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OFFICE OF INSPECTOR GENERAL OFFlCJ:OFEVALUATION AND INSPECTIONS 

JUNE 1990 
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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. 

Created by statUte in 1976. the Inspector Genera keeps both the Secrta and the Congrss 

fully and curntly infonnedabout progrs or maagement problems and reommends 

corrctive acnon. The OIG perform its mission by conducting audits. investigations. and 

inspections with approximately 1,300 sta strtegicaly locate around the countr. 

OFFICE OF EVALUATION AND INSPECTIONS 

This repon is prouced by the Ofce of Evaluation and Inspeons (OE!), one of th major 

offces within the QIG. The other tWo ar the Ofce of Audit Servces (OAS) and the Offce 

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 

system in severa major cities. A separtcrepo identies prgrs and PI'edurs 

considere effective in workiQgwith crack adcte mothers and their babies. The study was 

prepar under thecition of Joy Quil. Regional Inspetor General, Ofce of Evaluation 

and Insptions, Region-llI.Pancipatig in ths prjec were the followig people: 

Philadelphia Headq uarters

Projecluader Al Levie Joseph G. Whte, 


Lois C. Lehmn 

Lida M. Ragone


. Isabelle Buonocor 

Cynthia R. Hasford 

San Francisco 

Cynthia A. Lemesh 

Mashall Schi 

Tricia Banniter 
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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 

and cocaie synonymously in this repon as their detetion in the boy does not differ. 

The Nationallnstitute on Drg Abuse (NIDA) estimates that over 6 mion women of chi)dbearng 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 drgexposed. While most expens believe that may crk babies wi 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. 

While some State and local governments have done studies on asts of the crk 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 

We conducte on-site intervews in 12 metropolita aras durng the last quanr of 1989. 

Respondents included child welfare admistrtors and casworkers, hospita soial servces 

staff. private agency representatives. foster parnts, State and local offcials. and national expens. 

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 visite could prvide the numbe of crk babies repo the chid welfar system. These eight cities handled 8,974 crk baby cass dmig the 

prvious yea. These cities resent 20 pent of the popultion of U.S. cities of mor than 

50,00. May crk cas ar unpo Some respndents estite tht only hal of the crk babies ar repo The actu figus we obtaed coupled with the undepog phenomenon, ar constent with Prsidnt Bush's Nationa Drg Contrl Strgy which estis 100,00 coaie babies bo pe yea. 

We est 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. 

Crk babies may also reui other ses. The Fl Dearnt of Heth and 

Rehabiltave Sers esttes an anua cost of over $4,00 pe chid to get cr babies 

rey for school. If other Stas in olDstdy wer to prvide simi1S1T seces for these 8,974 identi babies, the adtiona costs for developmenta inteention, edcaon, and heath seces thugh age 5 could be as high as $1.5 bilon. 

Whe these cacultions do not includ any costs for ses which may be reui by some crk-expse chin afte age 5, suh cost wi al be substati. In Pennylvan for 

exaple, one yea of sp edcaon in cls for a leg diled chi costs $7,90. A 

yea of residenti trnt and sp edcaon for an emotionay ditu chid cost 

$25,00 to $47.s00. Th averge episo of juvenie detention la 15 days and costs abut $2,20. If a juveni reuis resinti drg trnt, cost ca be $15,00 or mo. 

The NIA is cuntly sug reh on the cost to counties of prvidig comphensive ses to adct prgnt women and their chidrn. Addtiona reseah is 

plaed on cost an benefits of foste ca. 

There is no tyical crllk baby. 

Ther is no tyic set of sign or pa by which to identi a coe-e se inant A 

Los Angeles County stdy found tht 70 pent of cr babies ar ful te 2 One exp 

suggests th beus the babies ap heathy, do fruently do not detet the subtle 

signs of coce expsur. Therfor, so 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; 

Develop guidelines and trning for child welfar sta; 

Establish reportng and trcking systems; 

Expand interagency mechansms to coordnate servces and integrte fundig. 

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; 

Conduct shon- and long-tenn research on the effects of prenata exposur. 

treatment mOdels. and placement outcomes; 
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PromOte drg abuse training in medical schools. hospitals. and child welfare 

agencIes; 

PromOte prevention through public outTeach and inf:'nnationaJ materials. 

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The rublic Health Sen.'ice And The Health Care Financing Administraton Should: 

Continue to suppon targeted. intensive outrach and prenata1 care for substanceabusing 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 

and a number 0 " technical corrections have ben incorprate into the repon. We also 

expanded discussion on some issues in respnse to comments frm al respondents. The full 

te\.l of comments received appear in the appendi. 
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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 

to all drugs, not just crack. . 

RECOMMENDATIONS 

ENDNOTES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

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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 ar using ilegal substaces; for mion ths mes coce. 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 

respirtory and neurological problems. Crk babies have a signcatly higher rate of 

Sudden Infant Death Syndrome (SIDS) than babies who have not ben prnatay drgexposed. 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 

in crack baby birs: the Offce of Huma Development Servces (HS), the Public Health 

Service (PHS). the Health Car Financing Admstrtion (HCFA), and the Soc Securty 

Admnistration (SSA). These Fedra agencies fund servces for crk-adte mother and 

their babies thugh a varety of prgr, most operate at the State and loc level. 

When crk babies ar identied loc chid welfar agencies ar usuay notilC to prvide protective servces, social servces, or foster ca. 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' with an average age of 
 to 28 year. Usualy, they have between two and four other childrn. Crk babies 

2S 

repo to the chid welfar system ar priy bla, with a smer number of Hispanics 
 d even fewer whites. 

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 

York City, Newark. Oakand. Philadelphia. Phoenix. San Francisco. Tacoma and Washington, 

C. We selected these sites to give a perspective on how cities of varng siz and location 

were being affected by crack baby bins. 

Respondents included child welfar adnistrtors and casworkers. hospita soial services 

staff, private agency representatives, foster parnts. and State and local offcial. We also 

interviewed national expert and reviewed studies and public documents on the subject. 
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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 8,974 crk 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 crck babies r:ad ' for school. If other States in our stdy wer to prvide simila servces for 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 clas for a leang disabled child costs $7 900. A year of residential treatment and c;pccial education for aJ emotionally di!;turbe chHd Ci.sts pi: :)(e 
 S25. to $17, 5() The :)ve:r:tge f;l,v "i11" deientif)n lnc;t 15 day:. ",fIr! I'''IS bi),.!( $2.250. If a J'JVt!l j UU' C:- " ;dc1.IJ;. lt alrnni , co.;ts can t) :1 i,:X:r: 

Tbe NlDA is cUIcntly supportng res ch on ..he costs i" communities ,; ('v' : n "sive services to addicte pregnant woml n and their children. '\d,1.iridi f I,-S 1"".,,,, ir. 11 is
 ","' costs and benefits of foster car. 

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 babies ar full term 2 One expen . ."C";'': 


:hat because the babies appear healthy, doctors fruently do not detet the subtle p:. of 
 '.Jaine exposure. Therefore. some babies are discharged without being reognize 1: -"."r"'': 
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Crk babies ar mor lily to be born prmatu and to have sp mecal nee. Expns 

repon th crk babies ar nealy 4 tis mor liely to be bo with low bir weights 

(under 2500 gr 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 4 One respndent told us reui

that morn tehnology alows physicians extende intensive ca.


to save may babies who would not have surved even a few yea ago. Th is espaly 

tre of the ver low bir weight babies (5001500 gr, abut 1 to 3 pounds).. . 

