Mental Health and care situation in school-aged children prenatally exposed to alcohol and other substances: a hospital based study
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Background: Prenatal exposure to substances, including alcohol, opiates and illicit drugs, may influence a child’s neurodevelopment and possibly impact on their subsequent mental health. Maternal use of substances is an increasing public health problem, and it is difficult to obtain a true estimate of the prevalence of prenatally substance-exposed children, partly due to stigmatization and the illegal nature of substance use. Alcohol has well-known teratogenic effects, and its prenatal exposure is associated with fetal alcohol spectrum disorders (FASD), with the development of neurodevelopmental impairments across the lifespan, including an increased risk of various mental health problems. In contrast, less is known about the long-term consequences of prenatal exposure to substances other than alcohol, and previous studies examining its possible effects on neurodevelopment and mental health have shown mixed results, although some studies have reported neurodevelopmental impairments persisting into school age and later into adolescence. It is difficult, however, to distinguish between the possible effects of prenatal substance exposure and those of other factors associated with a child’s neurodevelopment and mental health such as genetic and environmental factors, including the caregiving environment. Objective: The objective of this study was to assess mental health and investigate the care situation and use of supportive measures in a hospital-based population of schoolaged children prenatally exposed to alcohol and other substances, compared to a reference group. Methods: This study included children, aged between 6 and 14 years, with prenatal substance exposure who were referred to the Department of Pediatrics at Haukeland University Hospital in Bergen, Norway, from January 1997 to December 2012. Referral criteria included symptoms of developmental impairment, in the presence of a medical history of prenatal exposure to substances. Children with confirmed prenatal exposure to substances, including alcohol, illicit drugs, illegal use of prescription drugs, and opioids used in opioid management treatment programmes (OMT), were included in the study. Of a total number of 128 children referred, 87% (n = 111) gave informed written consent and were included in the study. Based on the mother’s main substance of use during pregnancy, children were systematically categorized into two groups: (1) prenatal exposure to alcohol (FASD group); and (2) prenatal exposure to other substances. Information on the care situation and use of supportive measures was obtained from the children’s medical records, and relevant questionnaires were completed by their caregivers. Mental health was assessed using three different standardized questionnaires: (1) the Strength and Difficulties Questionnaire (SDQ); (2) the Swanson, Nolan and Pelham Questionnaire, revision IV (SNAP-IV); and (3) the Autism Spectrum Screening Questionnaire (ASSQ), which were completed by children’s current caregivers. For mental health assessment, outcomes were compared to a reference group derived from the population-based Bergen Child Study (BCS). Results: Of 111 children prenatally exposed to substances, 50 (45%) children were prenatally exposed to alcohol and 61 (55%) to other substances. More than half (59%) were boys, and 86% were living in foster care, of whom 30% were placed into foster care during their first year of life. In addition, 92% of the children in foster care had additional supportive measures, including reinforced foster care, school and/or social support. In the assessment of mental health using the SDQ, 105 children completed the questionnaire and were included in this part of the study. SDQ subscale mean scores, total difficulties scores and total impact scores were statistically significantly higher in the group of exposed children, compared to the reference group, indicating a higher rate of mental health problems in the exposed group, as well as problems in more than one domain of mental health. There was no statistically significant difference in scores between the group of children mainly exposed to alcohol and the group mainly exposed to other substances. Further evaluation of mental health problems associated with social skills challenges, hyperactivity and inattention was performed for the group of children exposed to substances other than alcohol, using the SNAP-IV and ASSQ. The children’s caregivers reported an increased number of symptoms associated with attention-deficit/hyperactivity disorder (ADHD) in the areas of both inattention and hyperactivity/impulsivity, as well as a higher number of symptoms associated with autism spectrum disorders (ASD), compared to the reference group. Conclusion: In this hospital-based population of children prenatally exposed to alcohol and other substances, the children were found to have an increased risk of mental health problems affecting their daily life functioning, when compared to a reference group. The mental health problems present were not restricted to one specific area, but rather represented problems in more than one domain of mental health. Children mainly exposed to substances other than alcohol were found to have an increased level of symptoms associated with ASD and ADHD in the areas of inattention and hyperactivity/impulsivity. A high proportion of the prenatally exposed children lived in adoptive homes or in foster care. Children in foster care often had supportive measures, in addition to their placement outside their biological home. The high level of use of care and supportive measures could be a reflection of the children’s increased care and support needs, which, in turn, may be associated with an increased risk of mental health problems in the group of substance-exposed children. Further research is needed both on diagnostic investigation of mental health problems and on determining the care and support needs in children prenatally exposed to substances. Clinical implications: Because of the increased risk of mental health problems associated with prenatal substance exposure, early mental health assessment in children prenatally exposed to substances should prove beneficial. In addition, children’s caregivers should be aware of the range of mental health problems that exposed children are at risk of, and increased levels of supportive measures should be put in place accordingly.
Has partsPaper I: Sandtorv, L., Haugland, S., & Elgen, I. (2017): “Care and Supportive Measures in School-Aged Children With Prenatal Substance Exposure”, Scandinavian Journal of Public Health, Vol. 45: 782–8. Full text not available in BORA due to publisher restrictions. The article is available at: https://doi.org/10.1177%2F1403494817713544
Paper II: Sandtorv, L., Hysing, M., Rognlid, M., Nilsen, S., & Elgen, I. (2017): “Mental Health in School-Aged Children Prenatally Exposed to Alcohol and Other Substances”, Substance Abuse: Research and Treatment, Vol. 11: 1–8. The article is available at: http://hdl.handle.net/1956/18048
Paper III: Sandtorv, L., Fevang, S., Nilsen, S., Bøe, T., Gjestad, R., Haugland, S., & Elgen, I. (2018): “Symptoms Associated With Attention Deficit/Hyperactivity Disorder and Autism Spectrum Disorders in School-Aged Children Prenatally Exposed to Substances”, Substance Abuse: Research and Treatment, Vol. 12: 1–8. The article is available at: http://hdl.handle.net/1956/18885