( ' 
..- -'
f;; 
OF INSPECTOR GENERAL 
OFFICE 
OFFlCJ:OFEVALUATION  AND INSPECTIONS 
1990 
JUNE  - - ' '"- '.. . (?
4 .  . 0 
. 1

'i 
'7' 
OFFICE OF INSPECTOR GENERAL 
The mission of the Offce of Ins  ctorGenera (OIG)is to promote effciency, effectiveness.--
and integrty of program in the United States Dcparent of HealthlJd Huma Services / 
(HS). It does this by developirigmethOds to detect and prevent frud. waste. and abuse. 
Secrta 
and the Congrss 
statUte in 1976. the Inspector Genera keeps both the 
Created by 
progrs 
fully and curntly infonnedabout  or maagement problems and reommends 
corrctive acnon. The OIG perform its mission by conducting audits. investigations. and 
sta 
inspections with approximately 1,300  strtegicaly locate around the countr. 
OFFICE OF EVALUATION AND INSPECTIONS 
th 
This repon is prouced by the Ofce of Evaluation and Inspeons (OE!), one of  major 
Ofce of Audit Servces (OAS) and the Offce 
offces within the QIG.  The other tWo ar the 
of Investigations (01). The OEI conducts inspetions which ar tyically shon-tenn stUdies 
designed to determne progr effectiveness. effciency and vuerabilty to frud and abuse. 
The purse of thisreponis to examne how crack babies ar afectig the chid welfar 
prgrs 
system in severa major cities. A separtcrepo identies  and PI'edurs 
adcte 
mothers and their babies. The study was 
considere effective in workiQgwith crack 
prepar under thecition of Joy Quil. Regional Inspetor General, Ofce of Evaluation 
Region-llI.Pancipatig in ths prjec were the followig people: 
and Insptions, 
Philadelphia  Headq uarters
Al 
Projecluader  Levie 
Joseph G. Whte, 

Lehmn 
Lois C. 
Lida M. Ragone

. Isabelle Buonocor 
Cynthia R. Hasford 
San Francisco 
Cynthia A. Lemesh 
Schi 
Mashall 
Tricia Banniter  .... , "- ) '
 . - - 
CRACK BABIES

Richard P. Kusserow 
INSPECTOR GENERAL 
OEI-03-S9-01540  JUNE 1990
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EXECUTIVE SUMMARY 
PURPOSE 
Thi  repon examines how crack babies ar afectig the child welfar system in several major 
cities. 
BACKGROUND 
Crack is cocaine in a smokeable fonn. It fIrst appear in the Unite States durng the 
mid-1980' s. Although crck is on.1Y one method of ingesting cocaine, we use the terms crack 
boy 
and cocaie synonymously in this repon as their detetion in the  does not differ. 
The Nationallnstitute on Drg Abuse (NIDA) estimates that over 6 mion women of chi)d-
bearng age are using ilegal substaces; for 1 millon this means cocaine. The President's 
National Drg Control Strategy estimates that 100,00 cocaine expose babies are born each 
year. 
Prnatal cocaine exposur can lead to prematu bin, low binweight, bin defects. and 
respirtory and neurological problems. Crk babies have a signcantly higher rate of 
Sudden Infant Death Syndrme (SIDS) than babies who have not ben prenatay drg
wi 
exposed. While most expens believe that may crk babies  sufer developmenta 
disabilties, the full rage of long-tenn effects of prenata cocaie exposur is not known. 
When crck babies ar identied. local child welfar agencies ar usualy notied to provide 
prOtective services, social services. or foster car. However. these agencies ar often unable to 
meet the needs of crack babies and their mothers. 
asts  crk 
While some State and local governments have done studies on  of the  baby 
problem, linle data is curntly available at the national level. Severa studies ar underway 
the Federal level to gain insight into this problem. 
METHODOLOGY 
Wee coxnductep on-sitee intervnews ins 12 m.etr opolita aras durng the last quanr of 1989. 
casworkers, hospita soial servces 
Respondents included child welfare admistrtors and 
staff. private agency representatives. foster parnts, State and local offcials. and national
We also reviewed numerous studies and public documents on ths subject.  ~~~
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FINDINGS 
WE ARE ONLY SEEING PART OF THE PROBLEM 
The scope of th problem is wid-raging. 
Ony two-th of the cities we  crk  repo
visite could prvide the numbe of  babies 
the chid welfar system. These eight cities handled 8,974 crk baby cass dmig the 
prvious yea. These cities resuennt p20o p ent of the popultion of U.S. cities of mor than 
50,00. May crk cas ar  estite tht 
crk babies ar repo The actu figusS owmee  orebstpanedden tcos upled with the ounlny dhael pofo tghe
phenomenon, ar constent with Prsidnt Bush's Nationa Drg Contrl Strgy
which estis 100,00 coaie babies bo pe yea. 
est 
We  the cost for hospita deliver, peata car, and foste ca thugh age 5, for
those chidrn who nee it, for just these 8,974 identi babies wi apprxite $500
mion. 
Fl 
ses. 
Crk babies mSaye arlsso  eresuttie ost her  The  Dearnt of Heth canrd  
Rehabiltave  anua 
rey  an  cost of over $4,00 pe chid to get  babies 
idenftoir  school. If other Stas in olDstdy wer to prvide  simi1S1T seces for these 8,974
adtiona 
babies, the  costs for developmenta inteention, edcaon, and heath
seces thugh age 5 could be as high as $1.5 bilon. 
ses 
Wcrkhe-e txhepses cea cculhtiionnss  apdfote  n aotg ei n5c,l suud ha cnyo scto swts if oarl  lbee sgu bwshtiacht im. Iany  bPee rnenuylvia nby f soorm  e
exaple, one yea tofr  nt edcsaopn  in  cls for a  diledd cihtui c osts $7,90. A 
yea of residenti  and  edcaon for an emotilonaa y  chid cost 
$25,00 to $47.s00. Th averge episo of jutvrenniet d,e tention  15 days and costs abut 
$2,20. If a juveni reuis resinti drg  cost ca be $15,00 or mo. 
sug reh 
The NIA is cusnetlys   on the cost to counties of prvidig
adct prgnt 
comphensive  to  women and their chidrn. Addtiona reseah is 
plaed on cost an  foste ca. 
benefits of 
There is no 
tyical crllk baby. 
pa 
Ther is no tyic set of sign or  by which cto rid enti a coe-e  se inant A 
exp 
Los Angeles County stdy found athpt 7 0 pent odf o  babies ar ful te 2 One 
th beus 
suggests  the babies  heathy, 
coce  so  fruently do not detet the subtle 
signs of  expsur. Therfor,  babies ar dischaed without being reognze 
as drg-expsed 
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People Are Worred About The Effects Of Prenatal Exposure To AU Drugs, Not Just Crack. 
Crack is not the only drg threat to the lives of crack mothers and their babies. 
Respondents want leadership and action. 
RECOMMENDATIONS 
Slale And Local Go).'ernmentsShould: 
Encourage outreach and community involvement with aggrssive campaigns 
emphasizing the dangers of prenata drg and alcohol exposur; 
Reduce placement barers by reviewing and revising existing laws and policies on 
abandonment. termination of parntal rights. and interracial placement; 
sta; 
Develop guidelines and trning for child welfar 
Establish reportng and trcking systems; 
integrte fundig. 
Expand interagency mechansms to coordnate servces and 
The Office Of Human Development Servces Should: 
Identify and disseminate practices considere effective in dealing with 
drg-exposed baby cases; 
Focus service strtegies on serving the famly; 
Evaluate obstacles to placement including policies on famy reunification, 
voluntar termnation of parnta rights, and restrctions on foster car and 
adoption. 
The Office Of Human Development Servces And The Public Health Serve Should: 
Coordinate Depanmenta activities relatig to drg-exposed babies and their 
families; 
exposur. 
Conduct shon- and long-tenn research on the effects of prenata 
treatment mOdels. and placement outcomes;  / . 
. .--. - - -- .
PromOte drg abuse training in medical schools. hospitals. and child welfare 
agencIes; 
PromOte prevention through public outTeach and inf:'nnationaJ materials. 
;f 
Sen.'ice And The Health Care Financing Administraton Should: 
The rublic Health 
Continue to suppon targeted. intensive outrach and prenata1 care for substance-
abusing pregnant women and their babies. 
COMMENTS 
;..cJ comments on the draft repon from the Offce of Huma Deveiopment Services
.. .1;..

(HDS), the Public Health Service (PHS). the Health Cae Financing Admnistrtion (HCFA). 
and the Assistant Secrtar for Planning and Evaluation (ASPE). Respondents were generally 
supponive of our findings and recommendations. Suggestions to strngthen recommendations 
ben incorprate into the repon. We also 
and a number 0 " technical corrections have 
expanded discussion on some issues in respnse to comments frm al respondents. The full 
appendi. 
te\.l of comments received appear in the  . ..  ...   ...   ...   ...   ....    ....    ....    ....    ....    ....    .....     .....     .....     ......      ......      ......      ......      ......      ......
. . . . . ..  ..  ..  ..  ..  ..  ....    ....    ....    ....    ....    ....    ....    ....    ....    ....    ....   . .... .   .  .. ...     .....    . .... .    . .... .    .. ...  .   .. ...  .   .. ...  .   .. ... . .   . . ... . .   . . ... . .   . . ... . .   . . ... . .   . . .. . .  . . .. . .  . . .. . .  . . ...  .   .. ...  .   .. ..  .  .. ..  .  .. ..  .  .. ..  .  .. ..  .  .. ..  .  .. .   ..;  -..  ..  ..  ..  ..  ..  .. .
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TABLE OF CONTENTS 
EXECUTIVE SUMMARY 
INTRODUCTION 
FINDINGS 
We are only seeing part of the problem 
The child welfare system struggles to cope 
Most crack babies go home, 
but many go into foster care 
People are worrierl about prenatal exposure 
crack. . 
to all drugs, not just 
RECOMMENDATIONS 
ENDNOTES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
. . . . . . . A. 1 
AGEtJCY COMMENTS  INTRODUCTION