Some crk babies reui sp medca attntion af hospita dichae. These chidrn 

ar designat as medcaly neey and reui sp seces frm their mother or foste 

fames. 

Most crt1c babies Il not idntfid li bir 

Inconstent testig is one reon may crk babies ar not idntied at bir. Accorg 

respndents, publi hospita ar the only ones testig; most prvat hospita and physici do not test. Whe no Sta visite madas unver testig of mother for contrlled 

substaces, Indian dos reui tetig if ther is suspicion of drg expsur. One hospita in 

our saple te al newbo. 

The majorty of hospita in our suey rely on mother to self-re drg use. At leat four 

us th as their pr methOd of identication. Some respondents crtici usg ths 

methOd exclusively. A suey in one Florda hospita found only 27 pent of the prgnant 

women testig positive for drg us at la an dever ha adtt their use. 

Five of 13 hospita visite us spc teg prtols, and thes va in deta and sc. Testig crte ca include suspte drg use, la of prna ca, prma delivery, 

neona intensive ca adsion, and indicaons of a sexuy trsmtt dise. Some 

respndents ar conceed th relice on self-repog and the absence of spc testig prtools me tht low-inco 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 

Even when tests ar conduct they prvi only lite inortion. Most tests can detet 

coaie in the system for only 24 to 48 hour. 

Crll1c babies IlIe fue problems. 

When consideg how soety wi de with crk 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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May respondents ar concerned tht drg-expose babies wi 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. 

May respondents wor what wi happen when crk babies reach school. Those who have 

worked with crk babies say the chidrn wi have sever leag disabilties as they grw 

olde. We were told, "These chidrn nee speia education. If they don t get th we ll se 

them in juvenie cour late." The Los Angeles Unied School Distrct has develop a 

spial curculum for drg-expse babies at the preschool level. si prgr exits in 

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 stay as 3 yea and 4. yea respetively. 

Chdrn ar also enteg foste ca at a younger age. Accg to a rent New York State 

repo "In 1980, only 19 pent of the foste ca caloa was unde 5. Tody it is over 50 

pent, pry due to crk. .. 

Accorg to sever respndents, crk baies have mor prblems bondig th 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 

prblem to organc dage cause by the drg exposur. 

The followig grph depict the potenti populaton of drg-expse chidrn bo th 

dead, bas on curnt anua estites of crk-, coce-, and drg-expsed birs 

Whe the prjections shown assue no change in anua drg-expsur birs, ther ar 

indications the numbe of drg-expse birs is incrg. In Caora, th hospita 

re the num of drg-expsed bir have at let doubled sice 1986. One of these 

re an 84 pent incr in 2 ye. 

Inteewees tell us the afhocks of the crk epidmi wi be felt by soety for may 

yea. As one respndent sad, ' ven if we sto crk use right now, we woul st be 

deg with its effects in som way for the next 50 to 75 ye. The racaons ar 

forver.. s a horble cycle!" 
........................................................................ . .............................................................. ..... . ................................................................ . ......................................................... . ................. . :::: ::: ::::.............:.. ,.::....................... ........ :. . :::;,. . : :................................ ................. ........... . :.... .:................... .. .:....... ...::. :. ...

Projection of Drug Exposed Children by the Yesr 2000 

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Nwbe of 

LO I8TE IITlI8TE IDunTE 

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AN ALREADY OVERBURDENED CHILD WELFARE SYSTEM STRUGGLES 

TO COPE. 

Crack baby caes ar compUct*d tU ti-consming.


In most cities vite an incrg majorty of chid welfar cas ar drg rela The New 

York City Mayor s Tas For on Chd Abuse and Neglec re a 72 pent incr 

chid abuse JCla to drg dendnc, pry cr fr 1985 to 1988. 

State offci contend tht cr baby cas ar mo complex th other chid welfar cas. 

One offci sad, "Cr us reprsent a diernt kid of (pteve seces) 

ca. TheJC is a lot mor abandonmnt an vio enc. Cr baby caes reui extensve 

trkig and follow-up. Th ca be dicult for caewor to prvide when confnte 

with the reties of an aly overhelmg caloa 

Drg us ca sup al other as of the lives of cr-adte mother. In the word 

of one cawor, worg with the mother "i li betig your hea agat a brick 

wal...beause you ar deg 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 

abandon their babies. Oter ti-cnsumg acvities include fidig emergency placements, 

foster ca, parnta drg tttmnt, and seces necssa for spal nee chin. 
Chid welfar caswor is a dagerus job, acorg to sever respndents. Caeworer 

home evaluations ca involve enterig hostie sitUations, unescon and without rao 

contat. Peronal dager, strss, and relatively low pay contrbute to casworke burout or 

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 prtetive worer is 2 yea. High tuover results 

in lak of servce contiuity and complicates legal prgs beause severa caworker 

may work on a case over the yea. 

We found lage chid welfar wor caseload in may cities. For example, one chid welfar 

agency offcia report an averge caeloa of 49 chidrn for foster car and 161 for 

protetive seces. The Ch Welfar Legue of Amerca reommnds not mor than 17 

acve cas for wor deg with abused or neglec chidrn and their fames. 

Prentl expsure to drgs nu not be trlld IU chi liuse. 

Babies who test positive for contrUed substaces ar not always repo to chid welfar 

offcials. The actions tan depend on how a Sta defies chid abuse or neglect. These

te ar not intehageable and the distiction ca be signcant. The Ofce of Intor 

Gener is curntly conductg a stdy to assess how Sta legal defitions afect the 

handlg of prnata drg expsu cas. 

Indi law prvis tht a chid bo ad to drgs ca be conside abuse 

neglecte In For Wayne, the baby and any sibligs ar pla in prtetive custOdy pendig 

an investigation. An Dlois law effecve Januar 1, 199 states tht prenata drg exposur 

is evince of neglect. 

Ony four States vite reui hospitas to repo a positive toxicology to the chid welfar 

agency or a centr Sta registr. 'Some hospitas in other sites visite mae refers 

voluntay. At one site, hospita have ben instrcte by the chid welfar agency to repo 

cases only when the mother coul not ca for her chid. In another city, drg expsur cas 

ar investigate only if acoman by other facto, such as mother self-identication or 

pror abuse re. 

Several chi weUar agencs ar usng new /iproaehes to dell wi crtk bliy ClUes. 

Some citis have 9ni7OO high-ri drg baby unts to prvide inta and rik assessment for 

drg-expse inants. The cawor assigned to these unts ar spy tred to 

with the nee of the substace-abusig mother and her chid. In at leat one city, 

caworkers in these unts have ICce caload. 

One child welfar agency ha dentr serces into zones and comunty distrct. 

