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A Comparison Of Prenatally Drug Exposed Preschoolers To Non-Drug Exposed Preschoolers Using The Miller Assessment For Preschoolers

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A Comparison Of Prenatally Drug Exposed Preschoolers To Non-Drug Exposed Preschoolers Using The Miller Assessment For Preschoolers

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A Com parison erf PrenataHy Drug Exposed Preschoolers to Non-
drag Exposed Preschoolers Using th e Miller A ssessm ent for
Preschoolers
Angela Persic
A Thesis Presented to the
FACULTY OF THE GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF ARTS
(Occupational Therapy)
August 1995
UMI Number: 1378430
UMI Microform 1378430
Copyright 1996, by UMI Company. AH rights reserved.
This microform edition is protected against unauthorized
copying under Title 17, United States Code.
UMI
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UNIVERSITY O F SOUTHERN CALIFORNIA
THE GRADUATE SCHOOL
UNIVERSITY PARK
LOS ANGELES. CALIFORNIA 0 0 0 0 7
This thesis, written by
and approved by all its members, has been pre
sented to and accepted by the Dean of The
Graduate School, in partial fulfillment of the
requirements for the degree of
under the direction of h.S.C....Thesis Comm ittee,
Dtaa
D ate......
THESIS COMMITTEE
Chairman Chairman / \
ii
Acknowledgements
I would like to thank the m em bers of m y thesis com m ittee for
their knowledge and guidance in this project. A special thanks goes to
Dr. Diane Parham for the encouragem ent and feedback she gave m e as
I went through the m any revisions required to com plete this thesis. I
would also like to thank the schools which allowed m e to conduct my
research at their facilities, including St. John's Child Developm ental
Center and W est Los Angeles College Child Developmental Center. I
especially appreciate the assistance from M aryann Rinsch from
St. John's and Yvonne Simone from West Los Angeles.
Throughout the last two years my fiance', Greg Fritton, has been
m y inspiration to persevere to the end of this project. His patience,
support, and love gave m e the encouragem ent I needed to finally
finish this work. Thank you, Greg. I love you!
Last but not least, I would also like to thank my parents for all the
doors they opened for m e and all the tim es they supported m e in
achieving my goals. W ithout them, I would not have com pleted this
accomplishment. Mom and Dad, this is for you. Thanks for
persistently getting on m y case to finish this. I love you!
iii
Table of Contents
Problem Statem ent..........................................................................................1
Literature Review........................................................................................................6
T rends in D rug A b u se .......................................................................... 6
Physiological Effects of Illicit Drugs on A dults......................6
Problems With Identifying Pregnant Drug A busers....................9
P revalence an d In cid en ce..........................................................11
Developm ent of Drug Exposed Children.................................................. 14
Fetal D evelopm ent............................................................................. 14
N e o n ata l D e v elo p m en t...............................................................16
D evelopm ent of th e T o d d ler................................................... 19
Developm ent of Preschoolers.......................................................... 21
Physical grow th....................................................................... 22
Cognitive developm ent........................................................ 29
Language developm ent......................................................... 31
Behavioral developm ent...................................................... 33
Socioem otional developm ent............................................. 36
E nvironm ent....................................................................................... 37
Sum m ary...............................................................................................45
A Review of The Miller A ssessm ent for Preschoolers.................... 46
Overall Purpose of the M A P............................................................ 46
Overall C ontent and Form at of the MAP..............................47
History of Test D evelopm ent........................................................... 49
D evelopm ent of initial test item s....................................... 50
Pre-standardization test developm ent............................... 51
S tandardization of the MAP......................................... 52
Reliability studies of the M A P............................................. 54
Validity studies of the M AP................................................. 57
M ethods........................................................................................................................ 64
Research Design...............................................................................................64
Participants........................................................................................................64
Inclusion and Exclusion Criteria..................................................... 64
R ecruitm ent of p a rtic ip a n ts...................................................... 67
In s tru m e n ta tio n ........................................................................................... 73
Research Protocols.......................................................................................... 74
Statistical Analysis.......................................................................................... 76
Results............................................................................................................................77
Percentile Scores of Subjects..........................................................................77
iv
Wilcoxon Signed Rank Results................................................................... 78
D isc u ssio n .................................................................................................................. 81
Additional O bservations................................................................................86
Relevance to Occupational Therapy........................................................... 88
R e fe re n c e s.................................................................................................................. 91
List of Tables
v
D escriptive d a ta (Table 1)....................................................................72
Percentile sco res (Table 2)................................................................... 77
Wilcoxon Results for total MAP and Subscales (Table 3)................. 78
Wicoxon Analysis of Red, Yellow, & Green scores betw een the two
g ro u p s (T able 4)................................................................................79
vi
Abstract
The purpose of this study was to com pare the perform ance of
prenatally drug exposed preschoolers to non-drug exposed preschoolers
using the Miller A ssessm ent for Preschoolers (MAP). The sample
consisted of six prenatally drug exposed preschoolers who were
m atched to six prenatally non-drug exposed preschoolers for age,
gender, ethnicity, and socioeconom ic status. The drug exposed
preschoolers w ere identified through medical records.
The researcher expected to find a difference in MAP scores
betw een the two groups with, the drug exposed sample would scoring
lower. The Wilcoxon Signed Rank test was used to com pare the
num ber of red, yellow, and green scores betw een each group.
A strong trend in the expected direction was found betw een the
two groups when com paring the num ber of red and yellow scores in
the Complex Tasks Index and the Total MAP. However, the
differences in red scores were not found to be statistically significant
(p=.06 for both the Complex Tasks Index and the Total MAP). The p-
values for the differences in yellow scores in the sam e indices were
p=.06 and p=.09 respectively.
W hen com paring the num ber of green scores betw een each
group a statistically significant difference was found betw een the two
groups on the Verbal Index (p=.05), the Complex Tasks Index (p=.02),
and the Total MAP (p=.05). In addition, a strong trend indicating a
vii
difference betw een the num ber of green Foundations Index scores was
found (p=.06).
Because the prenatally drug exposed sample for this study
consisted of children w ho were referred to occupational therapy
services, these m ay be drug exposed preschoolers whose exposure has
affected their developm ental function m ore significantly than other
drug exposed children living in the community. Results from this
study suggest that prenatally drug exposed preschoolers who are
referred for occupational therapy services m ay dem onstrate delays in
their verbal skills and their ability to perform com plex tasks.
1
Problem Statem ent
This study was designed to describe the developmental
characteristics of preschoolers who have been prenatally exposed to
illicit drugs. This study focused on three to five year old children who
were passively exposed to illicit drugs in utero. The Miller A ssessm ent
for Preschoolers (MAP) was adm inistered to a group of six prenatally
drug-exposed children from a preschool associated with St. John's
Hospital in Santa Monica, California. A control group of six non-drug
exposed preschoolers from various preschools was m atched to the
drug-exposed preschoolers for age, gender, ethnicity, and
socioeconom ic background. Data from the MAP were interpreted
through statistical m eans discussed in chapter three using the Total
MAP scores and the M APs five subscales scores.
Before further discussing the following study, a rationale for
conducting this type of study m ust be established. Drug abuse am ong
pregnant wom en is a growing problem in the United States (Chasnoff,
1989; Ryan, Ehrlich, and Finnegan, 1987; Schydlower, 1989;
Silverman,1989). A survey conducted in 1985 estim ated that 1,960,000
w om en over the age of 18 years old use illicit drugs (Silverman, 1989).
These figures increased by 59.35% since an earlier 1982 survey.
Previous research has provided support indicating that prenatal drug
2
exposure has detrimental effects on infant developm ent. For example,
studies associate low birth weight, birth length, and small head
circumference in the neonate with prenatal drug exposure (Hurt, 1989;
Neuspiel and Hamel, 1991; Ryan et. al., 1987 ). Further research
indicates that children exposed to drugs in utero dem onstrate
neurodevelopm ental abnormalities, such as decreased organizational
responses, increased trem ulousness and irritability, state lability, and
poor consolability (Hurt, 1989).
If a significant num ber of w om en abuse som e type of illicit drug
during their pregnancy, then an increasing num ber of children run the
risk of developing these problem s as infants. How does prenatal
exposure to illegal drugs affect the child as he or she develops into a
toddler or preschooler? Few studies have focused on the developm ent
of toddlers and preschoolers who have been exposed to drugs
prenatally. These studies offer conflicting results from one study to
the next. Some studies suggest that prenatally drug exposed
preschoolers score lower on cognitive tests and sensory processing tests
than non-drug exposed preschoolers (Bauman and Daugherty, 1983;
Billing Eriksson, Steneroth, and Zetterstrom , 1985; Wilson, McCreary,
Kean, and Baxter, 1987 ). Other studies indicate that cognition and
sensory processing is not affected on a long term scale (Kaltenbach,
1978).