PURPOSE 
This repon examnes how crck babies ar afectig the child welfar system in severa major
cities. A companion repon identifies progrs 
and procedurs considere effective in 
workig with crck-addicte mothers and their babies. 
BACKGROUND 
Crack is cocaine in a smokeable form. It flIt appear in the Unite States durg the 
mid-1980' s. Although crk is only one methOd of ingestig cocaie, we use the terms crk 
and cocaie synonymously in this repo as their detetion in the boy does not dier. 
The National Institute on Drg Abuse (NA) estites tht over 6 mion women of chid
bearg age  ilegal substaces; for  mion ths mes coce. 
ar using  The Prsident 
National Drg Contrl Strategy estites that 100,00 coe-expose babies ar bo each 
year. 
Prnata cocaine exposur can lead to prmatu bir, low birweight, bir defects, and 
Crk  signcatly 
respirtory and neurological problems.  babies have a  higher rate of 
Sudden Infant Death Syndrome (SIDS) than babies who have not 
ben prnatay drg
exposed. Whle most expert believe that may crk babies wi sufer developmenta
disabilties, the full rage of long-term effects of prnata cocaie exposur is not known. 
Four Deparent of Health and Huma Servces agencies ar ditly afecte by the incrase 
birs: 
in crack baby  the Offce of Huma Development Servces (HS), the Public Health 
Service (PHS). the Health Car Financing Admstrtion (HCFA), and the Soc Securty 
adte 
Admnistration (SSA). These Fedra agencies fund servces for crk- mother and 
prgr, 
their babies thugh a varety of  most operate at the State and loc level. 
crk 
When  babies ar identied loc chid welfar agencies ar usuay notilC to prvide
ca. 
protective servces, social servces, or foster  However, these agencis 
ar oftn unable 
meet the nee of crack babies and their mothers. 
Most crck mothers ar not tenager. Most oftn, they ar between their ealy 20's and 30' 
cwithh ianl davrernage.  aCge orf k
  babies 2rS etpo o28  tyoe atrh.e  Uchsiuda lwye,l tfhaery  shyasvtee mb eatwr epenr twiyo a nbd lfaou,r  wotihthe ra smer 
d even fewer whites. 
number of Hispanics 

While some State and local governents have studied this issue, litte data is cWTntly 
available at the national level. Both HDS and PHS have studies underway to gai 
insight into
the problem. The Genera Accountig Ofce (GAO) is also studyig the costs of seces for 
this population. In addtion, the Ofce of Insptor Gener (OIG) is conductig two relate 
inspections on the termnation of parnta rights and laws regarg prnata exposur to 
substace abuse.
 . -
METHODOLOGY 
We conducted on-site interviews with over 200 respondents in 12 metropolita aras durng 
the last quanr of 1989. The sites included: Chicago, Fon Wayne. Los Angeles. Miam. New 
Washington, 
York City, Newark. Oakand. Philadelphia. Phoenix. San Francisco. Tacoma and 
varng siz 
and location 
C. We selected these sites to give a perspective on how cities of 
bins. 
were being affected by crack baby 
Respondents included child welfar adnistrtors and casworkers. hospita soial services 
local offcial. We also 
staff, private agency representatives, foster parnts. and State and 
interviewed national expert and reviewed studies and public documents on the subject.  ()  , , 
._- , .. - -  , '  . p 
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L. 
FINDINGS 
WE ARE ONLY SEEING PART OF THE PROBLEM 
The scope of the problem is wid-ranging. 
Only two-thirds of the cities we visited could provide the number of crack babies reponed to 
the child welfar system. These eight cities handled 8, crk 
974  baby cases during the
previous year. These cities represent 20 percent of the 
population of U. S. cities of more than
50,00. Many crack cases ar unrpone. Some respndents estite 
that only half of the
crack babies ar repone The actual figurs we obtaed coupled with the underrportng
phenomenon, ar consistent with Prsident Bush's Nationa Drg Control Strtegy repon
which estimates 100.00 
cocaine babies born pe year. 
We e:;timate the cost for 
hospita delivery. perinata 
car. and foster car thugh age 5, for
those children who nee it, for just these 8,974 identified babies wi 
approximte $500
milHon. 
Crack babies may also reuir 
other servces. The Florida Deparnt of 
Heath and
Rehabiliutive Services estimates an anua 
cost of over $4,00 pe chid to get 
r:ad ' for school. If other States in our stdy wer to prvide simila servces for crck babies
these 8.974
ide  rified babies, the addtional costs for developmenta 
inteention, edu ation. and health
ser\'kt"I; through age 5 could be as high as $1.5 bilon. 
Whi;e these calculations do not include any costs for servces which may be 
recuir by some

.:k :" :;:.:s:d children after age 5. such coSts wil 
also be substatial. In Pennsylvana, for
exarnpk, one year of special education in a  leang 
clas for a  disabled child costs $7 900. A
year of residential treatment and 
c;pccial education for aJ emotionally di!;turbe 
chHd Ci.sts 
S25.  to $17, 5() The  f;l,v 
$2.250. If a  :)ve:r:tge  pi: :)(e 
 "i11" deientif)n lnc;t  15 day:. ",fIr!  I'''IS  bi),.!(
J'JVt!l j  UU' C:- "  ;dc1.IJ;.  lt alrnni , co.;ts can t)  :1 i,:X:r: 
is cUIcntly supportng res 
Tbe  NlDA  ch on ..he costs i" communities ,; 
('v'  : n
"sive services to 
1"".,,,,  addicte pregnant woml n and their children. '\d,1.iridi f I,-S 
","' costs and benefits of foster car.  ir. 11 is

There is no typical crack baby. 
There is no tyical set of signs or pattrns by which to 
identi a cocaie-ex  sed inant. A
..U  Count)' study found that 70 percent of crk 
. ."C";'': 
 babies ar full term 2 One expen
:hat because the babies appear healthy, doctors 
fruently do not detet the subtle 
'.Jaine exposure. Therefore. some babies are discharged without being 
p:. of 
 reognize
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sp 
Crk 
babies ar mor lily to be born prmatu and to have  mecal nee. Expns 
repon th crgkr b abies ar nealy 4 tis mor liely to be bo with low bir weights 
(under 2500  or about 5.5 pounds) than babies not expse to drgs in Ute. 
An estite 18 pent of crk babies ar bo prma with complicatons and reui
4 One respndent told us 
morn 
extende intensive ca.
 that  tehnology alows physicians
to save may babies who would not have surved even a few yea ago. Th is espaly 
gr, 
tre of the ver low bir weight babies (5001500  abut 1 to 3 pounds).. . 
sp 
Some crk babies reui  medca attnstiopn a f hospita dichae. These chidrn 
ar designat as medcaly neey and reui 
seces frm their mother or foste 
fames. 
bir 
Most crt1c babies  idntfid li 
Il not 
Inconstent testig is one reon may crk babies ar not idntied at bir. Accorg 
hospita  physici
respndents, publi  ar the only ones testig; most prvat hospita and 
do not test. Whe no Sta visite madas unver 
testig of mother for contrlled 
substaces, tIend ian dos reui tetig if ther is suspicion of drg expsur. One hospita in 
our saple  al newbo. 
re 
The majorty of phosrpit a in our suey rely on mother to self- drg 
use. At leat four 
us th as their  methOd of identication. Some respondents crtici usg ths 
methOd exclusively. A suey in one Florda hospita found onaly d27t tp ent of the prgnant 
women testig positive for drg us at la an dever ha 
their use. 
Five of 13 hospita visite us spc teg plrato ls, and thes va in deta and sc.
Testig crte ca include suspte drg use,  of prna ca, prma delivery, 
neona intensive ca adsion, and indicaons of a sexuy trsmtt dise. Some 
spc 
respndents ar conceed th relice on self-repog and the absence of  testig
inco 
prtools me tht low- and miorty women ar being teste whie white and midde 
clas women ar not. Th results in mo miorty and low-income babies being identied as
drg-expse 
lite 
Even when tests ar conduct they prvi only  inortion. Most tests can detet 
coaie in the system for only 24 to 48 hour. 
fue 
Crll1c babies IlIe  problems. 
crk 
When consideg how soety wi de with  babies, some respndents emphas that 
the envinmnts in which these chin ar rase wi playa major role in their 
development. In one exp s view, the re issue is how much dage is acaly attbutable 
to the chid' s home envinment as oppse to in ute expsur to drgs.  / . 
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wi 
May respondents ar concerned tht drg-expose babies  sufer long-te prblems. 
They caution that the effects of cocaie expsur may not appear unti the age of 2 or 
These effects may include neurlogical and behavior problems, attntion deficits, and 
:f 
developmenta delays. 
wor  wi  crk 
May respondents  what  happen when  babies reach school. Those who have 
leag 
worked with crk babies say the chidrn wi have sever  disabilties as they grw 
olde. We were told, "These chidrn nee speia education. If they don t get th we ll se 
si 
them in juvenie cour late." The Los Angeles Unied School Distrct has develop a 
prgr 
for drg-expse babies at the preschool level.  exits in 
spial curculum 
Chcago. 
May chidrn ar stayig in foste ca longer. As rently as 1985, nationwide mean 
foste ca stays raged frm 9 month, for those who ha left foste ca, to 1.5 yea, for 
those who sti rema. However, offci fr 2 cities in our suey repo the cunt 
average lengt of  yea and 4.  yea respetively. 
stay as 3 
Accg 
Chdrn ar also enteg foste ca at a younger age.  to a rent New York State 
repo "Ipn 1r98y0,  only 19 pent of the foste ca caloa was unde 5. Tody it is over 50 
pent,  due to crk. .. 
th 
Accorg to sever respndents, crk baies have mor prblems bondig  other 
babies. Researher repo tht even in the ca of their natu parnts or a peent fostr 
parnt, crk babies have diculty bondig. Some reseher attbute a pon of 
dage 
prblem to organc  cause by the drg exposur. 
drg-expse chidrn bo th 
The followig grph depict the potenti populaton of 
dead, bas on curnt anua estites of crk-, coce-, and drg-expsed birs 
birs, 
Whe the prjections shown assue no change in anua drg-expsur  th  ther ar 
irndeica tions the numbe of drg-expse birs is incrg. In Caora,  hospita 
num  bir 
re the  of drg-expsed  have at let doubled sice 1986. One of these 
incr  ye. 
an 84 pent  in 2 
Inteewees tell  afhocks of the crk epidmi wi be felt by soety for may 
us the  sto crk 
woul 
yea. As one respndent sad, '  ven if we  use right now, we  st be 
deg  ye.  racaons ar 
with its effects in som way for the next 50 to 75  The 
forver..  s a horble cycle!"  - - 
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Projection of Drug Exposed Children by the Yesr 2000 
4,1 
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Nwbe of 
I8TE  IITlI8TE  IDunTE 
LO 
01 '
C..I "D'u
  