Caeworers ar now physicay locte close to the fames they see. Ths enables 

caworker to prvide bett suppo for fames and beme more fam with local 

servces. 
. . . ,

Cities ar prvidig mor casworer trg; New York City tred 1,264 new caeworer 

in 1989. May respndents felt tht chid welfar worers nee mor trg to identi and 

assess the nee of substace abuser and their chidrn. Oter respndents sai casworker 

nee for gulies for mag desions regardig teation of parnta rights. 

Hospit Il beginning to perform chi 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 losses that result frm ret foste parnts. extende unecssar stays. In some cities, hospitas now actively 

espy among their own sta. Some hospitas now ma placment reommndations to 

chid welfar. 

Sta at sever hospitas now locat, prvide, and coate seces for crk-adct 

mother and their babies. Oter hospitas have begu to trk clients afte dichae. 

Intragenc coordintn helps chi wel/Me "gencies cope. 

Lak of coodiaton is the most dicut prblem fac in prvidig serces to crk babies 

and their fames. acg to may respndents. One inteewee sad, ''Itegency cae 

magement is the key to adssig th issue, if anytg wor. 

Some States and prvat agencies ar taklg the issue of coation. Dlois ha a prgr 

of collabtion among chi welfar, alcoholim and substace abuse. and rela prgr. 

The cooate effor ha "reuce systems baner to integrte seces and alowed for a

fu complement of servces to be ma avaiable to high-ri fames. ,,8

The famy cour divion, attey gener's offce, and chid welfar agency in 

coo seces by "fast trg" cas thugh the system. Fas trkig is a prss 

wher the cour agr to set aside spc tis to hea dependency cas. Mi offci 

nt deons. repo th th prss ha alowe for mo and fa 

In may sites, goveror or mayor have crte ta fors to adss the crk baby 

prblem. Staed by prvat citins, governt offci. and meca and chid 

development exp, the ta fors identiy aDd pul together sece prvi, remmend 

monies for seces to high-risk fams. 

policis, and integrte 


helping crll1c-lted mothers tU their is essent in Comprehenrve clle 1Igement 

btlies. 

Cae maagement consists of guidg fames to seces such as eay intention. 

educaton, heath car, counlig, physica therpy, drg rehabiltation, and parntig clases. 

Respndents say that reuig clints to sek out suppove seces on their own does not 

work with crk adct. Client nee ar so complex and their adction so overwhelmg 

tht prfessiona ca magement is nee 
.. ,

,. . .... _. . ._. _._... _.. . :"J n. ..--­ -- 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 

dierent sece provide simultaeously." A case maager ca gu and motivat mothers 

and supese car of the chidrn. Ca maagement is widely sen as the respnsibilty of 

the chid welfar agency. 

Successful cas maagement reuis tht seces be rey acssible, accorg to may 

respndents. They emphas the nee to locate servces in the counity and prvide 

trsponation and chid car. Their most fruent comment was tht centr locons with 

multiple serces wor best; "one stop ca," sai one caewor. 

Even when seces ar availe, however, crk mother don t always parcipat. 

Accorg to respndents, crk adC1on results in demadig, imatient behavi. Crk 

mother someties deny they have a prblem and refuse serces altogether. 

MOST CRACK BABIES GO HOME, BUT MANY GO INTO FOSTER CARE. 

Most babies go home wih mothr Dr II rellve. 

Although few sttistics ar ket, respndents offer pena insights into the demogrphics 

of crk baby fames. USuy SO to 75 pent of identied crk babies go home with their 

mother or a relave, although the rage is SO to 95 pent at the sites vite At two sites, a 

baby is put into tempo prteve custoy (for up 10 72 hour) whie the chid welfar 

agency investigats.


Matern grdmother ar the relave most lily to tae the baby. Most chid welfar 

worker tr to plac a baby with the grother befor mag any other kid of plament 

Respndents at five sites say grdmother, who oftn ca for sever chin, ar 

overwhelmed by the nee of drg-expse babies. Ofci repo fater ar raly 

involved with the cutoy of the baby. 

Some relaves reive foste ca reimburements. Most chid welfar agencies prfer 

relative to foste plaments, but relaves often caot afor to ta ca of the babies. New 

York City prvides State-apprved relaves with fost ca reimburments, but opinons on 

ths appach var. Whe soe believe th apph is fai and results in bett 

monitog, other say such prgr delay reuntion of mother and baby, crte famy 

antagoni and petU the bay s foste ca st. At lea one respndent sad 

crtes oppoties for frd. 

When mother ente drg trnt 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 

the trtiona adult orntaon of trtment progr. Some mother must atnd out-patient 

us some drg tratment progr as a condition for keeping their babies. Respndents te 

mother dr out of trtmnt or resu usg drgs, but most trtment prgr do not 

trk redivi among the mother. 
............ ................................ ....... ....... 

.................. ...... .................... ... .

Many babies go into foster care. 

Most offci estite 30 to 50 pent of identiie crk babies go into foste ca, although 

a rage of 5 to 50 percnt was repo Accorg to some off. chin may be left 

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 Wayne and Phoeni have litte diulty fidig foster fames. Both 

cities have compartively sm num of drg-expse babies. 

As shown in the char below, the num of chidrn in foste ca plaments ha incred 

On a given day in 1982. ther wer 262,00 chin in plament; 280,00 in 1986; 293, 

in 1987; 330,00 in 1988; an an stmate 360,00 in 1989. 

Children In Foster Placement 

Ony SUy


11 ....... 


.,0 . 

tll tll 

Nu In ..It 

..: M8 NI.. II Ct 

Respndents spulte the incr of chidrn in fost ca is due to incred parnta drg 

abuse, but ths caot be conf Dat to demonstte th connection is not coUecte 

nationwi by chid welfar agencis.


Low reimburment was the most commonly cite reason for a shorge of foster parnts. 

Respondents say reimbmsements ar to low to attt fu-tie foste parnts, spialy for 

medcaly neey babies. 
.

Rate schedules ar complex and lack unorty. Varables afectig rates include the chid' 

age and heath, the placment agency, and the servces or pructs that qual for 

reimbursement. For examle, one city has eight categories of reimburment for inants wh9 

do not reuir consistent medcal attntion and four categores for inants who do reui / 

consistent medca car. With eah categor, chid welfar ha the flexibilty to determe 

the exact reimburment rate. Over, reimburment rages frm $3,233 to $30,730 

anualy. 

Respndents also repo shorges of black foste parnts and homes that acpt inants. . 

five cities respndents repo a parcul shorge of homes for inants with sp nee. In 

intm plaments, the babies ar prmiantly blak, but there ODe State tht restrcts 

a shorge of blak foste parnts. To de with the demad, some agencis put mor chidrn 

in eah foste home, shit chin betWeen homes, sear sibligs, and pla chidrn 

grup homs. 

Respndents told us repeatey tht foste parnts nee trg and suppo servces. 

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 

therpeutic), trsption, respite, and bett acss to physical and menta heath servces 

for their foster chidrn. 

In sever cities, outrh effor have pruce goo results. Strtegies fruently 

incorte newspaper stoes, rao and TV ta shows, and paid advering. Oter 

retmnt appaches include m1ng prvate fost car agencies with sp hospita, 

offerig bonuses to fost parnts who ret other foste parnts, and worg with loc 

churhes and communty grups. Ch welfar agencies and privat agencis ar 

expandig the pol of potenti foste parnts by acptig singles and ful-ti employees. 

