Tronick E Z, Beeghly M
Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.
Clin Perinatol. 1999 Mar;26(1):151-71.
On the whole, the literature suggests that toddlers and young children who are exposed prenatally to cocaine exhibit few, if any, consistent differences in developmental functioning compared with demographically similar, nonexposed, age-matched controls. The paucity of cocaine-related findings does not mean that prenatally cocaine-exposed children are free from developmental problems. Cocaine-exposed infants may well have specific deficits that are masked by confounding factors in study designs; however, more important is the worrisome finding that the average performance of both drug-exposed and nonexposed children in the literature tends to be poorer than expectations for age. This problem likely stems from the fact that most study children in the literature (regardless of exposure status) come from low-income backgrounds and consequently have been exposed to multiple medical and social risk factors associated with long-term poverty. The fact that exposure to multiple risk factors has powerful, compromising effects on children's outcomes may overshadow any specific effects of prenatal cocaine exposure. The problem of high cumulative risk in the literature raises both methodologic and clinical issues. To disentangle the relationship among prenatal cocaine exposure and other comorbid risk factors in predicting children's outcomes, investigators in future studies should recruit samples with varying levels of accumulated risk. This increased range of risk will also permit researchers to evaluate the interaction of exposure status and risk status and identify specific protective factors that may contribute to resilient outcomes for these infants. This information will be helpful in the design and timing of intervention services for these high-risk infants and their families. On a clinical level, when exposed children present for interventional services, professionals must not limit their remedial efforts to drug treatment alone. Rather, clinicians should also view prenatal drug exposure as a possible marker for the presence of multiple medical and social risk factors (e.g., maternal psychopathology, social isolation, child maltreatment, domestic violence, or inadequate caregiving). Because any of these factors may place children in developmental jeopardy, these comorbid risk factors must be considered, together with prenatal drug exposure, and, when possible, treated. Although confronting this wide range of problems may seem overwhelming, many conditions associated with poverty are treatable. Moreover, from the perspective of the cumulative risk model, interventions are most likely to succeed if they attempt to reduce the overall burden of risk rather than targeting single risks.
总体而言，文献表明，与人口统计学特征相似、未接触可卡因且年龄匹配的对照组相比，产前接触可卡因的幼儿和学龄前儿童在发育功能方面即便存在差异，也是极少且不一致的。与可卡因相关的研究结果较少，并不意味着产前接触可卡因的儿童没有发育问题。接触可卡因的婴儿很可能存在一些特定缺陷，但在研究设计中被混杂因素掩盖了；然而，更令人担忧的是一个令人不安的发现，即文献中接触毒品和未接触毒品的儿童的平均表现往往都比预期的年龄水平要差。这个问题可能源于这样一个事实，即文献中的大多数研究儿童（无论接触状况如何）都来自低收入家庭，因此接触了与长期贫困相关的多种医学和社会风险因素。接触多种风险因素对儿童的结局有强大的负面影响，这一事实可能会掩盖产前接触可卡因的任何特定影响。文献中高累积风险的问题引发了方法学和临床方面的问题。为了厘清产前接触可卡因与其他共病风险因素在预测儿童结局方面的关系，未来研究的调查人员应招募具有不同累积风险水平的样本。这种风险范围的扩大也将使研究人员能够评估接触状况和风险状况之间的相互作用，并确定可能有助于这些婴儿获得良好结局的特定保护因素。这些信息将有助于为这些高危婴儿及其家庭设计干预服务并确定干预时机。在临床层面，当接触毒品的儿童前来接受干预服务时，专业人员绝不能将补救措施仅限于药物治疗。相反，临床医生还应将产前药物接触视为可能存在多种医学和社会风险因素（如母亲精神病理学、社会隔离、儿童虐待、家庭暴力或照顾不周）的一个标志。因为这些因素中的任何一个都可能使儿童处于发育危险之中，所以必须将这些共病风险因素与产前药物接触一并考虑，并在可能的情况下进行治疗。尽管面对如此广泛的问题可能看似势不可挡，但许多与贫困相关的状况都是可以治疗的。此外，从累积风险模型的角度来看，如果干预措施试图降低总体风险负担而不是针对单一风险，那么这些干预措施最有可能取得成功。