AN ALREADY OVERBURDENED CHILD WELFARE SYSTEM STRUGGLES 
TO COPE. 
Crack baby caes ar compUct*d tU ti-consming.

vite  incrg  re  rela 
In most cities  an  majorty of chid welfar cas ar drg  The New 
incr 
York City Mayor s Tas For on Chd pAbrusye an dc Nreg lfecr    a 72 pent 
JCla to drg dendnc,  1985 to 1988. 
chid abuse 
cr 
th 
State offci conteCnd rth tu  s rebparbseyn ct aa sd aierr nmt oki dco omfp l(epx tevoet hseer ccheisd) w  elfar cas. 
One offci sad, " Cr 
ca. TheJC is a lot mor abandonmnt an vio enc.  baby caes reui extensve 
trkig and follow-upa. Tlyh  ca be dicult for caewor to prvide when confnte 
caloa 
with the reties of an  overhelmg 
sup  as 
adte 
Drg us ca  of the lives of cr- mother. In the word 
al other 
"i  agat a 
of one cawor, worg with the mother  li betig your hea  brick 
deg 
wal...beause you ar  with somne who ha no contrl over her lie. She s wored 
about her next hiL

Caework ca spnd days trkig mother who give false adsses to hospitas and then 
ti-cnsumg 
abandon their babies. Oter  acvities include fidig emergecnhcyi npl.a cements, 
foster ca, parnta drg tttmnt, and seces necssa for spal nee  acorg 
to sever respndents. Caeworer 
Chid welfar caswor is a dagerus job, 
rao 
home evaluations ca involve enterig hostie sitUations, unescon and without 
casworke burout or 
contat. Peronal dager, strss, and relatively low pay contrbute to 
resignaton. One city offci repo ha of the sta had ben workig less than 1 year. In 
another city, the average tenur of a chid prtetivep wrorger sis  2 yea. High tuover results 
caworker 
in lak of servce contiuity and complicates legal  beause severa 
yea. 
may work on a case over the 
wor caseload in may cities. For example, one chid welfar 
We found lage chid welfar 
agency offcia report an averge caeloa of 49 chidrn for foster car and 161 for 
Ch  mor 
protetive seces. The  Welfar Legue of Amerca reommnds not  than 17 
acve cas for wor deg with abused or neglec chidrn and their fames. 
chi 
nu  liuse. 
Prentl expsure to drgs  not be trlld IU 
repo 
Babies who test positive for contrUed substaces ar not always  to chid welfar 
te  tan depend on how a Sta defies chid abuse or neglect. These
offcials. The actions  Intor 
Ofce of 
ar not intehageable and the distiction ca be signcant. The 
Sta 
Gener is curntly conductg a stdy to assess how  legal defitions afect the 
expsu cas. 
handlg of prnata drg 
ad 
Indi  bo 
law prvis tht a chid  to drgs cpa lbae  conside abuse 
neglecte In For Wayne, the baby and any sibligs ar  in prtetive custOdy pendig 
an investigation. An Dlois law effecve Januar 1, 199 states tht prenata drg exposur 
is evince of neglect. 
vite reui  repo a  chid welfar 
Ony four States  hospitas to  positive toxicology to the 
refers 
agency or a centr Sta registr. 'Some hospitas in other sites visite mae 
repo 
voluntay. At one site, hospita have ben instrcte by the chid welfar agency to 
ca  drg expsur cas 
coul not  for her chid. In another city, 
cases only when the mother 
acoman 
re. if  by other facto, such as mother self-identication or 
ar investigate only 
pror abuse 
wi crtk 
Several chi weUar agencs ar usng new /iproaehes to dell  bliy ClUes. 
dSormge -ceixtipss eha ve  9ni7OO chiaghw-rio drr g baby unts to prvidea irn tsap anyd  rtikr easdse stos ment for 
inants. The  assigned to these unts 
with the nee of the substace-abusig mother and her chid. In at leat one city, 
ICce caload. 
caworkers in these unts have 
dentr 
ha  serces into zones and comunty distrct. 
One child welfar agency 
Caeworers ar now physicay locte close to the fames they sefea.m Th s enables 
caworker to prvide bett suppo for fames and beme more  with local 
servces.  . . . ,
tred  caeworer 
ar prvidig mor casworer trg; New York City  t1,r26g4 n ew 
Cities 
worers nee mor  to identi and 
in 1989. May respndents felt tht chid welfar 
casworker 
assess the nee of substacme aabgus er and their chidrn.t eOtaetri orensp ondf epnatrsn tsaa iri ghts. 
nee for gulies for  desions regardig 
chi 
Hospit Il beginning to perform  welftlfunctions in some ci&s. 
Sever hospita offcis told us that bese chid welfar agencies ar overhelmed they 
ar tag acon. They say hospita caot aford the fiancial losrsees tth at result frm
unecssar  foste parnts.
extende  stays. In some cities, hospitas now actively 
espy  ma 
among their own sta. Some hospitas now  placment reommndations to 
chid welfar. 
adct 
coate 
seces for crk-
Sta at sever hospitas now locat, prvide, and 
mother and their babies. Oter hospitas have begu to trk clients afte dichae. 
chi 
Intragenc coordintn helps  wel/Me "gencies cope. 
Lak of coodiatoan ics tghe m ost dicut prblem fac in prvidig serces to crk babies 
'Itegency cae 
fames.  to may respndents. One inteewee sad, '
and their 
adssig th  anytg wor. 
magement is the key to  issue, if 
prgr 
ar taklg  coation., D8lois ha a 
Some States and prvat agencies  the issue of  rela prgr. 
chi 
welfar, alcoholim and substace abuse. and 
of collabtion among 
The cooate effor ha "reuce systems baner to integrte seces and alowed for a
ma 
of servces to be  avaiable to high-ri fames. ,
fu complement 
Tcheo faomy  cour divionf,a asttt etyr ggener's offce, and chid welfar targeknicgy  in  prss 
seces by " " cas thugh the system. Fas cas. Mis ai  offci 
agr  spc tis 
wher the cour  to set aside  tfo ahe a dependency 
repo th th prss ha alowe for mo and  nt deons.
crte  adss  crk 
In may sites, goveror or mayor have  ta fors to  the  baby 
prvat citins, governt offci. and meca and chid 
prblem. Staed by  sece 
exp,  prvi, remmend 
development  the ta fors identiy aDd pul tofgaetmhesr . 
monies for seces to high-risk 
policis, and integrte 

helping crll1c-lted mothers tU their 
Comprehenrve clle 1Igement  is  essent  in
btlies. 
eay intention. 
such as 
Cae maagement conscisotsu onf lgiugi,d pgh yfasimcae tsh etorp sy,e dcregs  rehabiltation, and parntig clases. 
educaton, heath car, 
reuig clints to sek out suppove seces on their own does not 
Respndents say that 
work with crk adct. Client neen are seo c omplex and their adction so overwhelmg 
tht prfessiona ca magement is  -- 
.. ..."  ,.-'. - ._. --- ,.. . ---- --" ._"-'-. ---' -'--.' ._. ._- ..- . - _.. - - .
n. ..--
:"J  -- n 
The cas maager is an advocate who lea fams thugh the system. In the wor of one 
respondent, it is unalstic to expt a crk-adcte mother to meet the "demads of 8 to 10 
ca gu 
dierent sece provide simultaeously." A case maager  and motivat mothers 
and supese car of the chidrn. Ca maagement is widely sen as the respnsibilty of 
the chid welfar agency. 
rey 
reuis tht seces be  acssible, accorg to may 
Successful cas maagement 
emphas the nee to locate servces in the counity and prvide 
respndents. They 
Their most  centr locons with 
trsponation and chid car.  fruent comment was tht 
caewor. 
multiple serces wor best; "one stop ca," sai one 
Even when seces ar availe, however, crk mother don t always parcipat. 
Crk 
Accorg to respndents, crk adC1on results in demadig, imatient behavi. 
mother someties deny they have a prblem and refuse serces altogether. 
FOSTER CARE. 
MOST CRACK BABIES GO HOME, BUT MANY GO INTO 
Most babies go home wih mothr Dr II rellve. 
offer pena insights into the demogrphics 
Although few sttistics ar ket, respndents 
crk 
of crk baby fames. USuy SO to 75 pent of identied  bavbieist geo  home with their 
mother or a relave, although the rage is SO to 95 pent at the sites  At two sites, a 
baby is put into tempo prteve custoy (for up 10 72 hour) whie the chid welfar 
agency investigats.

welfar 
Matern grdmother ar the relave most lily to tae the baby. Most chid 
mag 
worker tr to  the grother befor  any other kid of plament 
plac a baby with 
ca 
for sever chin, ar 
Respndents at five sites say grdmother, who oftn 
Ofci 
nee of drg-expse babies.  repo fater ar raly 
overwhelmed by the 
involved with the cutoy of the baby. 
ca 
reive foste  agencies prfer 
Some relaves  reimburements. Most chid welfar 
relative to foste plaments, but relaves often caot afor to ta ca of the babies. New 
fost ca 
reimburments, but opinons on 
York City prvides State-apprved relaves with 
th apph  bett 
ths appach var. Whe soe believe  is fai and results in 
monitog, other say such prgr delay reunstiotn.  of mother and baby, crte famy 
petU  ca 
the bay s foste  At lea one respndent sad 
antagoni and 
frd. 
crtes oppoties for 
trnt 
When mother ente drg  cente tht do not acpt inants, their babies go to 
relatives or foste ca. The restrctions agast inants may be due to insuce libilties and 
progr. 
the trtiona adult orntaon of trtment  Some mother must atnd out-patient 
drg tratment progr as a condition for keeping their babies. Respndpenrtsg ter   us some 
mother dr out of trtmnt or resu usg drgs, but most trtment  do not 
trk redivi 
among the mother.  ...
....... ........... .................. ...... .................... ..
............ ................................ ....... .......
Many babies go into 
foster care. 
Most offci estite 30 to 50r peepnot  of identiie crk babies go into foste ca, although 
Accorg to some off. chin may be left 
a rage of 5 to 50 percnt was 
with their natu parnts beause no foste plaments ar availe. 
Ofcials in Chcago. Newar. and Washigtn, D.C. repo crtical foste car shorges, but 
other ar coping. For Wasymne  anndu Pmhoe ni hdarvge- elixttpe sdei ubltayb fiideigs .f oster fames. Both 
cities have compartively  of 
incred 
num of chidrn in foste ca plaments ha 
As shown in the char below, the  chin 
00  in plament; 280,00 in 1986; 293, 
On a given day in 1982. ther wer 262,
in 1987; 330,00 in 1988; an an  stmate 360,00 in 1989. 
Children In Foster Placement 
Ony SUy

11 ....... 