Although outrh effor oftn result in an outpmig of coty respnse, the numbe 

who acy be fost parnts is lowe th the numbe who aply. Some applicats 

disquaed whie other lose intest Respndents also say ther ar obstales to incring 

the pol of foste parnts and keping them. These include reuiments that foste parnts 

live with ce geogrphic lits an restrctions on intm plaments. 

On the other had, so respndents say tht stada for foste parnts have delied 

Accordig to a West Coast cawor, applicants with ' 'm'' quacatons who would 

have ben nued away a few ye ago ar now being acpte 

Ajew go to othr care settngs. 

Crk babies ar oconay pla in other argements, such as emncy or congrgate 

car. Emergency car is a tempo plament pendig retU to a parnt or placement in 

foste ca. Emergency ca ca be a sm grup home, a lare shelte, or a foster famy. 

When a long-te placment caot be ma, caworker may be for to move babies 
... .

.

frm one emerency placment to another. Two cities repo tht they nee but do not have 

emergency placment facilties. 

Congrgate car is usualy perment grup home. Whe use mostly for olde chidrn, 

some babies have ben pla in such ca. Ofals in one city reived strong public 

crticis of the car provide to babies in congrgate car. As a result, al babies orgialy 

pla in congrgate car have ben plac in foste homes. Washigtn, D.C. is now 

buidig two grup homes for inants to cope with crti foste ca shorges. 

We encountere strng opinons about congrgat ca. Of 58 respndents who commnte 

nealy ha (27) believe congrgat ca ca work as a substtute for foste ca as long as the 

homes ar sm, kep sibligs together, and ar maaged prfessionay. Twenty-one 

respndents th congrgat ca is a bad id 10 have mi opinons. 

A few babies go with their mother to residenti drg trtmnt cente. Mother and babies 

sty at these cente frm 6 to 24 months, dendig on the prgr and the mother 

trtment nee. Seven citis vite have at leat one such cente, and respndents say may 

mor ar n 

Som babies rema in the hospita even though mecay rey for dihae. Known 

boar babies," these inants sty in the hospita due to legal colications, questions abut 

parnts' abilty to ca for them, or lak of ca alternves. Respndents frm five cities with bo babies say they ar able to ma plaments in tily maer. Four other cities 

repo they ar not able to ma tiely plaments. The th remaining cities did not 

the issue. Mor inoron on th issue is prsente in our companon repo "Boa 

Babies. 

Few crack babies lue been tUP"d. 

Whe respndents prfer adtion to peent foste ca, opinons on adtion verus 

famy reuncaon dier wily. May respndents sad the exig policy goa of fay 

reuncation is unc for may cr babies and sily prlongs the adoption prss. 

But other feel strngly th chid welfar s goa of fay reunon shoul rema. 

Th adtion prss is long, dit, an expDsve. Acg to a rent re frm a 

chidrn advoc grup, cawor gug the prss nee to be mo aggrssive 

chaenge the hures of the adtion prss, to fac a cour which seems reluctt to apprve 

adtion, _..to (confnt) the parnt, an to negoti th obstales of the agency prss 

itslf. ,, 

Most prspetive parnts want babies. Ofals tell us tht teaton of parnta rights is 

usualy conteste and although the prss ca theoticay be coplete in 18 months, the 

rety is at leat 3 yea. By then, these chidrn ar less liely to be adpte they ar not 

babies anym. 
.:. 1 . i-. 

Respondents cite other hidrces to adtion. One referr to a law whih reuis a 

72-hour waitig periOd for a mother to voluntay reliquish parnta rights. Th respndent ad that a crk mother may dede to reliquish her rights when her baby is bo, then 

leave the hospita and disappe. Neither hospita nor chi welfar sta ca loc her. When 

th happens, the baby canot be ma avaible for adption unti the legal prss 

comlete. 

Another long-stadig barer to adtion is the bias agait intc plament Some 

respndents say white fames don t want blak babies; other say States and agencies 

slow to apprve intemc adtions. 

May respondents believe tht even if parnta rights wer teate most cr babies 

would not be adte One caworke fry sad ther ar not enough pele wig 

adpt "these kid of chidrn." Prspve parnts fea long-te effec of crk and 

potentiy expnsive medca, edcaona, or psychologica nee. Adption subsidies for 

ha-topla chidrn, availe in al States, ar being used in som cities vite 

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 

On the West Coast, the next drg cris is aly her. Chi welfar agencis ar prparg 

for babies bo to user of a methamhetae devative caed "ice." Although ice is mor 

expnsve than crk, the long-lag high mas it attve 10 drg abuse. 

Methphetae is known 10 prce raid extensve feta dage. 

May respondents, espy on the Eat Co we conceed abut the ovep of AIS 

and crk. In the wor of one off "You ca sear th cr baby prblem frm the 

AIS prblem." Th over of AIS an drgs for these inants oftn me we ar deg 

with the sam ri grups, offerg the sa messages, and oftn prvig seces to the 

sae babies. 

Respndents sad may cr-adct womn engage in high-ri behavior and 

AIS-inecte babies. Fuly 70 pent of peatrc AIS cas ar the result of drg abuse 

by the mother or her sexua par. A loc heath offci sad, "AIS is now th laest 

kir among young women (her). We may not have to wor abut (crk baby) mother; 

they ll al be de" 

RespoJUnts want letUrship II Ilti01L 

Respondents repey caed for stng leahip, acurte inortion, and heightened 

public awarness. They point out that crk adcts use so may other drgs and alcohol that 

it is futi to taget just cr Although ther is no clea consnsus on exatly what to do, 

peple expss a sens of urency. 
One suggestion by respndents was to establih a national commssion on prenata drg 

exposure. Many respondents point to the succss of the National AIS Commssion in rasing 

awareness and educating the public about prevention. They urged the HHS Secta to tae 

this proposal to the Prsident. These respndents se a national commssion as a way to 

galvanize public attention, promote grater parcipation by State and local governments and 

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 

issue of prnata expsur to al drgs and alcohol. We also reogn tht the impact of 

inants prnatay expse to drgs extends beyond the purew of th Deparnt. Whe we 

reogn tht some policy issues rema unsolved our reommndations focs on acons 

which we believe ca be accomplished without adtiona authorties or signt fudig. 

STATE AND LOCAL RESPONSIBILmES 

Encourage out/Ih lI communit involvement State and loc governts 1. 

should conduct aggrssive outrh to prvi prnata ca for at-rik prgnt 

women. These effor must emha the dager of prna drg or alhol 

expsur. Communty and religious grups shoul be involved in idntig and 

helping mother and chin at rik. It is impot to wor with loc blak and 

Hispanc lea. 