Wilson (1987) com pared a group of heroin-exposed preschoolers
to three other control groups and found that the drug-exposed children
3
scored lower on a general cognitive index and on the perceptual,
quantitative, and m em ory portions of the McCarthy Scales than other
groups. She also discovered that this group scored lower on visual,
tactile, and auditory portions of perceptual tests. On the other hand,
Kaltenbach (1978) found that preschoolers bom to wom en who used
m ethadone during pregnancy did not have significantly different
scores from non-drug exposed preschoolers on four developm ental
tests. Because the findings in all of these studies widely vary, one
m ajor research question m ust be asked when addressing the possible
problem s associated with this population: Do these children have any
notable developm ental problem s, and if they do, what are their areas of
weakness? This was one of the primary questions behind this study.
If these children have developm ental areas of weaknesses, then
a sensitive developm ental assessm ent in addition to an in-depth
teacher report regarding each child m ust be used to determ ine where
these w eaknesses lie. For the purpose of this study, the researcher
selected the Miller Assessm ent for Preschoolers (MAP) as the m ethod
of determ ining each child's developm ental status and function. The
MAP is renow ned as an instrum ent adequately sensitive to detect
developm ental problem s in preschoolers (Miller, 1982).
The MAP is the only general developm ental assessm ent
available that includes items that are sensitive to neurodevelopm ental
processes (Miller, 1982). This was crucial to investigate because many
studies on the developm ent of prenatally drug exposed neonates
dem onstrate that drug exposed neonates develop neurological deficits
that m ay b e indicative of later neurodevelopm ental problem s. This
tool also is designed to create a profile of the child's different abilities
rather than just focus on his or her disabilities. In addition, the MAP
has good predictive validity as found in three different studies (Cohn,
1986; Lemerand, 1985; Miller, 1986). In all the studies the MAP was
successful in identifying m ost of the children who later developed
academ ic problem s in school. Because of these reaso n s, the researcher
felt that the MAP was the m ost appropriate assessm ent tool to use in
conducting this study.
This study was designed as a com parative correlational study.
The MAP was adm inistered to two groups m atched for age, gender,
ethnicity, and socioeconom ic status. The target sam ple consists of six
children who w ere prenatally exposed to drugs. The control group
consists of six children who have not been exposed to illicit drugs in
utero. Child perform ance was converted into percentile scores for the
entire MAP and for each index. The researcher perform ed several
statistical analysis of the MAP scores to identify patterns of strengths
and w eaknesses that differ betw een drug exposed versus non-drug
exposed preschoolers. The details of the statistical design will be
discussed further in chapter three and the results will be discussed in
chapter four.
Tliere were several problem s in this type of study. The first
problem was finding a sample. Because m any w om en who abuse
5
drugs during pregnancy do not seek prenatal care, it is difficult to
identify w hether or not a child has a history of prenatal drug exposure
(Udell, 1989). Although a child m ay have a docum ented history of
drug exposure, the transient lifestyle of the drug abusing m other
makes it difficult to count on her participation or cooperation in any
study (Chasnoff, 1989). A viable solution which decreased this
problem was to include subjects from foster hom es and adopted hom es
w hose caregivers m ay be m ore cooperative in this type of study. The
second problem was finding non-drug exposed subjects who m atched
the drug exposed for age, gender, ethnicity, and socioeconom ic status.
Although the drug exposed subjects w ere m atched to non-drug
exposed subjects for age, gender, ethnicity, and socioeconom ic status,
there never will be able to determ ine w hether they truly com e from
similar environm ental and social backgrounds. In addition, even
though a child does not have a docum ented history of prenatal drug
exposure, it is not guaranteed that the m other did not abuse drugs
during her pregnancy. In this study the researcher attem pted to obtain
a signature from the non-drug exposed child's Physician stating that
the child has no docum ented history of prenatal drug exposure.
However, not all of the Physicians responded. In the cases in which
the Physician did respond there can not be a 100% guarantee that there
was no drug abuse during pregnancy. These issues are discussed in
m ore detail in chapter two of this proposal.
6
Literature Review
Introduction
The first section of this literature review discusses the trends in
drug abuse in the U.S., with an em phasis on illicit drug abuse. This
section includes a discussion of the physiological effects of illicit drugs
on adults, the problem s with identifying pregnant drug abusers, and
the prevalence and incidence of drug abuse. The next section focuses
on research related to the neurological and physiological aspects of
developm ent of the drug exposed fetus. The following section
addresses the literature which focuses on physiological,
neurobehavioral, and the social developm ent of the neonate who has
been prenatally exposed to drugs. Then, a few studies in which the
hom e and social environm ent of the developing toddler w ho has been
prenatally exposed to illicit drugs are discussed. A final developm ental
section covers the studies related to prenatally drug exposed preschool
aged children and the m any factors that influence their developm ental
picture. Finally, this chapter discusses the Miller A ssessm ent for
Preschoolers which will b e the instrum ent used in this study.
Trends in Drug A buse
Physiological Effects of Illicit Drugs on Adults
The physiological effects of cocaine, heroin, and am phetam ines
will be discussed in this paper. These three drugs have been chosen
7
because the majority of the literature on prenatal drug exposure
includes primarily these three drugs. Each type of drug produces a
different type of intoxication and possesses a different level of
addictiveness. Some illicit drugs create a physical dependence, whereas
others produce only a psychological dependence. The three types of
drugs to be discussed in this section create som e level of physical
addiction. In order to understand what kind of im pact these drugs can
have on a developing fetus and child we m ust first understand how
these drugs affect adults.
Cocaine affects the central nervous system in such a way that the
user experiences tachycardia (rapid heart rate), hypertension (high
blood pressure), and vasoconstriction (narrowing of the arteries)
(Udell, 1989). This offers an explanation for why so m any cocaine users
have strokes, convulsions, cardiac arrhythmias, and heart attacks.
Cocaine causes a decrease of appetite and an increase in hyperactive,
stereotypical "high" behavior (Udell, 1989). Cocaine inhalation enables
the user to stay awake for extended periods of time (Udell, 1989). The
cocaine abuser uses cocaine in order to reach a state of euphoria and
excitement (Ciccone, 1990).
Cocaine and crack have very short half-lives. Drug half-life refers
to the am ount of time required for the drug to decrease by 50% through
hepatic m etabolism and renal excretion (Knoben & Anderson, 1988).
Cocaine is m ost com m only detected in hum ans through urine
screenings, however, it is difficult to detect cocaine in the urine when
8
the drug has reached its half-life. Cocaine can only be identified in the
urine up to 24 hours after the drug has entered the body. This presents
just one of m any problem s in identifying pregnant cocaine abusers.
More related problem s will be discussed in further detail in the next
section.
Heroin use can lead to tolerance and rapid addiction after only two
to three days of use (Berkow & Fletcher, 1987). The sym ptom s of acute
intoxication of an opiod type of drug include euphoria, drowsiness,
decreased respiration, bradycardia, decreased body temperature, and
hypotension (Berkow & Fletcher, 1987). W ithdrawal sym ptom s of
opiods elevates with an increase in dosage. Generally, the opiod user
experiences the opposite of the drug's initial effect during withdrawal,
including tremors, muscle-twitching, and increased perspiration
(Berkow & Fletcher, 1987).
Am phetam ines, like cocaine, act as stimulants resulting in
elevated mood, increase in energy, increased alertness, decreased
appetite (Goodwin & Guze, 1989). Users are attracted to am phetam ines
for the euphoric feeling that the drug produces and the slight
im provem ent in task perform ance that the drug creates (Goodwin &
Guze, 1989). Large doses of am phetam ines can result in drug-induced
psychosis and hallucinations. A person w ho is experiencing
withdrawal sym ptom s from am phetam ines m ay experience both
fatigue and depression(Goodwin & Guze, 1989).
9
Because m any illicit drugs leave the m others' bloodstream
shortly after their consum ption, it is extrem ely difficult to identify
when a wom an has abused drugs during the pregnancy. The next
section will discuss the com plications involved with identifying
pregnant wom en who abuse drugs.