.,0 . 
tll  tll 
Nu 
..It 
In 
..: M8 NI.. II 
Ct 
Respndents spulte thec ioncnrf o f chidrn in fost ca is due to incred parnta drg 
th 
ths caot be  Dat to demonstte  connection is not coUecte 
abuse, but 
nationwi by chid welfar agencis.

shorge of foster parnts. 
Low reimburment was the most commonly cite reason for a 
spialy for 
Respondents say reimbmsements ar to low to attt fu-tie foste parnts, 
medcaly neey babies.  ' .
unorty.  rates include the chid' 
Rate schedules ar complex and lack  Varables afectig  qual 
age and heath, the placment agency, and the servces or pructs that  for 
reimbursement. For examle, one city has eight categories of reimburment for inraentsu whi 9 / 
do not reuir consistent medcal attntion and four categores for inants who do 
medca car. With eah categor, chid welfar ha the flexibilty to determe 
consistent 
the exact reimburment rate. Over, reimburment rages frm $3,233 to $30,730 
anualy. 
acpt 
repo shorges of  homes that  spina nts. . 
Respndents also  black foste parnts and 
nee. In 
five cities respndents irenptom a p arcul shorge of homaers  pforrm iniaantns twlyith  
plaments, the babies  blak, but there
ODe State tht restrcts 
de  mor chidrn 
a shorge of blak foste parnts. To  with the demad, some agencis put 
chin  sear 
in eah foste home, shit  betWeen homes,  sibligs, and pla chidrn 
grup homs. 
trg 
repeatey tht foste parnts nee  and suppo servces. 
Respndents told us 
Accordig to one respndnt, ther is a colation betWeen such trg an a foste parnt 
wigness to contiue. Oter commente tht foste parnts nee day ca (regu and 
trsption,  bett acss 
therpeutic),  respite, and  to physical and menta heath servces 
chidrn. 
for their foster 
In sever cities, outrh effor have pruce goo results. Strtegies fruently 
ta 
incorte newspaper stoes, rao and TV  shows, and paid adverisngp. O ter 
retmnt  hospita, 
appaches include  m1ngr eprvta te fost car agencies witwh org  loc 
offerig bonuses to fost parnts wChoh    other foste parnptsr,iv aantd a genctisi  awri th 
churhes and communty grups.  welfar agencies and 
acptig  employees. 
expandig the pol of potenti foste parnts by  singles and ful-
coty 
Althoaugch you btrhe e ffor oftn result in an otuhtp mig of  respnse, the numbe 
who  fost parnts is lowe  the numbe who aply. Some applicats 
incring 
disquaed whie other lose intest Respndents also say ther ar obstales to 
the pol of fcosete  parnts and keping them. These incluidne rtemuim  ents that foste parnts 
plaments. 
live with  geogrphic lits an restrctions on 
so  stada  delied 
had,  for foste parnts have 
On the other  respndents say tht  'm'' 
Accordig to a West Coast cawor, applicants with ' quacatons who would 
ye  acpte 
have ben nued away a few  ago ar now being 
Ajew go to othr care settngs. 
Crk  ar oconay pla in other argements, such as emncy or congrgate 
babies 
is a tempo plament pendig retU to a parnt or placement in 
cfoars.te  Ecmaer.g eEnmcye rgceanrc y ca ca be a sm grup home, a lare shelfteo, ror  a foster famy. 
ma, caworker may be  to move babies 
When a long-te placment caot be  ....' .
repo tht they nee but do not have 
frm one emerency placment to another. Two cities 
emergency placment facilties. 
home. Whe use mostly for olde chidrn, 
Csoomneg rbgaabtiees c haarv ies  buesnu aplyl ap einr msuechn tc gar.u pO fals in one city reived strong public 
orgialy 
the car provide to babies in congrgate car. As a result, al babies 
cprtliaci si no cf ongrgate car have ben plac in fostec hrotmi es. Waschiag tn, D.C. is now 
foste  shorges. 
for inants to cope with 
buidig two grup homes 
commnte 
We encountere strng opinons about congrgat ca. Of 58 respndents who 
ca 
nealy ha (27) believe congrgat ca ca work as a substtute for foste  as long as the 
homes ar smt,h k ep sibligs together, andi dar  maaged mprfie ssionay. Twenty-one 
ca  opinons. 
respndents  congrgat  is a bad  10 have 
A few babies go with their mother to residenti drg trtmnt cente. Mother and babies 
prgr 
sty at these cente frm 6 to 24 months, dendig on the  and the mother 
vite  may 
trtment nee. Seven citis  have at leat one such cente, and respndents say 
mor ar n 
Som babies rema in the hospita even though mecay rey for dihae. Known 
abut 
boar babies," these inants sty in the hospita due to legal colications, questions 
pbaronts ' abilty to ca for them, or lak of ca alternves. Respndents frm five cities with
ma  tily maer. 
babies say they ar able to  plaments in  Four other cities 
repo they ar not able to ma tiely plaments. The th  remaining cities d"idB noot a 
inoron  th  repo 
Mor  on  issue is prsente in our companon 
the issue. 
Babies. 
tUP"d. 
Few crack babies lue been 
peent 
Whe  adtion to  foste ca, opinons on adtion verfuas y 
respndents prfer  exig 
famy reuncauonn dcier  wily. Mcayr  respndents sad the  policy goa of 
reuncation is  for may  babies and sily prlongs the adoption prss. 
fay reunon 
shoul rema. 
s goa of 
But other feel strngly th chid welfar 
Acg  re 
rent 
Th adtion prss is long, dit, an expDsve.  to a  frm a 
cawor gug  mo 
chidrn  advoc grup,  the prss nee to be  aggrssive 
chaenge the hures of the adtion prss, to fac a cour which seems relucptt rtos sap prve 
negoti th 
adtion, _..to (confnt) the parnt, an to  obstales of the agency 
itslf. ,, 
teaton 
babies. Ofals tell us tht  of parnta rights is 
Most prspetive parnts want 
although the prss ca theoticay be coplete in 18 months, the 
usualy conteste and  adpte 
rety  leat 3 yea. By then, these chidrn ar less liely to be  they ar not 
is at 
anym. 
babies  .:. 
1 . 
i-. 
Respondents cite other hidrces to adtion. One referr to a law whih reuis a 
Th 
7a2-dho ur waitig periOd for a mother to voluntay reliquish parnta rights.  bor,e spndent
that a crk mother may dede to reliquish her rights when her baby is  then 
loc 
leave the hospita and disappe. Neither hospita nor chi welfar sta ca  her. When 
th  ma  prss 
happens, the baby canot be  avaible for adption unti the legal 
comlete. 
intc 
Another long-stadig barer to adtion is the bias agait  plament Some 
respndents say white fames don t want blak babies; other say States and agencies 
intemc adtions. 
slow to apprve 
teate  cr 
Mwoauyld  rneospt obned aendts tbeeli eOven eth ct aewveonr ikf ep afrrnyta  risgahdt st wheer ra r not enougmho pste  le wbaibgie s 
crk 
adpt "these kid of chidrn." Prspve parnts fea long-te effec of  and 
potentiy expnsive medca, edcaona, or psychologica nee. Adptiovn istuebs idies for 
ha-topla chidrn, availe in  som cities 
al States, ar being used in 
PEOPLE ARE WORRIED ABOUT THE EFFECTS OF PRENATAL EXPOSURE TO 
ALL DRUGS, NOT JUST CRACK. 
not th onl, drg thretl to th li)'es of crllk mothrs tU thir babies.
Crllk  is 
aly 
On the West Coast, the next drg cris is  her. Chi welfar agencis ar prparg 
for babies bo to user of a methamhetae devative caed "ice." Although ice is mor 
lag  attve 
expnsve than crk, the long- high mas it  10 drg abuse. 
Methphetae  prce  feta dage. 
is known 10  raid extensve 
May respondents, espy ono thfe fE at Co we conceedc arbu t the ovep of AIS 
and crk. In the wor of one  "You ca  sear th  babmy perb lem frdm ethge  
AIS prblem." Th over of AIS an drgs for these inants oftn  we ar 
sa 
with the sam ri grups, offerg the  messages, and oftn prvig seces to the 
sae 
babies. 
ri 
Respndents sad may cr-adct womn engage in high- behavior and 
AIS-inecte babies. Fuly 70 pent of peatrc AIS cas ar the result of drg abuse 
AIS is 
by the mother or her sexua par. A loc heath offci sad, " now th laest 
kir among young women (her). We may not have to wor abut (crk baby) mother; 
de" 
they ll al be 
II 
RespoJUnts want letUrship  Ilti01L 
repey 
Respondents  caed for stng leahip, acurte inortion, and heightened 
public awarness. Theyc porin t out that crk adcts use so may other drgs and alcohol that 
it is futi to taget just  Although ther is no clea consnsus on exatly what to do, 
peple expss a sens of urency.  drg 
One suggestion by respndents was to establih a national commssion on prenata 
AIS 
exposure. Many respondents point to the succss of the National  Commssion in rasing 
Secta 
awareness and educating the public about prevention. They urged the HHS  to tae 
this proposal to the Prsident. These respndents se a national commssion as a way to 
galvanize public attention, promote  State and local governments and 
grater parcipation by 
the private sector. and generate potential solutions. It was suggested that this commssion be 
drawn from the public and private setor, and include represcntatives from a wide varety 
disciplines, such as education. health, child welfar. substace abuse. justice. and housing.  ... . ':..-.. :-- - ' . - -_.,--- - -__... ._.._- - ,. -_. _., .
RECOMMENDATIONS