2. Redue plaement bllrs Sta and local agencis should reuce bar 

placg drg-expse inants into foste ca and adtive homes. Th includes

reviwig and reviing existg laws and policies on abandonmnt, teon

parnta rights, and inteal plant. Cour should establish ''fas tr" 

procurs to expte chid welfar caes involvig drg abuse 

Develop guUnes tU trllnig. Stas should develop gudelies for chi 

welfar agencies to follow in respndig to drg expsur caes and in trg 

caworke to hadle such caes. Guidelies shoul cove ri assessment, famy 

reuncaton, and teation of parnta rights. Caworke should be tred 

identiyig substace-abuse behavior, reorg drg histors, and dontig 

evidence for cour 

4. EstlUsh reportg tU tr/Ildng "stms States should estalish crte for 

idntiyig and repog prna drg expsu as chid abus. Extig State 

chid abus reg an trkig systems should be expande and compute 

The inortion should be us not only for legal pmpses, but alo for the 

edcaon. prviion of heath ca and 

Swc and loc govents should develop S. Ezpll inmgency mec1ums. 

intitives such as ta fors to coate ses and integrte fuds. These 

intitives shoul involve cour and prseuto to review policis and expte 

legal preegs involvig drg-expse babies and their fames. 
/ 

DEPARTMENT OF HEALTH AND HUMAN SERVICES RESPONSIBIUTIES 

Offce of Huma Development Servce 

1. Disseminat effective practices. 'Te Ofce of Hum Development Serces 

(lS) should identiy pratices, prgr, and laws or reguations conside 

effecve in dealg with drg-expse baby cass and dissemiate th inortion 

to State and local goverents. 'Te HDS should also underte studies to 

evaluate the effecveness of these prtices. 

Foclls serve strate s on servng th jamily. Because of the rapidly grwig 

number of drg-expse babies, most wi be raed in their natu fames. 

May fames aly have multiple prblems, which wi be compunde fuer 

by havig to de with the prblems fac by drg-expse babies. In developing 

its serce strtegy for these babies, the HDS should plac priorty on prvig 

nee inteentions with the famy, to help ensur tht drg-expsed chidrn 

grw up in cag and suppove fay envinmnts. 

3. Evtzuate obstlles to plaement The HDS should evalua obstles to foste and 

adoptive placments, espy as they relate to drg-expsed babies. 

exaation should include CUInt policies regarg famy reuncaon, 

volunta parnta teation, and restrctons on foste ca and adption. 

Offce of Huma Development Servce and the Public Health Servce 

Coordi Deparnt activis. The HDS and the Publi Heth Ser 

(P) should cote Deparnta acvities relatig to drg-expse babies 

and their fames. Th reomndaon could be achieved thugh the expansion

inor integency coon activities of HDS and PHS. of the 


Reprsentatives fr the followig HH conents shoul be include: 

Ofce of Hum Development Seres 

Publi Heth Serce 

National AIS Prgr Ofce . 

PHS Pael on Women, Adolescnts, and Chdrn with mv Inecon and 

AIS 

Alcohol, Drg Abus and Menta Health Admstrtion 

Buru of Mate and Chd Heth and Resoures Development, Health 

Resours and Serces Admstrtion 

Nationalnstitute on Chi Health and Huma Development, National 

Insttutes of Heth 
...

: 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 

or semi-annual repons of findigs reui; 

evaluating long-tenn outcomes of varous tr:)tn' I't mod Jitje! in red cing or 

eliminating drg use by women of child-bearng ag who it aJcte 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 

prenata car in drg trattent progr 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 

students. MOdl brochurs (including eay to re ilustrte forts) and public 

servce announcements ar among the possible appro&;hcs. 

Public Health Service and the Health Care Financig Administion 

Continue to support t/eted outach tm prelUll CIl. The PHS and the 

Health Ca Financing Admnistron should contiue to suppo taete 

bt:nsive outrach intervention and prenata ca for substace abusing pregnant 

women and their babies. Ths includes identiyig and disseminatig prctices 

which encourge community involvement in prenata ca outrach and education. 
. r:- -

COMMENTS ON THE DRAFT REPORT 

Commnts reeived frm HDS, PHS, HCFA and ASPE wer genery suve of our 

reflecte a thoughtf reviw of the 

fidigs and reommendations. Al respndent comments
 dr and may excellent suggestions wer ma. May have ben incorte into the 

repo In adtion, the fu text of the commnts reived ha ben include in the appendi. 

The re wi fid much adtional usefu inortion in these comments. 

The HDS and ASPE reueste mo deta on our cost esttes for hospita deliver, 

peata ca, and foste ca thugh age We wi prvide ths inortion to them. S. 

The HDS felt tht whi the selecon of cities as the sour of inoron for the re was 

renable, ther was an imlicaon th the prblem of inants expse to crk wa 

urban phenomenon. We be1i e tht the purse stament of the stuy cleay defies that we 

exaed the afec of crk babies on the chi welfar systm only in sever major cities. 

The HDS al felt the re woul be stngtened by prvidig fuer dontaon. 

have respnde by indicag the sours of da in cha and by prvig spc citations 

in footnotes. Since we intewed sever respndents in eah city, we di not feel tht an 

itemion of the numbe would ad signcatly to the 

The ASPE suggeste adg hospita st to our State and local reommndation on 

development of gudelies and trg for chi welfar sta. Ou rendaons to HDS 

and PHS aly adss prtion of such trg in meca schools and hospita, and 

believe th is the most effecve apprh for adssig these ar with heath prfessiona. 

With respt to our rendaon on integency cotion, PHS and ASPE pointe out 

that crk baby issues relat to public heath as well as so seces. We agr, and have 

moded our remmndation to refl the crss-cttg na of the prblem. 

The PHS suggeste th the re foc on raer th jus th cr for of coe. 

As stte in the re we have us the te cr and coe syonymously as their 

detetin in the boy do not dier an may respndents adsse their conts usg 

the te intehagely. . 

Another ar of PHS conce was th the re faied to diuss the avaiilty of drg 

trtmnt prgr for prgnt women. We have include descptions of such prgr 

and other tys of ses di to the drg expse chin and fames in our 

companon repo "Cr Babies: Modl Prgr. 

The PHS also prvide sever tehnca conts, may of which we incmte in the 
The HCFA suggested we reword our reommendation on expande availabilty of prenata 

care to at-risk mothers and their babies. We agr and have made the suggested change. 

However. because of space considerations we have not included the American Bar 

Association s monograph Drug Exposed Infanls and Their Familes: Coordination Responses 

ofrhc Legal, Medical and Child Proleclion Syslem which PHS provided with its comments.
. : , ..,. / / 

. a. ,_ 

ENDNOTES 

Vilova Universty, Hum Orantion Science IntitUte. unpublished 

1990. 

2. D. McAlter, County of Los Angeles. Deparnt of Health Servces, Drg 

Abuse Prgr Offce. 1987 Drug-Related Costs in the Coun of Los Angeles, 

Septembe 1988, p. 17. 

State of New Yor Senate Commtt on Investigations. Taxtion. and 

Governt Options, Crack Babies: The Sha of New York, Dembe 20, 1989, p. 4. 


(MAlste, 1988. p. 17) 

5. E.S. Bandstr B.W. Stele. G.T. Burett D.C. Paow. N. Levandosk. and 

Rodguez. "Prvalence of Perta Coaie Exsur in an Urban Multi-Ethc 

Population, Apri1989 as cite in the U.S. Congrss. House of Peditr Res. 
 Born Reprsentaves, Select Cott on Chn, Youth and Fames, 

(Washigton. Hooked: Confontng the 1mpacl of Perinata Substae Abuse, 

C.: GPO. 1989). p. 6. 