Problems With Identifying Pregnant Drug Abusers
Several factors complicate the identification of drug abuse during
pregnancy. Many w om en never are screened for drugs during their
pregnancy, therefore m any prenatal drug abuse cases go unreported.
In addition, testing during pregnancy does not guarantee that all drug
abuse cases will b e identified. This section will discuss in detail the
problem s associated with identifying those wom en who abuse drugs
during pregnancy.
Some experts believe that the solution to the problem of
unreported cases would be to m ake drug screenings m andatoiy for all
pregnant women. However, patient confidentiality and privacy raise
ethical questions with medical personnel about routine drug
screenings for pregnant patients. Many physicians feel that m ost drug
abusers will avoid prenatal care if drug testing becom es a routine
screening procedure (Chavkin, 1990).
Because m any drug abusers deny their own drug abuse, medical
professionals are unable to rely upon the patient to provide an accurate
history (Giacoia, 1990). However, in m any cases pregnant wom en are
only tested when there is reason for suspicion that the wom an is
10
abusing drugs, such as a histoiy of poor prenatal care or previous drug
abuse (Giacoia, 1990; Hurt, 1989). Some additional justifications for
toxicology screenings are: a m other or neonate w ho dem onstrates
stereotypical sym ptom s of drug abuse, a m other who lives in a drug
infested neighborhood, or a pregnant w om an w ho is less than 20 years
old (Chavkin, 1990). Unfortunately, in m any cases racial bias also
determ ines who is drug tested and who is not (Chavkin, 1990).
As stated earlier, m any times the screening of wom en and
neonates produces negative test results although drug abuse has taken
place during the pregnancy (Udell, 1989). As noted earlier, cocaine has
a veiy short half-life. An infant will only test positive for up to 72
hours after the m other has used cocaine and a m other will only test
positive for up to 24 hours after cocaine use (Udell, 1989). If the m other
abused a drug during the first trim ester of pregnancy and sought
medical care during the third trimester, the screening m ay yield
negative results even though the m other used drugs during pregnancy
(Chasnoff, 1989).
Drug screening not only offers health professionals knowledge of
w hether a pregnant wom an has abused drugs or not, but it also can
identify the type of drug that was used during the pregnancy.
However, polysubstance abuse is a com m on problem am ong the drug
abusing population. Although drug screens can identify the types of
abused drugs, polydrug use makes it difficult to distinguish which drug
is creating the negative effects (Chasnoff, 1989). Because m any drug
11
addicts abuse m ore than one drug, this creates a m ajor problem for
health professionals in identifying the specific effects that various
drugs have on the fetus, infant, and toddler, and preschooler
(Chasnoff, 1989).
These multiple factors m ake it difficult for researchers to
determ ine a realistic num ber of drug abuse cases in this country,
including cases of pregnant women, or to determ ine the effects of
prenatal drug exposure on the developing child. The next section will
discuss surveys that attem pted to estim ate the prevalence and
incidence of drug abuse within the general American population and
within the population of pregnant women. However, when reading
the section on prevalence and incidence it is im portant to rem em ber
that the factors that limit our ability to identify wom en who have used
drugs while pregnant also limit the extent to which we can rely on the
prevalence estim ates reported in the literature.
Prevalence and Incidence
In the new s we constantly hear how drugs are affecting the world
around us. The new spapers tell us about gang shootings, suicides, and
other crimes associated with drug abuse. We are repeatedly rem inded
of the im pact that intravenous drug use has on the spread of the HIV
virus. In addition, personal observations of drug use am ong college
students have been noted as common.
Although cocaine and cocaine derivatives are som e of the m ost
com m on drugs used in America today, m any other types of illicit drugs
12
continue to plague the country. In addition, these drugs are affecting
not only the people who abuse them, but also the children who are
bom to a drug abusing parent. A study conducted in 36 private and
public hospitals indicated that approxim ately 11% of the wom en in the
delivery room have adm itted to abusing illicit drugs throughout their
pregnancy (Chasnoff, 1989). It has been estim ated that one in ten
children bom will have had som e type of prenatal exposure to illicit
drugs (Pruitt et al., 1990). In a national survey 8.8% of wom en of
childbearing age have adm itted to abusing som e type of drug within
the past m onth (Silverman, 1989).
A national survey conducted in 1985 indicated that 8 million
Am ericans used cocaine at that time (Silverman, 1989; Ryan et al.,
1987). Five to twenty percent of those users w ere thought to be
addicted to the drug (Ryan et al, 1987). In the sam e survey, cocaine
addiction was not found to be dependent on socioeconom ic status
(Ryan et al, 1987). Although these figures alone are staggering, what is
even m ore troubling is the num ber of users who are pregnant. A
survey conducted in 1985 estim ated that 1,960,000 w om en over the age
of 18 years old use illicit drugs. These figures increased by 59.35% since
an earlier 1982 survey (Silverman, 1989). In Septem ber 1989 the
National Institute of Drug A buse conducted a survey across the entire
country. Although the results of this study reflected that 37% fewer
Am ericans abused illegal drugs in 1988 than in 1987, the results also
13
indicated that 33% m ore Americans frequently abused cocaine than in
the previous year (Schydlower, 1989).
Unfortunately, the results of this studies estim ate that over
100,000 babies are bom each year to drug abusing women (Schydlower,
1989). A study conducted in Illinois in 1988 indicated that the num ber
of babies exposed to cocaine in utero increased by 78.8% in a six m onth
period of tim e ( Silverman, 1989). It is difficult to determ ine the true
num ber of babies that have been exposed to cocaine in utero because of
the m any reasons discussed in the previous section.
A survey of five health clinics in Pinellas County, Florida
conducted betw een January 1,1989 and June 30,1989 show ed that 14.8%
of pregnant wom en produced a positive urine toxicology for cocaine
(Chasnoff, 1989). This survey also illustrated that the percentage of
wom en in this study from the private sector who abused cocaine
during pregnancy did not differ significantly from the percentage of
wom en in this study from the public sector w ho abused cocaine during
pregnancy (Chasnoff, 1989). The sam e study indicated that 14.1% of the
black w om en in the study as opposed to 15.4% of the white wom en in
the study had cocaine positive urine sam ples (Chasnoff, 1989). Because
in this sam ple the percentage of white and black cocaine abusers was
not significantly different, results suggest that cocaine abuse is not
predom inantly a problem of minority ethnic groups.
Although cocaine abuse tends to be the primary focus of the
prenatal drug exposure research, other drugs also m ust be considered.
14
Alcohol is probably the m ost com m only abused drug in the United
States, how ever for the purposes of this study alcohol will not
considered in the study. Heroin, am phetam ines, marijuana, opiods,
hallucinogens in addition to cocaine are the types of illicit drugs that
are m ost comm only seen on the streets. This study will cover those
drugs which are m ost com m only found in the literature.
D evelopm ent of Drug Exposed Children
Fetal Developm ent
Over the past five years there has been an increase in the am ount
of research focusing on the effects of prenatal drug exposure on the
developm ent of the fetus and neonate. However, only a limited
num ber of studies have focused on the developm ent of the toddler
who has been exposed to drugs in utero. Even fewer research studies
have examined how prenatal drug exposure effects the preschool aged
child.
Although the m ajority of the recent studies focus on m aternal
cocaine abuse in reference to fetal developm ent identified the
physiological effects and the neurological implications, som e studies
have focused on the affects of other illicit drugs consum ed during
pregnancy. In the m other, cocaine decreases uterine blood flow which
in turn decreases the am ount of blood that flows to the fetus
(Giacoia,1990; Hurt, 1989)). The decrease in placental blood flow m ay
result in fetal distress and a decrease in intrauterine growth of the fetus
(Giacoia, 1990). Because all illicit drugs enter the fetal circulation
15
through the placenta, the drug can cause toxic effects and dependency
on the developing fetus (Pruitt, Jacobs, Schydlower, Stands, and Sutton,
1990). Even the fetus can experience withdrawal sym ptom s when the
m other abstains from taking opiates (Pruitt et al., 1990).
A study conducted by Free (1990) stated that a decrease of blood
flow to the fetus can result in fetal tachycardia and hyperactivity. In
addition, perm anent neurological dam age can occur as a result of a
decrease in blood flow to the fetus during pregnancy (Rist, 1990).
Due to the nature of intravenous adm inistration of illicit drugs,
such as, cocaine and heroin the drug-addicted m other runs the risk of
contracting infectious diseases which can result in spreading disease to
the fetus (Hurt, 1989). This can lead to developm ental abnorm alities in
the fetus, such as growth retardation. Giacoia (1990) and Udell (1989)
reported that there was a high percentage of cocaine exposed babies
w ho had abruptio placentae, "a prem ature separation of a normally
im planted placenta from th e uterus" (Berkow & Fletcher, 1987).
