parents, which creates mistrust and an unwillingness to seek out support, Lester says. That is why “the best thing social workers can do is to work on gaining their trust. They have to believe that you’re on their side and that you want to help them […] not reject them.”

He adds, “If I were teaching social workers today, I would help them deal with their prejudices, if they have them, so they don’t visit them on patients.”

Morris-Jacobson advises social workers to help the child and parents surround themselves with supportive peers and well-resourced professionals who will celebrate the family, and to help arm them with “compassion and forgiveness for those who will struggle to understand the complexity and beauty” of the child.

“Children and their brains—even if substance-exposed—are incredibly unique, mysterious, and resilient. Their behaviors may sometimes get in the way of us being able to savor and appreciate their special gifts,” she says, adding that social workers should focus on helping parents and families understand. “There is always hope if you have the courage to pursue and embrace the journey hand in hand with your child.”

— Elizabeth S. Goar is a freelance health care writer from Wisconsin.

References
1. Young-Wolff KC, Slama NE, Sarovar V, et al. Trends in Self-reported and biochemically verified cocaine and methamphetamine use among pregnant individuals in northern California, 2011-2019. JAMA Netw Open. 2022;5(12):e2248055. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2799805.

2. Hayer S, Garg B, Wallace J, Prewitt KC, Lo JO, Caughey AB. Prenatal methamphetamine use increases risk of adverse maternal and neonatal outcomes. American Journal of Obstetrics & Gynecology. 2024. 231(3): 356.e1-356.e15

3. Kennedy E. Babies born to meth-affected mothers seem well behaved, but their passive nature masks a serious problem. ABC News, Australian Broadcasting Corporation website. https://www.abc.net.au/news/2020-01-03/the-hidden-problem-of-babies-born-to-meth-affected-mothers/11829668. Published January 2, 2020,  

4. Sam N. Behavioral problems in children born with meth or crack in their systems. Psychology Dictionary website.
https://psychologydictionary.org/article/behavioral-problems-in-children-born-with-meth-or-crack-in-their-systems/. Published January 9, 2016, . 

5. Lagasse LL, Derauf C, Smith LM, et al. Prenatal methamphetamine exposure and childhood behavior problems at 3 and 5 years of age. Pediatrics. 2012;129(4):681-8.

6. Diaz SD, Lagasse LL, Derauf C, et al. Effects of prenatal methamphetamine exposure on behavioral and cognitive findings at 7.5 years of age. The Journal of Pediatrics. 2014;164(6). 

7. “Prenatal Exposure to Drugs of Abuse May Affect Later Behavior, Learning.” NIDA Notes, National Institute on Drug Abuse, November 1998.
https://archives.drugabuse.gov/news-events/nida-notes/1998/11/prenatal-exposure-to-drugs-abuse-may-affect-later-behavior-learning. 

8. A Ornoy. The impact of intrauterine exposure versus postnatal environment in neurodevelopmental toxicity: long-term neurobehavioral studies in children at risk for developmental disorders. Toxicology Letters. 2003;140-141:171-181. https://www.sciencedirect.com/science/article/pii/S0378427402005052.