We agr with respndents that the prblems of crk babies ar inseparble frm the lager 
reogn tht the impact of 
and alcohol. We also 
issue of prnata expsur to al drgs 
inants prnatay expse to drgs extends beyond the purew of th Deparnt. Whe we 
reogn tht some policy issues rema unsolved our reommndatiosnisg foncst o n acons 
fudig. 
adtiona 
which we believe ca be accomplished without  authorties or 
STATE AND LOCAL RESPONSIBILmES 
loc governts
Encourage out/Ih lI communit  State and 
1.  aggrssive outrh to inpvolvremevnt  i prnata ca for at-rik prgnt 
should conduct 
must emha the dager of prna drg or alhol 
women. These effor  idntig 
expsur. Communty and religious grups shoul be involved in  and 
helping mloethaer .a nd chin at rik. It is impot to wor with loc blak and 
Hispanc 
bar 
reuce 
2. Redue plaement  Sta and local agencis should 
bllrs  ca  Th 
placg drg-expse inants into foste  and adtive homes.  teionclnudes
tr" 
reviwig and reviing existg laws and policies on abandonmnt, 
inteal plant. Cour  'fas 
parnta rights, and  should establish '
procurs to expte chid welfar caes involvig drg abuse 
chi 
Stas  trg 
Develop guUnes  should develop gudelies for 
tU trllnig. 
welfar agencies to follow in respndig to drg expsur careis  and in 
famy 
caworke to hadle such caes. Guidelies shoul cove  assessmetnrt,e  d 
reuncaton, and teation of parnta rights. Caworke shouldd boe  ntig 
reorg drg 
identiyig substace-abuse behavior,  histors, and 
cour 
evidence for 
crte 
4.  tU tr/Ildng  States should estalish  for 
EstlUsh reporrtegp og prna d"stmrs g expsu as chid abus. Extig State 
idntiyig arnde  g  compute 
expande and 
chid abus  an trkig systems should be 
us 
The inortion should be  not only for legal pmpses, but alo for the 
ca  edca
heath  on.
prviion of  and 
Swc ansd elosc  govents should develop
S. Ezpll inmgency mec1ums.  coate 
ta fors to  and integrte fuds. These 
intitives such as  expte 
intitives shoul involve cour and prseuto to review policis and 
fames. 
preegs involvig drg-expse babies and their 
legal  / "

DEPARTMENT OF HEALTH AND HUMAN SERVICES RESPONSIBIUTIES 
Offce of Huma Development Servce 
1.  Hum  Serces 
Disseminat  'Te Ofce of  Development 
effective practices.  prgr,  conside 
(lS)  and laws or reguations 
should identiy pratices, 
th inortion 
effecve in dealg with drg-expse baby cass and dissemiate 
to State and local goverents. 'Te HDS should also underte studies to 
evaluate the effecveness of these prtices. 
grwig 
Foclls serve strate  s on servng  Because of the rapidly 
th jamily. 
number of drga-elxyps e babies, most wi be raed in their natu fames.f uer 
wi be compunde 
May fames  have multiple 
prblems, which 
by havig to de with the prblems fac by drg-expse babies. In developing 
prvig 
its serce strtegy for these babies, the HDS should plac priorty on 
nee 
inteentions with the famy, to help ensur tht drg-expsed chidrn 
fay 
grw up in cag and suppove  envinmnts. 
3. 
Evtzuate obstlles to  The HDS should evalua obstles to foste and 
eplaemsent py 
adoptive placments,  as they relate to drg-expsed babies. 
exaation should include CUInt policies regarg famy reuncaon, 
ca 
volunta parnta teation, and restrctons on foste  and adption. 
Offce of Huma Development Servce and the Public Health Servce 
Ser 
Coordi Deparnt  The HDS and the Publi Heth 
cote  activis. 
(P)  Deparnta acvities relatig to drg-expse babies 
should 
and their fames. Th reocmondoaonn  could be achieved thugh the expansion
inor 
inftreg ency  activities of HDS and PHS.
of the 

Reprsentatives  the followig HH conents shoul be include: 
Hum  Seres 
Ofce of  Development 
Publi Heth Serce 
National AIS Prgr Ofce . 
PHS Pael on Women, Adolescnts, and Chdrn with mv Inecon and 
AIS 
Admstrtion 
Alcohol, Drg Abus and Menta Health 
Mate 
Buru of  and Chd Heth and Resoures Development, Health 
Serces Admstrtion 
Resours and 
Chi  Huma Development, National 
Nationalnstitute on  Health and 
Heth 
Insttutes of  ' -
...
: J 
Famly Suppon Admnistrtion

Health Cae Financing Admistrtion 
Social Securty Admnistrtion 
Assistant Seceta for 
Planning and Evaluation 
Conduct short. and long-term research. 
 The liS and the PHS should conduct 
both shon- and long-tenn research on the effects of 
prenata exposur to drgs. 
including crck cocaine. on babies and their mothers. 
Specific aras for shon-term researh include: 
determning optimal tratmnt for 
cocaine-addcte mothers durng pregnancy 
ensur the bir of a minimally afected inant; 
examning the risk factors respnsible for drg abuse so effective prevention can be 
implemented; and 
establishing a monitoring system to surey the extent of the crk epidemic,
espeially among women of chid-bearg age. 
Speific aras for long-term reseah include: 
:udying the long-rage effects of prenata drg exposur on physical. 
psychological, and neurlogica development longitUdial reseah on these 
topics could conceivably tae up to 15-20 yea on the same subjects, with annual 
reui; 
or semi-annual repons of findigs 
evaluating long-tenn outcomes of varous tr:)tn'  I't mod Jitje!  in red  cing or 
aJcte 
eliminating drg use by women of child-bearng ag  who it  to crack 
cocaine or other drgs; and 
asSessing perment placement options and outcomes for drg-expose 
babies as 
compar 
to other babies and chidrn in the custOdy of chid welfar agencies. 
The long-tenn resources reuir (stafig as well as fundig) for each of these 
groups could also be compard. 
PromolC drug abuse training. 
 The liS and the PHS should promote drg abuse 
training in the following areas: 
k.dical schools and hospitas - Most physicias ar not traied to reognze the 
signs of drg use. As a result, physicians ar faing to identi may prgnant
women who ar using drgs as well as newbos expose in ute. Medcal school  and continuing education curcula could.include: identifyipg drg abuse 
behaviors, documenting drg and lifestyle histories, and reommending 
appropriate drg trattents. 
Child welfar agencies - MOdl trning materials should be develope and 
disseminate to State and local child welfar agencies. These materials could 
include: techniques to reognize and assist drg-abusing famlies and their 
children and examples of successful case management tehniques. Traning 
IJ.aterials should also address parallel 
servce delivery problems such as providing 
progr 
prenata car in drg trattent  and drg tratment in prenata care 
progr. 
Promote preventin through public outreach and info17onll matris. 
Existing anti-drg messages do not sufciently emphasize the dagers of prenata 
drg exposur. A comprehensive strtegy should be develope to taget al women 
of child-bearg age. including tenager, as well as junior high and midde school 
re 
students. MOdl brochurs (including eay to  ilustrte forts) and public 
servce announcements ar among the possible appro&;hcs. 
Public Health Service and the Health Care Financig Administion 
Continue to support  The PHS and the 
Health Ca Financintg/e tAed odutmach ntm ipsretlUrlol CnIl.  should contiue to suppo taete 
ca 
bt:nsive outrach intervention and prenata  for substace abusing pregnant 
women and their babies. Ths includes identiyig and disseminatig prctices 
ca 
which encourge community involvement in prenata  outrach and education.  . '
' '
. r:- -
COMMENTS ON THE DRAFT REPORT 
suve 
wer genery  of our 
Commnts reeived frm HDS, PHS, HCFA and ASPE 
reflecte a thoughtf reviw of the 
fidigs and reommendations. Al respndent comments
 incorte 
dr and may excellent suggestions wer ma. May have ben  into the 
repo In adtion, the fu text of the commnts reived ha ben include in the appendi. 
inortion 
re wi fid  in these comments. 
The  much adtional usefu 
esttes 
The HDS and ASPE reueste mo deta on our cost  for hospita deliver, 
inortion 
peata ca, and foste ca thugh age  S.  We wi prvide ths  to them.
re 
inoron 
The HDS felt tht whi the selecon of cities as the sour of  for the  was 
th  expse to crk wa 
renable, ther was an imlicaon  the prblem of inants 
stuy cleay defies that we 
urban phenomenon. We be1i  e tht the purse stament of the 
exaed the afec of crk babies on the chi welfar systm only in sever major cities. 
al  re  fuer dontaon. 
The HDS  felt the  woul be stngtened by prvidig  spc 
cha  prvig 
have respnde by indicag the sours of da in  and by  citations 
intewed sever respndents in eah city, we di not feel tht an 
in footnotes. Since we 
itemion of the numbe would ad signcatly to the 
st 
adg 
The ASPE suggeste  hotspritga   to our State and local reormemnndadtaioon nons  
sta. Ou  to HDS 
development of gudelies and  for cthir wgel farm  eca 
and PHS aly adss prtion of such  in  ascrho ols and hospita, and 
believe th is the most effecve apprh for adssig these  with heath prfessiona. 
rendaon 
With respt to our  on integency costioo n, PHS and ASPE pointe out 
that crk baby issues relat to public heath as well as  nase ces. We agr, and have 
moded our remmndation to refl the crss-cttg  of the prblem. 
re  cr  coe. 
The PHS suggerstee th  the  usfoc  on  te cr raerc toh eju s th  for of 
Ades tstetettien   iinin  ntthhee  btoey dhwoe a hnaovtg ed ieer atlhney  ma.y  r.es pndanedn ts adsssyeo ntyhmeiro cusolyn atss th euirs  g 
the 
re 
Another ar of PHS conce was th the  faied to diuss the avaiilty opf drrgg r 
trtmnt prgrs foer psr gdnti w omen. We have inclucdhe idnes cptions of such 
and other tys of  Cr  to the drg expse  and fames in our 
companon repo " Babies: Modl Prgr. 
we incmte in the 
conts, may of which 
The PHS also prvide sever tehnca  The HCFA suggested we reword our reommendation on expande availabilty of prenata 
agr 
care to at-risk mothers and their babies. We  and have made the suggested change. 
However. because of space considerations we have not included the American Bar 
Association  Drug Exposed Infanls and Their Familes: Coordination Responses 
s monograph 
ofrhc Legal, Medical and Child Proleclion  which PHS provided with its comments.
Syslem  / '
" . : , ..- - " "---- -" ,'-- . - - -  / "
. a. ,_ 
ENDNOTES 
Vilova Universty, Hum Orantion Science IntitUte. unpublished 
1990. 
2. D. McAlter, County of Los Angeles. Deparnt of Health Servces, Drg 
Prgr  Drug-Related Costs in the Coun of Los Angeles, 
Abuse 
Offce. 1987 
Septembe 1988, p. 17. 
1State 9of Ne8w Yo9r Se,nate C ommptt o.n Inv estiga4tions.. Taxt ionD. a
endm  be 
Governt  Sha of  20,
Crack Babies: The  New York, 
Options, 
(MAlste, 
1988. p. 17) 
5. E.S. Bandstr B.W. Stele. G.T. Burett D.C. Paow. N. Levandosk. and Ethc 
Rodguez. "Prvalence of Perta Coaie Exsur in an Urban Multi-
PRoeppurlsaetinonta, vPeedsit,r  SRees.l e
 ct CAoprit1t98 9o na sC cihten i,n  tYhoe uUt.hS a.n Cd oFanmesg, rss. HoBuosren of
Hooked: Confontng the 1mpacl of Perinata Substae Abuse,  (Washigton.
C.: GPO. 1989). p. 6. 
Yor Senat. Commtt on Investigations, Taxtion. and 
State of New 
Sha of  Dember 20.
Governt 
Crack Babies: The  New York, 
Options. 
1989. p. 5. 
7. DJ. Beshav, .'Te Chdrn of Crk: Wil We Prte Them?' Public Welfare. 
Fa11989, p. 7. 
Natna  The Whte Hous, Septembe 1989. p. 44. 
Drug Contol Stratgy,  Pe 
Adction Reseh and 
U. Choff, M... Nationa Assoction for 
Natna Hospit Incidnce Surey. 1989.
A First: 
Education. 
Dearent 
Famy Serces. Dlois 
State of Dlois. Deparent of Chidrn and 
Assocon for Perata 
and the Natonal 
of Alcoholism and Substace Abuse. 
Reseh  The Illinois Model: A Staewi4 Collaorative 
Addction 
and Education, 
an 
Program for Alcohol  Other Drug Using Pregna Women.  p. 3.
Citins for Chidrn and  In Their Second Bes Inzresl, 1989. 
9. Philphia  Youth, 
30.  APPENDIX 
OPDIV COMMENTS ON THE DRAFT REPORT  . .
DEPARTMENT OF HEALTH I. HUMAN SERVICES  OFFI  igF  roR 
6EliER;'. 
Wasing. D.C. 20201