A bruptio placentae can result in fetal cardiac distress or even death.
Spontaneous abortions and fetal deaths are a very serious risks for
the fetus who has been exposed to drugs in utero. A study conducted
by Ryan et al. (1987) in 1984 divided pregnant m others into three
groups: (1) m others w ho used cocaine and m ethadone during
pregnancy, (2) m others w ho were on a m ethadone m aintenance
treatm ent during pregnancy, and (3) m others who did not use any
drugs during pregnancy. M ethadone is a medically prescribed drug to
16
assist in weaning an addicted person off of heroin. In this study there
were 50 subjects in each group. The cocaine/m ethadone group had one
spontaneous abortion (2%) and four fetal deaths (8%). The m ethadone
group had zero spontaneous abortions and two fetal deaths (4%). The
drug-free group had zero cases of spontaneous abortions and fetal
deaths. This study, therefore, found that there is a greater chance of
fetal death in the drug-exposed groups than in the drug-free group.
In addition to the chance of spontaneous abortion and fetal death,
the drug exposed fetus runs the risk of being bom prem aturely
(Giacoia,1990; Neuspiel, 1991). A truncated gestational period can lead
to an im m ature neurological system at birth. Prematurity, in itself,
creates a num ber of additional risk factors that m ay influence later
developm ent (Berkow & Fletcher, 1987).
Neonatal Developm ent
The majority of the prenatal drug exposure studies have focused
on the physiological, neurobehavioral, and social problem s of the drug
exposed neonate. Two studies have shown that cocaine use during
pregnancy increases the chance of congenital abnormalities (Giacoia,
1990; Hurt, 1989). The first study identified a significantly greater
num ber of genitourinary tract m alform ations and neural tube defects
in neonates w ho have been exposed to cocaine in utero (Giacoia, 1990).
In addition, neonates w ho were exposed to cocaine in utero exhibited a
higher percentage of cardiac, intestinal, and central nervous system
abnorm alities than neonates that were not exposed (Hurt, 1989).
17
Many studies agree that prenatal drug exposure results in a higher
incidence of neonates with low body weight, decreased body length,
and decreased head circumference (Hayford, Epps, and Dahl-Regis,
1988; Hurt, 1989; Johnson, Glassman, Fiks, and Rosen, 1989; Neuspiel&
Hamel, 1991; Ryan et al, 1987). Studies show that infants bom to
m others w ho used cocaine during p : .gnancy display abnorm al
respiration rates (Free, Russell, Mills, and Hathaway, 1990; Ryan et al.,
1987). A study discussed in the previous section reported lower Apgar
scores for infants w hose m others used cocaine and m ethadone
com pared to m others w ho were drug-free during pregnancy (Ryan et
al, 1987). Olofsson (1983) also found infants bom to opiate abusing
m others have a 20% higher incidence of low Apgar Scores.
Apgar scores are used by medical personnel to assess the state of
the neonate's cardiac, neurological, and respiratory system s after the
birth process (Berkow & Fletcher, 1987). The assessm ent is given at one
m inute post birth and then again at five m inutes post birth. The
exam iner rates the baby's color, heart rate, reflex irritability, m uscle
tone, and respiratory effort. This assessm ent allows health
professionals plan for any special neonatal care that the new born m ay
need in order to decrease the chances of infant death or complications.
Many researchers have identified neurobehavioral problem s
characteristic of infants exposed to drugs in utero. The consequences of
prenatal cocaine abuse m ay include irritability, trem ulousness,
abnorm al sleep patterns, and feeding problem s (Free et al, 1987). Hurt
18
(1989) reported that cocaine-exposed neonates display state lability, poor
consolability, decreased organizational responses, and po o r visual
attention. Chasnoff directed a study com paring the offspring of 23
cocaine-using pregnant w om en with those of pregnant m ethadone
patients and drug-free pregnant wom en (Silverman, 1989). The study
revealed that infants exposed to cocaine dem onstrated lower
frequencies of interactive behavior and higher frequencies of startle
responses com pared to the other two groups.
On the other hand, heroin exposed neonates dem onstrate severe
withdrawal sym ptom s within the first 24 hours of life (Hayford et al.,
1988; Wilson et al., 1979). Hayford et al. (1988) investigated the
behavior and developm ent of children bom to heroin-addicted and
m ethadone-addicted m others. In their study they observed typical
behaviors in these opiate-exposed children including withdrawal
sym ptom s, irritability, increased tone, hyperactive deep tendon
reflexes, and abnorm al sleep patterns.
Cocaine-exposed infants have a startlingly high incidence of
seizures com pared to a norm al population (Silverman, 1989). A study
conducted at the University of Texas Southwestern Medical Center at
Dallas show ed that two out of 53 neonates with a history of prenatal
cocaine exposure experienced seizures (Silverman, 1989). In a normal
population approxim ately one to two out of every 1000 infants develop
seizures. This is notew orthy because seizures often are an early
19
indicator of m ental retardation, cerebral palsy, or other neurological
dysfunction.
Drug-exposed infants are not subject to physiological and
neurological com plications only at birth. The infants that do survive
the birth process must overcom e the risk of sudden infant death
syndrome(SIDS). In one study 15% of infants exposed to cocaine
in-utero died within one year as a result of SIDS (Giacoia, 1990). In the
study which com pared infants bom to cocaine-using wom en to infants
bom to m ethadone-m aintained m others and to m others w ho were
drug-free, two infants exposed to cocaine died within the first three
m onths(Ryan et al, 1987). No infants from the other tw o groups died
during the study.
Although the neonate has just begun a life, social issues begin
affecting his o r her life immediately. Many infants who are abandoned
in the hospital are babies whose m others have a history of drug abuse.
The Child Welfare League of America lead a survey in June of 1989 in
five m ajor American cities (Rist, 1990). Through the survey 304 infants
were reported as abandoned by their m others on the date of hospital
discharge. The survey went on to report that 69% of those infants were
prenatally exposed to illicit drugs.
Developm ent of the Toddler
Maternal drug use continues to affect the child long after birth.
Chasnoff (1989) reports that the num ber of child abuse cases associated
with m aternal drug use has increased over the past few years. In Los
20
Angeles alone there were 5,973 reported child abuse cases in 1985. Of
those cases, 538 (9%) were drug related. In the first six m onths of the
following year, 403 (9.4%) drug-related child abuse cases were identified
out of 4,299 cases. In the state of Illinois in 1986 a random sam ple of
385 child abuse cases were investigated. One half of those child abuse
cases were drug-related (Chasnoff, 1989).
Carol Cole, a Los Angeles teacher and child developm ental
specialist reported a typical pattern that she has observed in children
who were exposed to drug in utero (Rist, 1990). Cole stated that a
negative, vicious cycle develops for these children in which the
caretaker is unable to soothe the child, becom es frustrated, and
therefore hands the child over to som eone else. Often the child's
biological, drug-abusing m other releases custody to another family
mem ber, who eventually experiences frustration and turns the child
over to foster care.
Prenatally drug-exposed toddlers display m any deficits that could
later affect learning and social developm ent as the child transitions
into preschool. A study which followed 263 cocaine- exposed infants
for two years identified com m on deficits am ong these children as
toddlers (Chasnoff, 1989). These were decreased concentration,
decreased interactions with other children, and decreased ability to play
alone in an unstructured environm ent (Chasnoff, 1989). A nother
study conducted on 18 prenatally cocaine exposed toddlers indicated
that these children typically display a less m ature and lower frequency
21
of representational play com pared to a sam ple of high-risk preterm
toddlers (Howard, 1989). Play for the children in this study m erely
consisted of scattering, batting and picking up toys. Very little fantasy
play and curious exploration was observed in the drug-exposed
children in this study (Howard, 1989). Hayford et al. (1988) found
prenatally heroin and m ethadone exposed toddlers to be highly
energetic, talkative, and easily distracted. These children also
dem onstrate short attention spans, im m ature object manipulation, and
disturbances in speech, cognition, perception, and sleep patterns
(Hayford et al., 1988).
At the toddler stage there are m any m ore factors that play a part in
the child's developm ent rather than solely the prenatal drug exposure.
The hom e and social environm ents becom e significant factors in the
child's developm ent at this age. These children begin to dem onstrate
behavioral problem s and difficulty with unstructured time which carry
over into the preschool years. The next section will discuss in depth
the studies which have focused on the developm ent of the preschooler
w ho has been exposed to illicit drugs in utero.