State of New Yor Senat. Commtt on Investigations, Taxtion. and 

Dember 20. Governt Options. Crack Babies: The Sha of New York, 

1989. p. 5. 

7. DJ. Beshav, .'Te Chdrn of Crk: Wil We Prte Them?' Public Welfare. 

Fa11989, p. 7. 

Natna Drug Contol Stratgy, The Whte Hous, Septembe 1989. p. 44. 

U. Choff, M... Nationa Assoction for Pe Adction Reseh and 

A First: Natna Hospit Incidnce Surey. 1989. Education. 

State of Dlois. Deparent of Chidrn and Famy Serces. Dlois Dearent 

of Alcoholism and Substace Abuse. and the Natonal Assocon for Perata 

Addction Reseh and Education, The Illinois Model: A Staewi4 Collaorative 

p. 3. Program for Alcohol an Other Drug Using Pregna Women. 

9. Philphia Citins for Chidrn and Youth, In Their Second Bes Inzresl, 1989. 

30. 
APPENDIX 

OPDIV COMMENTS ON THE DRAFT REPORT 
. .

DEPARTMENT OF HEALTH I. HUMAN SERVICES OFFI igF roR 

6EliER;'. Wasing. D.C. 20201


1990 I-tAR 12 P'rt 1 9 

ttO 'el- DIAI 

DIG-EX DIG 

MEORADUM 

Richard P. Kusserow 

Inspector General 

TO: 

AIG-MP 

OOIIG EX SB 

DATE SD 

and Evaluation

FROM: Assistant secretary for planning


0.3-69- 4/S'/0 SUBJCT : Crack Babies Report 

overall I found this report informative, supporting many of the
 I do,


anecdotes we have been hearing about these children. 


however, have several comments which I note below.


xssue. no
 Ken ione4:

I suggest that you note somewhere that existing evidence


indicates that many (though certainly not all) of these children


will have long term needs. In addition, it looks as though w
 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 

is counter productive because its most likely effect will be to
 furer drive drg abusing women away from prenatal care, 

damaging the child.


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


On page 3, paragraph 2 you estimate the cost of caring for the


children you observed though age 5 to be $500 million. I find 

this figue confusing without f er explanatio regarding your 

assumptions. For example, what proportio are you assuming will 

be in foster care? It would also be helpful to cite a compariso 

figure regarding norml children. 

, In the final paragraph on page 3 and the first paragraphs on page 

4 you note, qui te appropriatelY" that few of these children are


being identified. What you fail to point out, however, but that


we find to be an important issue, is that the lack of appropriate


seem to 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.


Certainly, they cannot identify cause. In 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' 

drug of choice among certain populations , "ice" or something


else will soon come along to replace it. Straight line 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.


This is especially important for woman of childbearing ageMost 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


add the need for better identification of drug exposed infants, 

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. 
Page 3 - Richard . Kusserow


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


report written by my staff which outlines many of these efforts. 

Your Recommendation numer 4 for the Office of Human Development Services (page 5) suggests the need for interagency coordination of acti vi ties regarding these children and. families. 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 

and a social services one. 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


Cj, 

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

- I , ' . .i 

Off Ice ot 

".."t, Human Development Services 

DEPARTMENT OF HEALTH &. HUMAJ" SERVICES 

Assistant Secretary 

Washington DC 20201 

30 1990 A.OR 

'10 : Ricbard P. Eusserow 

Xnspector General


FROM: ssistant secretary 

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 draft report of the (OIG) anti tled "crack Babies.


Office of xnspector General 


'1he report provides valuable information and a vood overview of (e. V., .edical, 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


rehabilitation, .ental healtb, juvenil tbat the findinv are 

or proj ected into tbe future. We Dote y other 

asis. here is also
 venerally consistent vi tb tbose eing reported 

investigators on a national and regional 
 cocaine is
 agreement vi tb tbe consensuS of tbe respondents interviewed for


exosure to other tbe report tbat tbe problem of infants exposed to crack
 interrelated vi tb tbe larger issue of prenatal (page 13). drugs and alcobol as vell as &IDS 


irst, page 3 of tbe


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


perinatal care, and foster care tbrougb age 5 for just
 We suggest tbat


abies approximate $500 aillion.
 identified 

roken down and justified so tbat tbey can 
 abut tbe five tbese costs 


better understood. .e are concerned, for example,
 care. Xn addition, tbe


year projected lengtb of stay in foster nine day


ini tial draft of tbe OXG report factored in costs for a 

hospi tal stay for heal tby abies, vbicb considerablY exceeds the 

norm of tbree days or less. informati 

second, vbile tbe selection of cities as tbe source of 
 is tbat the problem


for the report vas reasonable, tbe implicati pbenomenon. '1be 

of infants exposed to crack cocaine is an urban 

/ .

usserow 2 - Richard P. 


staff of the Children'S Bureau are beginning to receive reports


from small towns and rural areas which indicate that the problem
 Officials in the state

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, rather than to child
 hese officials indicate,


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.


documentati For example, the numer hird, the report would be strengthened by the provisi
 of respondents interviewed

10. Xn by site sbould be provided, as sbould the sources for the


information presented in the charts on pages 5 and 
 page- 9 of the text and in the


addition, the data presented on 


chart on page 10 relate to a one day count of children in foster
 1983-1986, the last years


care, not to entry rates for the years (VCXS) data are


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 to the advent of the phenomenon of infants
 cocaine. 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. 

s recommendations must 

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 

APR - I, 8 

Dat! 

Fro- Gail R. Wilensky, Ph. qcJ Administrator 

S..:, OIG Draft Report - Crack Babies, OEI-03-89-01540 

The Inspector General 

Office of the Secretary


We have reviewed the subject draft report It examied how crack babies 

have affected the child welfare system in 12 metropolitan areas. 

Though the report makes several recommendations to locl. State and 

Federal agencies, only one recommendation is addressed to HCFA The report 

recommends that HCF A and the Public Health Servce (PHS) continue to 

support expanded availabilty of prenatal care to at-rik mothers and their babies. 

Vle believe that the wording of the recommendation is to vague. Rether than 

expansion. we support targeted or intensive outreach intervention and pren !:a! 

are for substance a usmg pre nant women. We are already .engaged 

. O


i enti ng an lssemmanng practices which encourage community involvement 

in prenatal care outreach and education, as this recommendation further 

suggests. 

In addition to the drug abuse training cited on page 16, we believe 

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. 

Finally. we have one techncal comment. The PHS components listed on 

page 15 should be clared to read: 

Bureau of Maternal and Child Health and Resources Development, 

Health Resources and Servces Admitration 

National Institute of Child Health and Human Development, National 

Institutfls of Health 
Page 2 . The Inspector General


AJcohol, Drurz Abuse and Mental Health Administration 

- National stitute on Drug Abuse 

. Office of Substance Abuse Prevention 

. Offce for Treatment Improvement 

Thank you for the opportunity . to review and comment on this draft report. 

Please ad\ise us whether you agree with our position at your earliest 

convenience. 
. ...,.. . ..g;;:, , , ., . ,.... 