P'rt 
1990 I-tAR 12  1 9 
ttO  DIAI 
'el-
DIG-EX
DIG 
MEORADUM  AIG-MP 
OEOXIIG SB 
TO:  Richard P. Kusserow  SD 
Inspector General  DATE 
and Evaluation
Assistant secretary for planning

FROM: 
0.3-69- 4/S'/0
SUBJCT :  Crack Babies Report 
overall I found this report informative, supporting manIy d oo,f
 the

anecdotes we have been hearing about these children. 

however, have several comments which I note below.

Ken  ione4:
xssue. no

I suggest that you note somewhere that existing evidence

certainly not all) of these children

indicates that many (though 
In addition, it looks as though w

will have long term needs.  canot cue, their
can help these children compensate, but

deficits. 
lso 
Your discussion of testing and tracking these children might 

mention the growing tendency by local and state officials to

prosecute pregnant women. I believe this very punitive approach 
furer
is counter productive because its most likely effect will be to

drive drg abusing women away from prenatal care, 
damaging the child.

..en  b. ..port:
Regar4ing specific s
 . in 

On page 3, paragraph 2 thyoouu gesht iamgaet e5  tthoe  bceo s$t5 0o0f  mcialrliinogn .fo rI  tfhien
d 
children you observed  regarding your 
this figue  er explanatio 
confusing without f 
are you assuming will 
assumptions. For example, what proportio 
be in foster care? It would also be helpful to cite a compariso 
children. 
figure regarding norml 
, In the final paragraph on page 3 and the first paragraphs on page 
appropriatelY" that few of these children are

4 you note, qui te 
fail to point out, however, but that

being identified. What you 
issue, is that the lack of appropriate

we find to be an impsoeretman tt o result in discrimination against
testing guidelines  women. Therefore, more minority and low 
minority and low income 

income children are identified.
 -. ' ,-.,  ".' .. ;,. - .' ., .  '''- _- --
Page 2 - Richard P. Kusserow

Your discussion of identifying these children (page 3-4) might

also mention that it is difficult to identify them as they grow

up because of the limits of existing developmental tests.

cause. In 
Certainly, they cannot identify  addition, most such 
tests are structured, catering to the strengths of these

children. The deficits we are finding in these kids are

primarily in their abilities to structure their own activities

and emotions without help. They perform in the low normal

range on structured tests. It is in unstructured activities

(like play and interacting with other children and adults) that

their problems show up.

On page 5 you note infant attachment problems among many of

these children placed in foster care, particularly if the

infant has been moved from home to home. I share your concern

but note that several researchers have also found attachment

problems in these children when they remain with their

biological parents or a single caretaker. A portion of the 
problem may be organic rather than environmental, relating to

the damage done by the drug.

The chart at the bottom of page 5 fails to recognize the issue

which you note later (on page 13) that while crack is today' 
it. 
drug of choice among certain populations, "ice" or something

Straight line
else will soon come along to replace 
proj ections of the number of crack babies is therefor somewhat 
misleading. 
Regarding Your Recommendations:

I would add to your recommendations of state an Local

Responsibilities 
(page 141) the active establishment and 
promotion of drug use prevention and rug treatment programs.

age-
This is especially important for woman of childbearing 
Most anti-drug messages are now aimed at teenagers, and as your

report notes, these are not teenage mothers. 
In addition, few 
treatment programs are set up to treat pregnant women or

mothers effectively. For example, few provide child care. 

recent study found that 87% of the existing drug treatment

programs in New York City would not treat pregnant, Medicaid

eligible crack users.

Your state and Local Recommendation number 4 notes the need for

better reporting and tracking of these children. I would also

infants, 
add the need for better identification of drug exposed 
including crack and other drugs. While you note in

Recommendation 3 the need for training and guidelines for child

welfare workers, it is hospital staff who must first identify

these mothers and children. As your report notes, only 1/3 of

the hospitals you visited had testing protocals in place. As

noted above, this leads to racial and socioeconomic

discrimination.  . Kusserow

Page 3 - Richard 
You offer a list of recommendations regarding Federal activities

which are needed. 
While it is an appropriate list, I would 
suggest that you also mention existing activities which address

many of the needs you mention. Your staff are aware of a recent

efforts. 
report written by my staff which outlines many of these 
numer 
Your Recommendation  4 for the Office of Human Development
Services 
5) suggests the need for interagency coordination
of acti vi (page  . families. 
ties regarding these children and While we 
agree with that assessment, we are less certain to which agency

the lead should be assigned. 
This is both a public health issue 
one. 
and a social services  The lead could appropriately come 
from a variety of sources. In addition, I believe that the

Social Security Administration should be added to your list of

agencies w ich should be involved because of their role in

funding services for these children (particularly through the SSI

disabled children program).

r J

err 
Cj, 
Martin  /'S  - '
- -:...  , .'/--

-I , ' . .i 
Off Ice ot 
".."t,  Human Development Services 
DEPARTMENT OF HEALTH &. HUMAJ" SERVICES 
Assistant Secretary 
Washington DC 20201 
30 
1990
A.OR 
Ricbard P. Eusserow 
'10 : 
Xnspector General

ssistant secretary 
FROM: 
for Human Development services

SUBECT:  Office of Xnspector General Draft Report on "Crack

Babies, " 01:1-03-89-01540 
'1hank you for tbe opportunity to review the "dcrraafctk  rBeapboirest. 
of the
(OIG) anti tled 
Office of xnspector General 

'1he report provides valuable information and a vood overv.eiedwi coafl,
(e. V., 
tbe scope of tbe problem of infants exposed to crack cocaine and

fare and otber systems

of its impact on cbild vel  justice) either currently

are 
rehabilitation, .ental healtb, juvenil tbat the findinv 
or proj ected into tbe future. We Dote  y other 
venerally consistent vi tb tbose  eing reported  here is also

asis.
investigators on a national and regiotnalb 
e consensuS of tbe respondents interviewceodc afionre 
 is

agreement vi tb  other
exosure to 
tbe report tbat tbe problem of infants exposed to crack

interrelated vi tb tbe larger issue (opfa gper e1n3a)t. al
drugs and alcobol as vell as &IDS 

irst, page 3 of tbe

hospital delivery and

We do, however, bave several concerns. 
 tbese 8,
report states tbat "We estimate tbe cost for 

perinatal care, and foster care tbrougb age 5 fWoer  sjuugsgte
st tbat

abies approximate $500 aillion.

abut tbe five
identified 
roken down and justified so tbat tbey can 

tbese costs 
 are concerned, for example,

better understood. .e  care. Xn addition, tbe

nine day

year projected lengtb of stay in foster 
ini tial draft of tbe OXG report factored in costs for a 
abies, vbicb considerablY exceeds the 
hospi tal stay for heal tby 
norm of tbree days or less. 
informati 
second, vbile tbe selection of cities as tbe souirsc et boaft  t
 he problem

pbenomenon. '1be 
for the report vas reasonable, tbe implicati 
of infants exposed to crack cocaine is an urban 
 / .

usserow 
2 - Richard P. 

staff of the Children'S Bureau are beginningO tfofi crieaclesi vien  rthepeo rsttas
te
from small towns and rural areas which indicate that the problem

has spread to these areas of the country. ' 
of wisconsin, for example, indicate that one reason that the .

pro  lem of infants exposed to crack cocaine aay )) underreporte' ' 
in such areas is that the babies are frequentlY referred to

developmental disabilities programs, rahtehsee ro ftfhiacni atlos  cihnidlidc
 ate,

protective services for assistance. 

moreover, tbat the increase in the problem in rural areas of tbe

state is equal to or greater than in the city of Xilwaukee.

hird, the report would be strengthened boyf  trhees ppornodveinstis
 interviewed
For example, the numer 
documentati 
10. Xn
by site sbould be provided, as sbould the sources for the

information presented in the chapratgse -o n9  poafg etsh e 5t eaxntd  a
 nd in the

addition, the data presented on 

chart on page 10 relate to a one day cou1n9t8 3o-f1 9c8h6i,l dtrheen  lians tf oysetaerrs