Development of Preschoolers
Very little research has been conducted on preschoolers w ho have
been exposed to illicit drugs in utero. The m ajority of the studies in
this area focused on prenatal exposure to heroin and its effects on the
developm ent of preschoolers. However, in a literature review of this
subject a few studies explored the developm ent of children who were
22
prenatally exposed to am phetam ines or to m ethadone. In this study
preschool-age is referred to as children betw een three to six years old.
Much of the research that has been conducted on the drug-
exposed preschooler has been directed toward identification of
developm ental problem s in these children. Because hum an
developm ent is influenced by m any different factors, however, and
because polydrug abuse is comm on, it is virtually im possible to
determ ine the effects that one drug introduced during fetal
developm ent can have on a preschool aged child. Furthermore,
complex external influences, such as the physical and social
environment, including parental attitudes, probably play a critical role
in the prenatally drug exposed child's developm ent at the preschool
age.
Studies that explored the developm ental picture of prenatally
drug-exposed children offer conflicting information. Because these
studies have been so inconsistent in their findings, it is difficult to
draw any reliable conclusions about the developm ent of preschoolers
who have been exposed to drugs in utero. The studies reviewed here
explored various aspects of growth and developm ent, including
physical, motor, perceptual, cognitive, behavioral, and social
developm ent of the prenatally drug exposed preschooler.
Physical growth: Physical growth includes height, weight, and
head circumference. Physical growth is an im portant factor in
assessing a preschooler's general developm ent for several reasons.
23
First of all, height and weight are directly related to head circumference
(Illingworth, 1987). Head circumference generally is indicative of the
size of the brain which influences neurological and m ental
developm ent (Illingworth, 1987). In addition, from personal
observations it appears that a child's overall body size could have an
impact on the child's social developm ent with respect to acceptance
am ong his or her peers.
The studies which investigated the heights, weights, and head
circumferences of drug exposed preschoolers offer conflicting results.
Olofsson et al. (1983), who examined 72 preschoolers who were born to
drug dependent m others, found no differences in weight or head
circumference when com paring their sam ple to norm ative data on the
general Scandinavian preschool population. On the other hand, they
did note that the heights in the drug exposed sam ple were significantly
lower than the norm s of Scandinavian preschoolers for age and sex
(p< 0.01).
Olofsson, Buskley, Anderson, and Friis-Henson (1983) also found
an association betw een the level of a m other's intake of m ethadone at
birth and the height, weight, and head circumference of the children
bom to wom en on m ethadone. The preschoolers b o m to wom en w ho
had a m ethadone intake of less than 20 milligrams at birth
dem onstrated no differences in any of these growth m easurem ents.
However, a significant num ber of these children (6 out of 31) fell below
the tenth percentile for height, weight, and head circumference (p<.05).
24
Johnson et al. (1989) found no significant differences in the
heights and weights of m ethadone exposed preschoolers com pared to
drug-free control group at 36 m onths. However, in this sam e study
Johnson et al. (1989) noted that there was a significantly higher num ber
of drug exposed preschoolers who fell below the third percentile for
head circumference than non-drug-exposed preschoolers. They also
n oted that abnorm al neurological evaluations were significantly more
com m on am ong the m ethadone group.
Wilson (1979) plotted height, weight, and head circumference of
drug exposed preschoolers on growth curves and com pared them to
age and sex specific percentile scores. In this study the drug exposed
preschoolers were found to have significantly lower body weights
(p<01) and head circumferences (p<.05) in com parison to three control
groups. W hereas 32% of the drug exposed children fell below the third
percentile for height, only 12% of the children in the com parison
groups fell below the third percentile for height. These results were
not statistically significant, however.
These studies yield inconsistent findings which create difficulties
in predicting the physical growth of drug exposed preschoolers. As a
result, few conclusions can be drawn regarding the im pact that drug
exposure will have on the physical growth of the developing drug
exposed child. However, the several studies which indicated that the
head circumferences for the drug exposed children are significantly
25
sm aller than non-drug exposed children suggest that neurological
developm ent m ay be disrupted in drug exposed children.
Perceptual and m otor development: Some studies explored the
perceptual and m otor developm ent of preschoolers who were
prenatally exposed to drugs. These studies, like the studies which
explored physical developm ent, also yielded conflicting results.
Kaltenbach, Graziani, and Finnegan (1978) used the Motor-Free Visual
Perceptual Test to com pare visual perceptual abilities of four year old
children bom to wom en who received m ethadone treatm ents during
pregnancy to those of a non-drug control group. They found no
differences betw een groups. Johnson et al. (1989) used the Merrill-
Palmer Scales to com pare perceptual developm ent of children bom to
m ethadone m aintained m others and children bom to drug-free
mothers. They also found no differences in perceptual developm ent
betw een the two groups. However, they did not specify what aspects of
perceptual developm ent the Merrill-Palmer scores reflected.
Wilson et al. (1979), on the other hand, found differences betw een
the perceptual developm ent of drug exposed children and that of non
drug exposed children. She com pared four groups in her study: a
group of preschoolers who were exposed to heroin in utero, a group of
preschoolers who w ere growing up in a drug environment, but were
not exposed to heroin in utero; a group of children who were
considered to be at high risk for death at their time of birth; and a group
of children that cam e from families with low socioeconom ic status.
26
The preschoolers who were exposed to heroin in utero scored
significantly lower on the visual, tactile, and auditory perception
portions of the McCarthy Scales than the three other comparisi
groups (p<.05).
Wilson and her colleagues (1979) were very specific in identifying
the aspects of perception in which these children had lower scores than
the controls, i.e., visual, tactile, and auditory (p<.05). Neither
Kaltenbach et al. (1978) nor Johnson et al. (1989) identified what areas of
developm ent were examined in their perceptual testing. One study
alone does not make a strong enough statem ent to lead researchers to
believe that perceptual problem s will be com m on am ong drug exposed
/
preschoolers. W hat these three studies suggest is that further research
in this area is needed in order to clarify w hether these children have
deficits in their perceptual developm ent com pared to non-drug
exposed children.
The majority of studies that examined m otor developm ent found
som e difference am ong prenatally drug-exposed preschoolers
com pared to non-drug exposed children, with the exception of
Kaltenbach et al. (1978). Kaltenbach et al. (1978) in exploring m otor
developm ent used the Imitation of Gestures test and found no
differences betw een children of drug addicted m others and a control
group.
Olofsson et al. (1983) used the Denver Developmental Screening
Test on 72 preschoolers who were bom to drug addicted m others and
27
com pared their test results to the norm s of normally developing
preschoolers. In this study 10% (n=7) were found to have severe
im pairm ents in their psychom otor developm ent. Olofsson et al, (1983)
attributed this to genetics, infections, deprivation syndrome, and
m inor organic brain syndrom es rather than to the drug exposure itself.
Olofsson et al. (1983) found 11% (n=8) to have slight im pairm ents in
psychom otor developm ent. This was attributed to deprivation
syndrome. Overall, in this study 21% (n=15) had som e level of
psychom otor impairment, suggesting that this m ay be a problem area
for these children. Although a high percentage of children in this
study dem onstrated problem s in the area of m otor development,
Olofsson and colleagues did not run any statistical tests. As a result it
would be unwise to conclude, from this study, that preschoolers
exposed to drugs have deficits in m otor developm ent.
Bauman and Daugherty (1983) com pared 15 preschoolers bom to
wom en on a m ethadone m aintenance (MM) program and 15
preschoolers bom to non-drug addicted (NDA) women. In this study
the children in the MM group scored significantly lower on m otor
developm ent (pc.Ol), m easured by the McCarthy Scales of M otor
Development, and expressive language (pc.005), m easured by the
M innesota Child D evelopm ent Inventory, than the children in the
NDA group. Bauman and Daugherty (1983) found a positive
correlation betw een the m otor scale scores and the expressive language
28
scores. In addition, they found significant weaknesses in m otor and
expressive language developm ent despite the small sam ple size.
Wilson et al. (1979) found differences in coordination am ong the
heroin exposed preschoolers as com pared to the three other groups in
her study. In this study the heroin exposed preschoolers dem onstrated
significantly poorer perform ances on rapid alternating hand
m ovem ents (p<.05).