'JtC .. ""II "881'" HrVIc;e 

::'Z 

Jf 21) 

Memorandum 

-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 

through public outreach, and (2) continue to 8upport prenatal 

care expansiou.


es O. K


Attachment 

10 ­
 PDIG 

DIG-AS 

JnG-EI 

a;Jg 

EX SEO
 0:: 

DATE n "" r: '0 ;- "T 
 1-

:- :: rr i- 0 
. _..

_0 ,. 0 ..­

TH OFF:CE OF 

TH SERVICE ON
REPORT

COMMENTS OF THE PUBLI 990 NSPECTOR 40.

K aAIES ' OEI 03­


Gene=ol Comments pa of the problem.

The OIG reports that we are only seeing 
 ba and most are not identified at

There is no typical crack tests can detect cocaine in the mother
 methods are birt. We concu that Howver, new an in hair. 

to measur cocaine in meconum for only 24 to 48 hours after use.
 becomng availabl 

These tests, if positive, would indicate prolonged use of


cocaine during pregnancy. related 

recognzes polyc9 abse an 

problem (e.g., AJDS), th reiew Although the report 
 adQrsses usues only Giva the 1.tauons to ths 

believ the te",S of crack-cocaine.
 report shoud concentrte narror focus, we. 

. cocaine , rather thn on the ' crack' form of cocain. believ atteUon, we 


Although the report' s title will attract 

statemnta on. the use of the term ' crack' and ' cocaie' 8Yonymsly may 

perhaps misleading differntially identify lead to inccurate and form of cocaine. 

prevalence since there is no way to
 hum boy ciS not differ by crack cocaine use from the use of other 


This is because presence in the 


form at intake. 


adQrssing the 1Jct of .crck-USin9 mothers clincal indications 

In addition. when addictg on the child welfare system, there are
 won uses the rapidly and highly becom metally that when a th if she used to sto crack' fa", of cocaine, she may more rapidlY
 using it,

incapacitate an unble tht th rert 80me other f01: of cocaine.
 fails to

wUh to highlight is drg tratmt program for Another point we 


. we believ tht ther should be coordnation discuSS the availability of 


amg substance abse trtmt, prim an pretal ca pregnnt program. 

HIV infection prevention 
 AI an dr9-esed 

aciss peatriC 


babies as pa of the s- problel. The overlap betWen the There is a need to 
 drgs for these infants means we

problels of AJDS and s- baies. groups, offering the 


ofte priding usually dealing with the SlUe riBk 
 services to the

me".ages, and 
 cases are a result of the
 sexl pa. peiatriC AJDS
 1Ico;tion

Fully 70 percent of 
 reflecte in the report, pacularlY d'I" abuse of the IIther or her thes local coordintion of of thiS fact should be
 recom Federal, State, an 

DS activities.
 pediatric HIV/

Page 2


DS Program


The surgeon General and the Director, National 


Office co-chair a PHS Panel on Women, Adolescents, and DS. fairs, This panel is comprised Children with HIV Infection and 


of all the PHS agencies and the Office of populati
 problem identified 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 


The following are our coments on the OIG recomendations. 

OIG Recommendation 

SB' dD LO USPORSIBILrfZS 

.ystems. States should and tracking 

Establish reporting 
 drg exposure as

establish criteria for reporting prenatal 


child abuse.


PHS coment 

We concur. However, the recomendation only centers on legal 

informtion should be used concuently to issues and this care. 

provide appropriate health education and 


OIG Recommendation


DEPAR'r 01' BE'l AI JI SERVICE RBSPOSIBILI'IES 

effective practices. 'le Office of Humn Dissemnate 

Development Services (HDS) should identify practices,


programs, and laws or regulations considered effective


in dealing with drg-exposed ba cases and dissemnate 

this informtion to State and local governnts. 

PHS Comment


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


practices considered effective, evaluation of their
 ttme.

effectiveness must be considered at the same 


OIG Recomendatio 

activities. 'te BDS should
 Deparental Coordinate coordinate Departental activities relatig to drgfamlies. exposed babies and their 


S Comment


tol: believe that PHS rather than BDS should be the lead OPDIV 

to coordinate Departent activities relating to drg-exposed 

famlies. 'lhere ia a need for education and 

babies and their 

... 

. ,.. )) 

Page 3


support t rough famly planing centers and prenatal program.. drg-exsed baies an 

We advocate this position because problem. We


their famlies encounter numerous medical 

problem are primrily medical or publi 

1', ' believe that these foste care or child abe matters. 

health issue., and not 


OIG Recommendation
 Beal 

of ll Delopt Serdc:s and Cbe PalJc 

Office Serice 

':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


We concur. In this regard, the Health Resources and Services


Adnistration' s (HR) Jlternl an subt Chld Health Research 

Grant program permts principal investigatorS to 

applications for long-te= research on "dr-esed" baies. 

If a proposed research prject in ths ara pros viable, it 

is considered for fundig. 

indispensa1)le. weYer , 
 short-term research is also
 state 

suggest added 1)ullets to 
 determne the optiml


short-ter. research should 


treatment to cocaine-addicted mothers during
 birt of a miimlly pregnancy to ensure the
 affected infant. 

factors responsible for


research examning the risk
 drg abse is needed if effective prevention is to 

imlemnted. 

national 8ureillance epidem system 8hould exist to 

monitor the extent of the crack
 specifically during pregncy. 

OIG Recomendation 

'fe BDS an the PH should trai!n. drg abuse 

proote in 

promote drg abuse traing 

Kedical Schools, and


Child welfare agenci

Page 4 .

PHS Comment
 fort our activities U\ 'tese following eets
 We concur. he 

areas. 

Medical school 

Kedicine. ore
 The Bureau of Health Professions, BRSA, recently awarded a
 contract to the society of 'lachers of ramly abut purose of ths contract is to train approximtely 180 famlymedicine physician faculty how to teaCh residents 


substance abuse.
 cotract to


se Bducation.
 ore Bureau of Health professions also awarded afro academc
 sponsor a Physician consortium on Substace 


ore consortium is comrised of representatives for the education
 resposibl 

and trainng of physicians. ore purse of the consortium is and professional organizations 
 reing to refine and imlemnt strategi wbich will ence an 

8ubstaCe 

build on existing medical education strategies for


arriers to preventiOn and early identification of


abuse. 

ld welfare Aaencies


Block Grant Program may


Haternal and Child Health (HC) to chld 

indirectly, though the States, allocata KC funs drg abuse traing. welfare agencies for 


OIG Recomendation 

Promote prevet10n W'ugb pub11 outrch and 

J.formt1onal _ter1als.


PHS coment 

We concu. Jler, the education should be exdedsince 

ourses in junior high achools and middle achool


prevention must begin early.