(VCXS) data are

care, not to entry rates for the years 
for which Voluntary cooperative Xnformation system

currently available. 
Horeover, in discussing the stress being placed on the child

protecti  system, the report did not note that the system was 
already overburdened, due to high caseloads and inadequate

resources, prior tcoo cthaei naed.v ent of the phenomenon of infants

Although some difficulties were
exposed to crack 

identified in the adoption process, adoption is a reasonabl

approach for infants exposed to crack cocaine with no parents or

relatives. 
adoption sUbsidies are currently available in all 
states. 
ons  must 
s recommendati
Finally, while ve recognize that the OIG' 

relate to the Department, ve would Suggest that 80me mention be

made of the fact that the impact of infants exposed to crack

cocaine extends beyond the purview of the Department of Health and

Human services to encompass education, housing, law enforcement

and other Federal" state aDd local agenci

i ty to review the report. 
Again, thank you for the opportu

, I  - : !:: .......--.- 
- .. ....
l.",r  " I . "'i...' . "'. 
Memorandum 
, 8 
APR - I
Dat! 
qcJ
Fro-
Gail R. Wilensky, Ph. 
Administrator 
S..:, 
OIG Draft Report - Crack Babies, OEI-03-89-01540 
The Inspector General 
Office of the Secretary

subject draft report It examied how crack babies 
We have reviewed the 
welfare system in 12 metropolitan areas. 
have affected the child 
Though the report makes several recommendations to locl. State and 
The report 
Federal agencies, only one recommendation is addressed to HCFA 
continue to 
recommends that HCF A and the Public Health Servce (PHS) 
support expanded availabilty of prenatal care to at-rik mothers and their babies. 
to 
Vle believe that the wording of the recommendation is  vague. Rether than 
expansion. we support targeted or intensive outreach intervention and pren  !:a! 
usmg pre nant women. We are already 
are for substance a  .engaged 
. On
 g an lssemmanng practices which encourage community involvement 
i enti 
this recommendation further 
in prenatal care outreach and education, as 
suggests. 
abuse training cited on page 16, we believe 
In addition to the drug 
Departmental effort must also address parallel servce delivery problems. 
Prenatal care servces or linkages must be provided in drug treatment programs. 
and drug treatment servces or linkages must be provided in prenatal care 
programs. 
PHS components listed on 
Finally. we have one techncal comment. The 
page 15 should be clared to read: 
Bureau of Maternal and Child Health and Resources Development, 
Admitration 
Health Resources and Servces 
Development, National 
National Institute of Child Health and Human 
Institutfls of Health  Page 2 . The Inspector General

Health Administration 
AJcohol, Drurz Abuse and Mental 
stitute on Drug Abuse 
- National 
Abuse Prevention 
. Office of Substance 
. Offce for Treatment Improvement 
to review and comment on this draft report. 
Thank you for the opportunity . 
agree with our position at your earliest 
Please ad\ise us whether you 
convenience.  ---
--. .-.-.,----.. -- ------. g';;-:,  ..- -
. ,. 
".-"-'."  , - , ., .. 
'JtC .. ""II  "881'" HrVIc;e 
::'Z 
Memorandum 
Jf 
21) 
-Date 
From  Assistant Secretary for Health 
Sub,e:t  OIG Office of Evaluation and.  nspections Draft .eport " Crack 
Babies , " OEI 03-89-01540, February 1990 
Inspector General, OS

Attached are the PHS comments on the f1ndinls and

recommendations contained in the subject Ole draft report.
e con cur vi t h the r e c 0 mm end a t ion s d 1 r e c t e d to  P R S t 0 
(1) conduct long-term research on prenatal exposure, treatment 
models, and placement outcomes; promote training in medical

5 c h 0011 and chi 1 d vel far e age n c 1 e s ; and pro mo t e pre ve n t i on 
prenatal 
through public outreach, and (2) continue to 8upport 
care expansiou.

es O. K

Attachment 
10 

PDIG 
DIG-AS 
JnG-
EI 
a;Jg  0:: 
EX SEO

DATE  n '"0"  r:
;- "T 

1-
:- :: rr
i- 0  ----
- . . --'- --_..- ---- ------
_0 ,.  0 ..
TH 
OFF:CE OF 
TH SERVICE ON

REPORT
COMMENTS OF THE PUBLI  990
NSPECTOR 
K aAIES  ' OEI 03
 40.
pa 
Gene=ol Comments  of the problem.
ba 
The OIG reports that we are onlya nsde emionsgt  
are not identified at
Tbheirret .is  no typical cractke sts can detect cocaine inm etthheo dmso tahreer

We concu that  Howver, new  an in hair. 
meconum
for only 24 to 48 htoou rms eaafstuerr  cuoscea.i
ne in 
becomng availabl 
These tests, if positive, would indicate prolonged use of

related 
cocaine during pregnancy. 
recognzes polyc9 abse an 
adQrsses usues only
to ths 
Although the repoArJtD 
S), th reiew  1.tauons 
problem (e.g.,  Giva the 
te",S of crack-cocabienlei.e
 v the report shoud ccoocnacienn. trte
narror  believ
focus, we.  the ' crack' form of 
rather thn on  atteUon, we 

. cocaine ,  title will atctorcaactie ' 8Yonymsly  may 
Although the report' s crack' and '  statemnta on.
the use of the term ' 
identify
perhaps misledadifinfgerntially 
lead to inccurate and  form of cocaine. 
prevalence since there is no way htuo
m boy ciS not differ by
crack cocaine use from the use of other 

This is because presence in the 

1Jct 
form at intake. 
 of .crck-USin9 mothers
adQrssing the  clincal indications 
addictg
In addition. when 
on the child wweolnfa rues essy sttheem ,r atphiedrley  aarned
 highltyh b eicfo m metally
that when a  she used
to sto 
using it,
crack' fa", of cocaine, she may more rapidlY

incapacitate an unble 
rert 
tht th 
80me other f01: of cocaine.
 fails to
wUh to highdlriggh tt riastmt program for
Another point we 
 should be coordnation
pretal ca
discuSS the ava.i lwaebi lbiettlyri etovfm  
thtt,  tphreirm   an 
pregnnt  abse 
amg substance  program. 
dr9-esed 
AI an 
HIV infection prevention 

s-
aciss peatriC 
 overlap betWen the
There is a pneaed  otfo  th
 e  problel. The 
babies as  drgs for these infants mesan-s we
groups, offering btahiee s
 .
problels of AJDS and 
ofte priding services to the
usually dealing with the SlUe riBk 
 pa. 
me".ages, and 

secxasle s are a res1uIlct oo;ft itohne

peiatriC AJDS

pacularlY
Fully 70 percent of 

reflecte in the report,  thes
d'I" abuse of the IIther or her  local coordintion of
orfe tchoiS mfac t sFheoduledr able, 
 State, an 
DS activities.

pediatric HIV/
 Page 2

DS Program

The surgeon General and the Director, National 
 DS. 
Office co-chair a PHS Panel on Women, AdTohlies spcaennetls ,i sa ncdo mfpariirsse,d 
Children with HIV Infection and 

of all the PHS agencies and the pOrfofbilceem o fi dpeonptuilfaiteid
  in this 
and addresses many of the same

report. 
Therefore, any DHHS effort to address the problems of
this panel.

drug-exposed infants should include 

recomendations. 
on the OIG 
The following are our coments 
OIG Recommendation 
LO 
SB' dD  USPORSIBILrfZS 
.ystems. 
States should 
drg 
exposure as
and  tracking 
Establish reporting 

establish criteria for reporting prenatal 

child abuse.

coment 
PHS 
on legal 
recomendation only centers 
We concur. However, the  concuently to
informtion should be used 
issues and this  care. 
provide appropriate health education and 

JI 
OIG Recommendation

BE'l AI 
SERVICE RBSPOSIBILI'IES 
DEPAR'r  01' 
Humn 
effective practices. 'le Office of 
Dissemnate  (HDS) should identify practices,

Development Services 
ba 
programs, and lawdsr go-re xrpegousleadt ions ccoansseisd earnedd  deisffseecmtnivaete
  
governnts. 
in dealing with 
State and local 
this informtion to 
PHS Comment

addition to the ident.ificatio
we concur. Howver, in 

ttme.
practices considered effective, evaluation of their

effectiveness must be considered at the same 

OIG Recomendatio 
re'ltaet iBgDS t osh odurlgd

aactivcities.t  ivities 
Deparental
Ccoorodinaote rdinate Departental  famlies. 
exposed babies and their 

S Comment

drg-exposed 
tol: believe thatD PeHpSa rrtaetnhetr a cthtiavn itBiDeSs  srheolualtdi nbge  ttoh e lead OPDIV 
to coordinate  famlies.  need for education and 
'lhere ia a 
babies and their 
 )) 
... - . " ,.. 
Page 3

rough famly planing cendtregrs- eaxnds epdre nbaataile sp raongr am..
support t 
problem. We

We advocate this position because 
their famlies encounter numerous medical medaibcael  or publi 
matters. 
problem are primrily 
foste  1', '
believe that these  care or child 
health issue., and not 

OIG Recommendation

Cbe 
ll Delopt Serdc:s and  PalJc  Beal 
of 
OSfficeerice 
':e BDS and the pHS should

Conduct long-term research. 

1)abies
conduct long-ter. research on the effects of prenatal

exposure to drugs, including crack cocaine, on 

and their mothers.