Sowder and Burt (1980) also found a statistically significant
difference in the m otor developm ent of prenatally drug exposed
preschoolers com pared to a control group. In this study an index group
consisting of children bom to heroin abusers and a com parison group
consisting of children from immediate, surrounding neighborhoods
were com pared to the age specific norms on the Bender-Gestalt test
which looks at visual-m otor ability. Fifty-six percent of the com parison
group scored below average on this test, w hereas eighty-five percent of
the index group scored below average (pc.Ol). Seventy-three percent of
the index group fell below the tenth percentile for age, whereas only
thirty-five percent of the com parison group fell below the tenth
percentile for age.
These studies strongly suggest, with the exception of Kaltenbach et
al., (1978), that children who have been exposed to illicit drugs in utero
tend to have problem s with their m otor developm ent. Further
research with m ore sensitive tests and larger sam ple sizes may provide
29
a m ore definitive answ er regarding the m otor developm ent of drug
exposed children.
Cognitive developm ent: Cognitive developm ent is defined as the
process of acquiring knowledge (Short-DeGraff, 1988). Knowledge is
gained by intelligence, reasoning, learning, problem solving, m em ory,
and thinking. Intelligence quotient is the m ost com m on m easure of
cognition. A num ber of studies on preschool children who were
exposed to drugs in utero found that they scored lower on IQ tests, but
not significantly lower, than non-drug exposed preschoolers.
Billing et al. (1985) com pared Swedish children who were exposed
to am phetam ines during pregnancy to norm ative data of norm al
Scandinavian preschoolers. In this study two out of sixty-nine children
had IQ's betw een 60 and 80, which is considered to be severely mentally
retarded by Scandinavian norm s. However, no statistical tests were
run in this study. In addition, both of the m entally retarded children
in this study had m others who not only abused drugs during
pregnancy but also abused alcohol. Although fetal alcohol syndrom e
could explain the lower intelligence of am ong these children, their
prenatal exposure to am phetam ines can not be ignored as a possible
contributing factor.
On the other hand, in both Bauman and Daugherty's (1983) and
Bauman and Levine's (1986) studies, preschoolers w ho were prenatally
exposed to m ethadone scored lower on IQ tests than control groups of
non-drug exposed preschoolers. Bauman and Daugherty (1983) first
30
perform ed a small scale study that Bauman and Levine (1986) would
later expand. Although Bauman and Daugherty (1983) found
differences am ong the m ethadone exposed children and the controls,
the results were not statistically significant. In both Bauman and
Daugherty's (1983) and Bauman and Levine's (1986) studies the
differences were statistically significant until they factored out the
m other's IQ. W hen this w as done the researchers found no differences
am ong the groups. These results are im portant in telling the readers
that the m other’ s IQ needs to be considered before drawing
conclusions regarding data on children's IQ scores. In addition these
results suggest that lower IQ could be due to genetic influence, and not
drug exposure.
Additional studies investigated specific cognitive and learning
abilities of drug exposed preschoolers. Billing et al. (1985) found
learning difficulties am ong prenatally am phetam ine exposed
preschoolers b ased on a psychological evaluation administered during
observations in the child's home. However, Billing et al. (1985) did not
discuss the nature of the psychological evaluation, nor did they even
offer the nam e of the tool used to assess learning problem s. In
addition, Billing and his colleagues (1985) did not indicate the criteria
they used to define learning difficulties in their observations.
Therefore, these results are not convincing.
Wilson et al. (1979) com pared McCarthy Scales Scores of a sam ple
of prenatally drug exposed preschoolers to three com parison groups.
31
Although Wilson et al. (1979) adm inistered the entire McCarthy Scales
to all four groups, statistical differences were fount inly three of the
five subtests. One of the areas, perceptual performa; was discussed
in a previous section of this chapter. Wilson et al. (1979) also found
that children who w ere prenatally exposed to heroin scored
significantly lower on the m em ory portion of the McCarthy Scales than
did the three com parison groups (p<.05). In addition the heroin
exposed group scored significantly lower on the quantitative portion of
the McCarthy Scales than the three control groups (pc.Ol).
Language developm ent: In exploring language developm ent of
drug exposed preschoolers the studies yielded mixed results. Wilson et
al., (1979) looked at the num ber, the intelligibility, and the articulation
of the words used. W hen com paring heroin exposed preschoolers to
three com parison groups she found no differences in speech between
the heroin exposed and control preschoolers. Kaltenbach et al. (1978)
used the Test of Language Developm ent (TOLD) and found no
differences in language developm ent in com paring children bom to
m ethadone m aintained m others and a control group of non-drug
exposed children.
Bauman and Daugherty (1983), on the other hand, found
differences in language developm ent betw een children bom to
m ethadone maintained m others and a control group of children bom
to drug-free mothers. On the M innesota Child Developm ent
Inventory (MCDI) the children exposed to m ethadone scored
32
significantly lower on expressive language than the non-drug exposed
children (p<.05). In addition, they found a statistic.-: significant
correlation betw een m otor scale scores and express mguage (p<.05).
This study not only suggests that there m ay a connection betw een
prenatal drug exposure and language developm ent, but there also m ay
be a connection betw een m otor developm ent and expressive language
development. In essence, these results suggest that when a child scores
low on expressive language tests, then they probably will also score low
on m otor developm ent tests, and visa versa.
Sowder and Burt (1980) used two assessm ent tools in determining
the level of language developm ent in heroin-exposed preschoolers.
They used the Peabody Picture Vocabulary Test and the Stanford-Binet
Vocabulary Test and com pared the age specific norm s to heroin
exposed children and children from surrounding neighborhoods.
Although both of these tests m easure language developm ent, they both
offered conflicting results. This could be a reflection of the differences
in sensitivity and nature of the two tests.
The Peabody Picture Vocabulary Test assesses cognition, language,
and verbal intelligence. From this test they identified the group m ean
scores of the index group to be 86.7, whereas, the group m ean scores of
com parison group to be 94.5. These scores were not significantly
different, suggesting that verbal intelligence is not limited in this
population. On the contrary, the Stanford-Binet Vocabulary Test
which examines cognition and expressive language yielded statistically
33
significant results (p=.0009). One third of the com parison group scored
below the average for their age group, w hereas two thirds of the index
group scored below average for their age group. The results of this test
suggests that language may be a weak area for these prenatally drug
exposed children.
Behavioral developm ent: Behavioral developm ent can be viewed
as a product of the developm ent of the central nervous system which
m ediates and regulates a child's behavior (Short-De Graff, 1988).
C om ponents of behavioral developm ent addressed in the literature on
preschoolers with prenatal drug exposure are: attention, adaptation,
activity levels, and sleep patterns.
Attention refers to the degree to which a child can selectively
orient to and concentrate on a stimulus while tuning out extraneous
stimuli (Short-DeGraff, 1988). According to the studies which looked
at attention of preschoolers who were prenatally exposed to drugs,
these children typically dem onstrate short attention spans (Olofsson et
al., 1983; Wilson et al, 1979). In studying 72 drug exposed children
Olofsson (1983) found 56% to have decreased concentration. These
results were determ ined by a follow-up exam and information
provided by the doctor and associated healthcare professionals. The
problem with this study is that the examiners w ere aware of the child's
prenatal history and there were no blind raters. This m ay have resulted
in biased test results.
34
Wilson et al. (1979) also reported deficits in attention am ong
children bom to heroin-abusing m others. These children
dem onstrated short attention spans and a decreased ability to persevere
on tasks for long periods of time. Wilson used tasks from the
McCarthy Scales of Children's Abilities and the Illinois Test of
Psycholinguistic Abilities that require attention, concentration, short
term memory, and internal m anipulation of symbols to draw these
conclusions. However, these two tests do not directly m easure
attention. Wilson et al. (1979) is not clear in their conclusions
regarding their results of this part of the study.
Adapting to changes was often reported in the literature as a
problem for prenatally drug exosed children (Bauman & Daugherty,
1983; Bauman & Levine, 1986; Billing et al., 1985; Wilson et al. 1979).
Bauman and Daugherty (1983) videotaped two play sessions with the
children in the study and rated them using the Interactional Coding
System. Through this m ethod of testing they found that children of
m others on m ethadone m aintenance program s during pregnancy
dem onstrated decreased socially adaptive behavior. Bauman and
Levine (1986) also studied the sam e population and found these
children to have a decreased ability to adapt to new situations.
Wilson et al. (1979) com pared adaptive behavior in heroin
exposed preschoolers to three com parison groups through parental
observations and reports. These researchers found statistically
significant problem s in these children. Parent and parental substitutes
35
rated their children on the child's physical, social, and self adjustment.