Abe pretion, AJ, on a joint ore office of Katemal an Chld Health, JI, is workig with 

the Office for Substace focusing on 

tratmt of drl/ use durinl/ pregnancy. demonstration grant prram to local coti 

prevention and 

intervtion teches denstration prjects in h1l/h-risk

priding tring 

date, a total of 45 


in developinl/ new funded. 

population areas have been 

Page 5


OIG Recommendation 

IId the
 Health Ca 7J.cJ Public Health serice 

Af'mirU Btraticm expansion. 'le PHS and
 care 

to support prenatal Adnistration Continue should continue

the Health Care Financing 


to support expanded availability of prenatal care to at
 baies. risk mothers and their 


PHS coment 

We concur. BRA' S Office of Maternal and Chld Health is 

werking with HCFA to expand availability of prenatal care to


more pregnant woen, including those with -drg-exposed" 

children. 

echnical coments 

'le title of ths report, .crack Baies, . is errneous and 

he appropriate te:cnology, whch is used by 

misleading. field, is -drg-exposed" or experts and professionals in the
 It is recomended that the title be


"drug-affected infants. -


changed thoughout the report to -drg-e8ed baie8. 

drg cocaine. It 

Crack is only one method of inge8ting the
 whether these baies were, virtually imo8sible to determne (snorted) 

in fact, exposed to crack, intra-nasally ingested
 comination of drgs during 

cocaine, or if the mother used a


her pregnancy. 'lhe curent research available indicates that 

most - crack" users ar poly drg usere, coming cocaine with 

other drgs. By focusing only on . crack. babies, a narrow and 

i8 creatad. Any


inaccurate perception of the problem ,


references to drg use among woen, 8uch as that on page 

. 8hould be changed to .drg-addicted 

crack addicted mothers,


mothers. " 

OUR PaQes i and 1, . 

.!be Rational


'le first paragraph 8hould be changed to read
 Insti tute on Drug Abuse (NIDA) estimtes tht ovr 6 million 

. instead of the 5 million cited
 woen of 
 ild bearing age....
 estimte 1s based on data fro the 

in the report. 'le 


Rational Household surey, 1988. 

pa e 1 Pifth Para a h


'te report' 8 exclusive focus on crack 8uggests there 1­
 amng teenage mothers. 

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 are abusing many hese young woen are or 

including other forms of cocaine. 
 endager the live. .oon might become pregnant and thus will 


their yet-to-be-born children. hese teenagera reire a wide 

tae into account their 

range of 8ervice. that are designed to 


developmental as well as their obstetrical Deed..


wide scope oUbe D%b ranaina. 

,acre 3


. 'te cost for


In the second paragraph, OIG reports cae . . 

hospital delivery and perinatal care, and foster
 approximte $500 million. 

Al though in this report the costs of fo.ter care, hospital ben pooled, it 

delivery, and .hort-term perinatal care have 


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

perinatal care apart
 perintal Informtion on cost to .upport hospital delivery and
 h1. i. ... contrast t.o the paucity of care i. now available. 


informtion on the actual cost of proic!g qulity cae indefinte periods of tie. 

foster homes over 


In response t.o these que.tions, .IDA i. cuently .upporting 

research demonstration studies that .oon will provide more
 detailed informtion on the cost to comunities to proide 

effective comprehensive .ervices, with and without case


maagement system in place, ben t.o addicted pregnt woen and 

their children. Although DO .tudies have as yet

.Ubtted, NIDA i. actively encouraging 

cl1ncal inve.tigators

tht vill critically 

ftifte the cut 

to design studi.s 


foster care .yatem in t.exm of coat and beneficial effectS.
 .OR crack Dot cal 

t .ost crack baies look 

In the firat .entence, OIG .tates 
 . We believ
 difficut t.o identi healthy and are therefore 

it may be more correct t. .tate the followinga


adver.e .igns or drg-induced 

here i8 DO typical .et of 


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


cocaine-fetally-eaed infant. t.s lack of differetially 

Several reasons account for 


discrete pattern of effectaa
 th cocaine­ 9 absers rather may (1 ) Host woen ar pol 

only, and therefore clinicians have identified


overlapping pattern. 
. . ). 

Page 7


accuate drg accuate enough to (2 ) In m08t ca8e8, it i8 impos8ible to get an 

U8e hi8tory from the mother, at lea8t 


relate a specific neonatal clinical patt.rn with the


mother' s use of a specific drg like cocaie. 

smll a numr of cas.s Where accurate 

(3 ) There still 1s too Qrg U8e hi8tori88 do exi.t to foxm the basi. upon which

to mae a differential diagnosi 

( 4) Very subtle eigns of cocaine expsure 11 utero are 

difficult to detect at the pre8ent time because of a lack
 d procedurs. of clinical instruents 
 describ the 

studies that a1m to 


NIDA is curently supportng fetus, newom, and 

effecta of cocaine exposure on the 
 instrent. and developing child as well as re8earch in the development of


clinically sensitive and useful diagnosti


procedures. sed Chldren the 

pa e 5 the chart 8pro ection of 


Year 2000 
 ch 1s not 

'lhe source for provided. the data used 11 the project1O!UP 'f 

!'aqe l..EOPL AR DRUGS. NOT JUST 


Fuer elabration 18 neces.ar on th8 8tat_nt. 

USPSIB
 DO 

laae 

82. Reduce placement bajer8. 8 'f date, 88Y of the ideas . nviewg an 

put fort to reuce placet baien by . 

on . . 
. 'te:mtion

revising existing laws and polici
 8 have addressed the i..ue of unfit


parental rights. 


mo'therhooc from the perspective of reov1lg the bab, and 

childr, fro the aother. unfortuntely, fewr vaen perhapa the other
 termnation of parental right. may result 11 

, voluntarily comg for prenatal-postntal cae or for 

(see attached copy of the


treatment for their addiction rug aed Infanta a
 a 8Ooqaph Medical American Bar a.aocietion'
 'reir !'amlies' Coordination Res n 8 of the La al 

Although t8porary placement rotect on Syatem and comity efforts and

for children i. often necessary, increase the


Xilitource. .hould be directed towrd method. to 

drg tratmnt numr of addicted vaen of program that are chldbaring age comng into the 

medical, .ocial .ervice, and
 cu--rently available. 
..

.(. _ _...  .... ?

Page 

, 84. 
 Coord nate Deparental act1.v!t!... l.aQe 

Pulic Beal th Service, the Rational Institute

Under the bullet 


on Drug Abuse and the Alcohol, Drug Abuse and Mental Bealth


Adnistration (ADAM) are listed .s being eqlAD. Also, 

organizations of PHS. RIDA is an Institute of with PHS, AD, BR, and 

there are other organizations whch have responsibility 

the National Institutes of Bealth ths report. BR' s Bureaus 

relating to the subject matter of professions 

of Health Care Delivery and Assistance and Bealth'
 Katemal and Chld 

should be included along with the Office ofDepartent Health in the PHS representatives for the
 activities. '.herefore, ths pa .hould read .. followl 

-- Rational AIDS program Offic
 Chldr with BIV 

-- PHS Panel on wom, Molescent., and 

Infection an AIDS 

th A"",i ft!-stration

-- Alcohol, Drug Abu.e and .ental Beal 


National Institute on Drug Abuse


Office for Substance Abuse Prevention


Office for -.reatment Imroemt 

Adnistration 

-- Beal th Resources and Services 


Bure u of Bealth Cae Delivery and Assistace 

Bureau of Health professions
 Office of Katemal and Chld Bealth 

Chld Bealth and BWI Developmnt, 

-- National Institute on
 National Intitutes of Bealth 

_n. 7111