PHS comment

this regard, the HealthC Rhelsdo uHrecaelst ha snRude sbSeeatrrvcihc es

We concur. In s (HR) Jlternl an 
Adnistration'  investig"adtorr-S etso ed" baies. 
permts principal 
Grant program  long-te= research on 
viable, it 
applications for  prject in ths ara pros 
If a proposed reseafrucnhd ig. 
is considered for 
indispensa1)le.
short-term research is also

weYer , 

state 
suggest added 1)ullets to 

determne the optiml

short-ter. research should 

birt of a miimlly
treatment to cocaine-addicted mothers during

pregnancy to ensure the

affected infant. 
factors responsible for

research examning the risk

drg abse is needed if effective prevention is to 
imlemnted. 
system 8hould exist to 
national 8ureillance  epidem
monitor the exdtuernitn go fp rtehge nccryac. k

specifically 
OIG Recomendation  an the PH should 
'fe BDS 
pproorte omote ddrg  rg aabusbe  use ttrraaiin!ng.   in 
Kedical Schools, and

Child welfare agenci
 4 .
Page 
PHS Comment
 fort 
our activities U\ 'tese 
following eets

We concur.  he 
areas. 
Medical school 
Kedicine. ore

The Bureau of Health Professions, BRSA, recently awa1r8d0e df aam
 ly
contract tot thhse  society of 'lachers oaf prparmoxlyim  telya but
purose of  contract is to train 
medicine physician faculty how to teaCh residents 

substance abuse.

cotract to

se Bducation.

ore Bureau of Health professions also awarded a
fro academc

comrised of representatives
sponsor a Physician consortium on Substace 
 resposibl  for the education

ore consortium is  purse 
of the consortium is
and professional pohrygasniciziaatniso.n os r
e  ence an 
trainng of  reing
and  wbich will 
imlemnt strategi 
to refine and  8ubstaCe 
build on existing medical education strategies for

to preventiOn and early identification of

arriers 
abuse. 
welfare Aaencies

ld 
Block Grant Progtora mc hmlady 

Haternal and Child Health (HC) 
though the States, atrllaoicnagta.  KC funs
indirectly,  drg abuse 
welfare agencies for 

OIG Recomendation  outrch and 
pub11 
prevet10n W'ugb 
Promote 
J.formt1onal _ter1als.

coment 
PHS  exded
Jler, 
since 
the education should be 
We concu. 
in junior high achools and middle achool

JI, 
ourses  with 
prevention must begin early.
 AJis, w  orkig 
Healcth,o  ti 
ore office of Katemal anA Cbhel dp retion,  on a joint
the Office for Substace  local  focusing on 
prram to  tring 
tratmt  durinl/ pregnancy.
demonstration grant  of drl/ use  priding 
prevention and  denstratiotne pcrhjeectss  
intervtion  in h1l/h-risk
date, a total of 45 

in developinl/ new  funded. 
population areas have been 
 Page 5

7J.cJ
OIG Recommendation  Ca 
Public Health serice  IId the
 Health
Btraticm 
Af'mirU
'le PHS and

to  support prenatal  Adcanre  istrexapanstioni. on should continue
Continue 
the Health Care Financing 

to support expanded avaiblaaibeilsi.ty of prenatal care to at

risk mothers and their 

coment 
PHS 
Health is 
S Office of Maternal and Chld 
We concur. BRA' 
-drg-exposed" 
werking with HCFA to eixnpcalnudd ianvga itlhaobsiel iwtyit ho f prenatal care to

more pregnant woen, 
children. 
ents 
echnical com
'le title of ths  report, .crack Baies, . is errneous and 
te:cnology, whch is used by 
he appropriate 
misleading.  field, is -drg-exposed" or
experts and professionals iInt  tihse 
re-cdormgen-dee8de tdh abta tihee8 t. itle be

"drug-affected infants. -

thoughout the report to 
changed 
drg 
cocaine. It 
baies were,
Crack is only one method of inge8tiwnhge tthheer
  these 
virtually  (snorted) 
imo8sible to determne 
crack, intra-nasally ingestedd
rgs during 
in fact, exposed to  comination of 
cocaine, or if the mother used a

her pregnancy. 'lhea cru rent rdersgea rucshe raev,a icloabmlei nignd iccoactaeisn et hwaitt h 
poly 
most -crack" users 
By focusing only on . crack. babies, a narrow and 
other drgs.  i8 creatad. Any

inaccurate percdeprtgi ouns eo fa mtohneg  pwroobleenm,  ,8
uch as that.d orgn -paadgdei cted 
references to 
. 8hould be changed to 
crack addicted mothers,

mothers. " 
1, .  OUR
PaQes i and 
.!be Rational

6 million 
estimtes tht ovr 
'le first paragraph 8houl(dN IbDeA )c hanged to read

Insti tute on Drug Abuse 
. instead of the f5r omi lthleio n cited

ild bearinegs taigme.t.e. .1
 s 
based on data 
woen of 

in the report. 'le s
urey, 1988. 
Rational Household 
a h

pa e 1  Pifth Para 
'te report'8 exclusive focus on cracka m8unggg teesetnsa tghee mreo t1h
 ers. 
relatively low use of crack cocaine

'lbis "finding" could be misleading in that a clinically  . . 
- .-,. .- - -- - .. ' . .
Page 6
drgs,
s1g.1fi  ant numr of teen age women haersee  yabouusnign gw moaenny are or 
endager the live.
reire 
including other forms of cocaine. 
 a wide 
.oon might become pregnant and thuhse swei ltelte a
nea gera 
be-
their yet-to- born children.  into account their 
range of 8ervice. that are designed to 

developmental as well as their obstetrical Deed..

ranaina. 
scope oUbe D%b  wide
,acre 3

. 'te ccosat ef o.r 
 . 
In the second paragraph, OIG reports 
hospital delivery and perinatal care, and foster

approximte $500 million. 
ben 
Al though in this report the costs of fo.ter care, hpoosoplietda,l it 
delivery, and .hort-term perinatal care have 

informtive to discuss hospital delivery and
fra 
might be more  the cost of foster cae. 
perintal
perinatal care apart

cost to .upport hospital delivt.eor yth aen dp
 aucity of 
Informtion on 
h1. i. ...p croonticra!sgt  qulity cae
tie. 
care i. now available. 
 the actual cost of 
informtion on  indefinte 
periods of 
foster homes over 
 i. cuently .upporting 
t.o these que.tions, .IDA 
In response 
proide 
comunities to 
research demonstration studies that .oon will provide more

cost to 
detailed informtion on the 
and 
effective comprehensivep l.aecrev,i ct.eos ,a dwdiitcht eadn dp rweigthnotu tw coaesne 

ben
maagement system in  cut 
their children. Although DO .tudies havec la1sn yceatl inve.tigators
.Ubtted, NIDA i. tahctti vveillyl  encouraging  ftifte the 
to design studi.s 
 critically 
foster care .yatem in t.exm of coat and beneficial effectS.

Dot 
crack 
.OR
cal 
baies look 
t .ost crack 
difficut t.o identi . We believ

Ihn tehe afirlatt h.enyten cae, nOIGd .ta taes r
 e therefore 
it may be more correct t. .tate the followinga

induced 
adver.e .igns or drg-
here i8 DO typical .et of 

pattern by which t. identify either a cocaine- or a crack

fetally-eaed infant.
cocaine-
t.s 
differetially 
lack of 
Several reasons account for 

th 
discrete pattern of effectaa

ar  cocaine
pol  9 absers rather  may
Host woen 
(1 )
only, and therefore clinicians have identified

pattern. 
overlapping  ). 

. .
Page 7

accuate drg
accuate 
enough to
(2 ) In m08t ca8e8, it i8 impos8ible to get an 
U8e hi8tory from the mother, at lea8t 

like cocaie. 
relate as  uspseec ioffi ca  nsepoenactiafilc  cdlirngi cal patt.rn with the

mother' 
smll a numr of cas.s Where accurate 
(3 ) There still 1s too
Qrg 
U8e hi8tori88 do exdii.atg ntoos if oxm the basi. upon which
to mae a differential 
expsure 11 utero are 
( 4) 
Very subtle eigns of cocaine 
difficult to detect at the dp rper8oecnetd tuirmse.  because of a lack

of clinical instruents 
 describ the 
studies that a1m to 

curently supportng  fetus, newom, and 
NIDA is 
effecta of cocaine exposure on the 
 instrent. 
and
developing child as well as re8earch in the development of

clinically sensitive and useful diagnosti

procedures. 
the 
sed Chldren 
pa e 5 the chart 8pro ection of 

provided.  ch 
Year 2000 

1s not 
'lhe source for the data used 11 the project1OU! P 
'f 
!'aqe l..EOPL AR 
DRUGS. NOT JUST 
 th8 8tat_nt. 
Fuer 
elabration 18 neces.ar on 
USPSIB

DO  8 'f  ideas
date, 88Y of the 
la8ae  2.  bajer8.  . nviewg an 
Reduce placementp lacet baien by . 
. 'te:mtion
put fort to reuce  on . . 

revising existing law8s  haanvde  paodldirceis
sed the i..ue of unfit

the bab, and 
parental rights. 

chpeirldspre,c tfirvoe  otfh ree aoov1thlge r. unfortuntely,
mo'therhooc from the  fewr vaen
perhapa the other
 may result 11  for 
termnation of parental right. 
comg for prenatal-postntal cae or 
, voluntarily 
(see attached copy of the

treatment for their addicati 8oOn oqaph  aed Infanta a

rug Medical
A'rmeeirri c!a'an mBalri eas.'a ocCioetoirodnin'
ation Res n  8 to8fp tohrea rLya  palalc ement
Although 
rotect on Syatem  comity 
efforts and
and  increase the

for children i. often necessary, 
Xilitource. .hould be directedc tholwdrbda mreinthgo da.g et oc omng into the 
numr of addicted vaen of  program that are
drg tratmnt 
medical, .ocial .ervice, and

cu--rently available.  .---.
..-.---"(- .- _ _-.-- -- --.-.-.---- . :?
Page 
Deparental act1.v!t!...
Coord 
, 84. 
 nate 
l.aQe  Pulic 
Service, the Rational Institute
Beal th 
Under the bullet 
 eql
AD. 
on Drug Abuse and the Alcohol, Drug Abuse and Mental Bealth

are listed .s being  Also, 
Adnistration (ADAM)  AD, BR, 
organizations of PHS. RIDA is wani tIhns titute of and 
PHS, 
there are other organizations  whch have responsibility 
ths report. BR' 
the National Institutes of Bealth  s Bureaus 
professions 
relating to the subject matter of 
Katemal and Chld 
of Health Care Delivery and Assistance and Bealth'

Departent 
should be included along with the Office of
ths pa  followl 
Haecatlitvh iitnie tsh.e  '.PhHeSr erfeoprree,s entatives f.ohro utlhde 
read .. 
-- Rational AIDS program Offic

Chldr 
wom,  with BIV 
Molescent., and 
-- PHS Panel on 
Infection an AIDS 
stration
A"",i ft!-
th 
-- Alcohol, Drug Abu.e and .ental Beal 

National Institute on Drug Abuse

Office for Substance AIbmusreo Permevetn tion

-.reatment 
Office for 
Adnistration 
-- Beal th Resources and Services 
 Assistace 
u of Bealth Cae Delivery and 
Bure 
Bureau of Health professions

Office of Katemal and Chld Bealth 
Developmnt, 
Chld Bealth and BWI 
-- National InsIntittituutet eosn
 of Bealth 
National 
_n.  7111