Children who were exposed to heroin in utero dem onstrated decreased
self-adjustment behaviors (p<05), decreased social-adjustment
behaviors (pc.Ol), and decreased physical-adjustm ent (pc.05).
However, Wilson et al. (1979) are not clear in defining these terms,
therefore, the reader is not able to draw an accurate conclusion.
Billing et al. (1985) studied sixty-nine children born to
am phetam ine addicted women. In their study the drug exposed
children dem onstrated a higher incidence of unsatisfactoiy adaptation
to new environmental changes. According to the article, a psychologist
assessed general behavior and concluded that adaptation was an area of
weakness for these children. However, the article was not specific in
identifying the criteria used to determ ine this.
Activity level is another m ethod of assessing a child's behavioral
developm ent. Several studies explored the activity levels of children
who w ere exposed to drugs in utero (Billing et al., 1985; Olofsson et al.,
1983; Wilson et al.,1979). Each study using a variety of m easuring tools
noted an increase in hyperactive behavior am ong drug exposed
children. Wilson, et al. (1979) during play sessions used ultrasonic
equipm ent that m easures the m ovem ent in a room and a device
which m easures the m ovem ent of a rocking chair to discover that the
heroin exposed children exhibit a significantly higher activity level
than the three control groups (pc.Ol). Olofsson, et al. (1983) noted that
36
56% of children bom to drug dependent wom en dem onstrate
hyperactive behavior in addition to a lack of inhibition.
Sleep patterns are reflective of physiological and psychological
states (Short-DeGraff, 1988). Consistent sleep patterns are crucial to
behavioral developm ent in that when they are disturbed they can
produce negative effects on the child's behavioral states (Short-DeGraff,
1988). Although sleep patterns are im portant in a child's state and
performance, only one study was identified that explored this area
am ong drug exposed preschoolers. Billing et al. (1985) through
observations found in their study that children of m others on
m ethadone m aintenance dem onstrated sleep disturbances, suggesting
that this is an area that needs to be explored further.
Socioem otional development: A nother area of developm ent
which is im portant to look at is socioem otional developm ent.
Socialization is the process of acquiring the appropriate behaviors of
the society in which a person lives (Short-DeGraff, 1988). Emotions are
feelings or tem porary reactions to the people or events in the
environm ent (Short-DeGraff, 1988). Sowder and Burt (1980) explored
socioem otional developm ent in heroin exposed children by using the
Draw-A-Person Test. The heroin exposed children were asked to draw
pictures of people, then an expert viewed them and analyzed the
significance of the pictures. From the pictures that the heroin exposed
children drew it was suggested that these children had a poor
socioem otional prognosis. The drug exposed children drew arms and
37
limbs much sm aller than the non-drug exposed children of the sam e
age. The expert interpreted this to suggest that the children viewed
them selves as worthless, untrustworthy, and unable to do small
simple tasks. Socioem otional developm ent is an area that has not been
thoroughly explored. Further studies need to be developed to increase
the knowledge of the socioem otional developm ent of children exposed
to drugs.
E nvironm ent
Several studies explored the environmental differences betw een
drug exposed preschoolers and non-drug exposed preschoolers. These
studies addressed both the physical environm ent and the social
environment. Wilson et al. (1979) found no differences in the physical
environm ent that heroin-exposed children lived in com pared to three
other control groups consisting of: a drug environm ent group, a high-
risk com parison group, and a socioeconom ic com parison group. In
this study the physical environm ent was rated by a social worker on a
19 item scale which consisted of three m ajor themes: interior order and
comfort, decoration or quality of home, and crowding. Because no
differences w ere found in the physical environm ents of the four
groups of this study, physical environm ent can not be considered to be
a significant factor in the developm ental differences betw een the
heroin-exposed children and the three control groups.
The social environm ent refers to the people that the child is
consistently surrounded by on a day to day basis. In the studies that
38
addressed this, som e children lived with their biological parents who
continued to use drugs (Olofsson et al., 1983; Eriksson et al., 1985).
Other children were rem oved from their natural parents' custody and
placed in foster hom es (Olofsson et al., 1983; Eriksson et al., 1985).
Either allowing the child to live with their drug addicted parents
or placing the child in a foster hom e can have serious implications for
the developm ent of the child (Billing et al., 1985; Eriksson et al, 1985).
Children who live with an addicted parent tend to have m ore
problem s and disturbances in function than children who have never
lived with a drug addicted parent (Billing et. al., 1985), yet m any
children continue to live with their biological, drug-abusing parents
(Olofsson et al., 1983; Eriksson et al., 1985).
Olofsson et al. (1983) conducted a follow-up study at an average
time span of 3.5 years on children who had been exposed to drugs in
utero. In his study Olofsson et al. (1983) found that 46% of the 89
prenatally drug-exposed children in his study continued to live with
their biological parents at follow-up. Olofsson et al. (1983) did not
explain how the sam ple was obtained for this study. This study does
not inform the reader of the actual percentage of children who
continued to live with a drug-abusing mother. However, it does
inform the reader of the percentages of w om en who continued to
abuse drugs at the time of follow-up. Only 19% of the m others were
drug-free for anytime from 14 days to five years (Olofsson et al., 1983).
Eighty-one percent of the m others in the study were taking som e type
39
of drug at follow-up ranging from opiates to m ethadone to
tranquilizers (Olofsson et al., 1983). Although not statistically
significant, these percentages are startling because m others who abuse
drugs m ay focus m ore on the desire to abuse the drug rather than on
the responsibility of providing consistent and nurturing care for the
child.
Eriksson et al. (1985) conducted a study which explored the
num bers of prenatally drug-exposed children from Scandinavia that
continued to live with their biological parents and the num bers of
those parents who continued to abuse drugs despite the presence of a
young child in their hom e. Eriksson et al. (1985) did not describe his
m ethods for obtaining his sam ple in his study. Eriksson et al. (1985)
broke the children up into three groups for follow-up at four years of
age.
Group I (n=16) consisted of children exposed to am phetam ines
early in the pregnancy, but not throughout the entire pregnancy. At
age four 12 of those children continued to live with their biological
parents. Three out of those twelve children were living with drug-
abusing m others (Eriksson et al., 1985). The rem aining four children
out of the sixteen in group I were living with foster parents at age four
(Eriksson et al., 1985).
Group II (n=36) consisted of children who were exposed to
am phetam ines throughout the entire pregnancy but w ere released to
the biological parents upon hospital discharge. At four years old half
40
(n=18) of those 36 children were still living with their biological
parents. However, fifteen out of those eighteen m others were addicts
(Eriksson et al.,1985). The remaining half of group II were reported to
be living in foster hom es at age four (Eriksson et al., 1985). Although
Eriksson et al. (1985) did not identify the m eans by which quality of
hom e environm ent was m easured, he indicated that both groups I and
II w ere living negative hom e environm ents at the time of follow-up.
Group III consisted of children (n=ll) that were exposed to
am phetam ines in utero, but were rem oved from the biological parent
at birth. All of the children in group III w ere living in foster hom es at
age four (Eriksson et al., 1985). In this study the hom e environm ents
for the children in group III were judged to be good (Eriksson et al.,
1985). These findings could indicate that children living with addicted
m others have a greater tendency to have unsatisfactory hom e
environm ents than children living in non-drug abusing
environm ents.
Although there is m uch controversy over the subject, Eriksson et
al. (1985) and Olofsson et al. (1983) believe that children should rem ain
with their natural parents while the parents receive treatm ent for their
drug addiction. Both researchers provide the rationale for this
statem ent in their studies by claiming that rem oving a child from their
biological parent and placing him or her in a foster hom e can create a
chaotic life for the developing child (Eriksson et al., 1985; Olofsson et
al., 1983). In m any instances children in foster hom es are frequently
41
m oved from hom e to hom e (Eriksson et al., 1985; Olofsson et al., 1983).
This does not create stability for the developing preschooler. In
addition, taking the child away from the drug abusing m other does not
solve the source of the problem by reducing the chances that the sam e
wom an can give birth to another drug exposed baby.
Wilson et al. (1979), Eriksson et al. (1985), and Olofsson et al.
(1983) indicated in their articles that a high percentage of drug exposed
preschoolers have lived in at least one foster hom e at one point in
time. In Wilson's et al. (1979) study a significantly higher num ber of
heroin exposed children lived with a substitute m other than non
heroin exposed children (pc.Ol). Olofsson et al. (1983) found in a four
year follow-up that 54% of the children in his study were living in
foster hom es away from their biological mothers. Eriksson's et
al.(1985) study revealed that 33 out of the 63 children w ho were bom to
w om en w ho abused am phetam ines during pregnancy were living in
foster hom es at the age of four.
According to Eriksson et al (1985) several studies indicate that
children in foster hom es m ay have school-related adjustm ent
problem s. Neither a drug-infested environm ent nor a foster hom e is
conducive to norm al developm ent. Both drug-infested environm ents
and foster hom es create an inconsistent living environm ent for the
child who needs continuity in h is/h e r hom e life in order to develop
normally. Although the underlying cause of the problem s in both
environm ents differ, both environm ents create uncertainty and lack
42
of continuity for the child which decreases the child's ability to create
effective bo n d s with a caregiver.
In m any cases, the children in foster hom es are m oved from one
hom e to another. Just as they develop an attachm ent to a caregiver,
they possibly can be m oved to another living situation. To protect
them selves from the disappointm ent of the loss associated with
frequent m oves they m ay com pletely alienate them selves from future
caregivers. If the child is unsuccessful in developing bonds with their
prim ary caregiver, then he or she m ay have even m ore trouble
forming meaningful bonds outside the hom e and in school.
The studies that explored the parental behaviors and attitudes of
parents w ho abused drugs before, during, and after the pregnancy
addressed three m ajor areas: parental attitudes tow ards themselves,
parental expectations for their children, and parental disciplinary styles.
Only one study investigated m others' attitudes about them selves
(Bauman & Daugherty, 1983).
In this particular study m others who were on a m ethadone
m aintenance program scored lower on tests which m easured self-
concept than did non-drug addicted m others (Bauman & Daugherty,
1983). Bauman and Daugherty (1983) used the California Psychological
Inventory (CPI) to m easure the personality structure and function of
drug abusing m others. The m ethadone m aintained (MM) m others
specifically scored lower on portions of the CPI that tested sense of well
being, responsibility, socialization, self-control, and tolerance (Bauman
43
& Daugherty, 1983). These sam e m others received significantly lower
scores on the communality, intellectuality, efficiency, and psychological
m indedness subscales of this test. Results of the CPI show ed that the
MM m others had higher scores in impulsiveness, irresponsibility,
immaturity, and self-centeredness than NDA mothers. These
personality traits in drug abusing parents could be potentially harmful
to the developing preschooler who needs consistency and continuity
from their parental figures in order to have an optim al developm ental
picture.
Bauman and Daugherty (!983) assessed mother-child interaction
styles for both the MM m others and their children and NDA m others
and their children by using video-taped sessions of parent-child
interactions and rating the interactions with the Interactional Coding
System ( Moore, Forgatch, Mukai, and Toobert, 1971) and two blind
raters. In their study, they also found that m ethadone-m aintained
parents dem onstrated a lower ability to adapt their personalities and
their behaviors toward their children than non-drug addicted m others.
As a result the drug-abusing parents tended to threaten their children
in their attem pts at discipline (Bauman & Daugherty, 1983; Sowder &
Burt, 1980).
In Sow der & Burt's (1980) study both heroin abusing and non
heroin abusing parents expressed a desire for their children to be
successful in the future, however, the two groups expressed their
wishes in two significantly different ways. The heroin-abusing parents
44
had high expectations for their children, which was m anifested by
dem ands. On the other hand, the non-heroin abusing parents had
high ambition for their children which was expressed as dream s or
wishes (Sowder & Burt, 1980).
In this study the non-heroin abusing parents gave their children
reasonable responsibilities, such as house chores, and m ade
significantly fewer unrealistic dem ands on their children than drug-
abusing parents (Sowder & Burt, 1980). The drug abusing parents, on
the other hand, did not implement simple disciplinary requests, but
continued to expect their children to becom e som ething great som e
day. This study indicates that the disciplinaty styles of drug abusing
parents conflict with expectations that they place on their children.
The results of this study suggest that children of drug-abusing
parents have a greater disadvantage in m eeting their parents'
unrealistic expectations than the non-drug exposed children because
the drug abusing parents do not teach their children to assum e
responsibility for the smallest tasks, such as house chores. In learning
simple household tasks the child is developing basic skills and learning
responsibilities that will be useful as the child enters m ore complex
roles in society. If the child does not learn these foundations before
entering the m ainstream of society, such as school, he or she m ay have
difficulty adjusting to the dem ands that m ay be placed on him or her.
45
Sum m ary
Although the results of these studies on prenatally drug-exposed
preschool aged children offer conflicting results, overall these studies
suggest that the population of prenatally drug-exposed preschoolers
have m ore difficulty adjusting to and being successful in their worlds
than non-drug exposed children. The studies discussed in this section
focused m ostly on heroin, m ethadone, and am phetam ine-exposed
children. At this point no research studies have been conducted that
explore the developm ental characteristics of prenatally cocaine-exposed
preschoolers.
Many of the studies on developm ent of preschoolers exposed to
drugs offer conflicting results. Sum e studies found significant
differences in IQ and learning abilities betw een drug exposed children
and non-drug exposed children (Bauman & Levine, 1986; Billing et al.,
1985). O ther studies found no differences in IQ when factoring out for
m others' IQ (Bauman & Levine, 1986). The studies which focused on
language developm ent also had contradicting results. Conflicting
findings preclude drawing any reliable conclusions regarding language
developm ent of prenatally drug exposed preschoolers. On the other
hand, the studies which focused on m otor developm ent consistently
identified m otor developm ent to be an area of weakness for drug
exposed children (Bauman & Daugherty, 1983; Olofsson et al., 1983;
Wilson et al., 1979).
46
One explanation for the wide variety of results in these studies is
that researchers adm inistered different assessm ent tools in each study.
Some tests are m ore sensitive, valid, and reliable than others. In
addition, the type of drugs which are focused on in each study also
widely varies in nature possibly explaining the different results from
one study to the next. More studies need to b e perform ed to clarify
w hether or not developm ental deficits characterize children with
prenatal drug exposure. Because these studies show ed m otor
developm ent to be an area of weakness for drug exposed children, the
assessm ent tool should be sensitive to m otor developm ent and the
foundations for m otor development. For this reason the researcher
chose the MAP for this study. The MAP will be discussed thoroughly
in the next section.
A Review of The Miller A ssessm ent for Preschoolers
Overall Purpose of the MAP
The Miller A ssessm ent for Preschoolers (MAP) is a standardized
screening tool used for early identification of preschoolers w ho are at
risk for pre-academ ic problem s and who m ay need further evaluation
(Miller,1982). In using the MAP the tester is able to define the areas of
strengths and w eaknesses for the developing child. The MAP was
designed to show developm ental progress across age groups of two
years, nine m onths to five years, nine m onths. The MAP was designed
to be a simple test that can be administered by clinical and educational
personnel and personnel with less testing experience(Miller, 1982).
47
Adm inistration takes approxim ately 20-30 m inutes and the tester
scores the test during administration. The only special requirem ents
for the MAP are that the room be at least four m eters by two m eters in
size and should contain a carpet, a child size table, and chair.
Overall Content and Format of the MAP
The MAP consists of 27 "core" items plus an additional section
referred to as the Behavior During Testing evaluation (Miller, 1982.)
Prior to administering the MAP, the adm inistrator gathers the
developm ental history of the child through an interview from the
caregiver. Next, the exam iner adm inisters the 27 items of the MAP,
which explores three m ajor categories of abilities: sensory and m otor
abilities, cognitive abilities, and com bined abilities (Miller, 1982.) After
adm inistration of test item s the examiner scores The Behavior During
Testing portion of the MAP which assesses the child's attention span,
social interaction, and sensory reactivity.
The 27 "core" item s of the MAP are m eant to be adm inistered
together, rather than separately. The sensory and m otor com ponents
of the MAP contain ten item s which m ake up the Foundations Index
and seven item s that m ake up the Coordination Index (Miller, 1982).
The Foundations Index includes the basic com ponents of standard
neurological exam inations identifying m otor function and sensory
awareness. The purpose of the Coordination Index is to test the m ore
com plex fine, gross, and oral m otor tasks.
48
In the cognitive portion of the MAP four items test the child's
verbal skills and five item s test the child's non-verbal skills (Miller,
1982). The Verbal Index includes tests for m em ory, sequencing
comprehension, association, and expression. The Non-verbal Index is
also used to test m em ory and sequencing however, it also tests
visualization and perform ance of m ental manipulations. The final
portion of the "core" of the MAP includes the Complex Tasks Index
(Miller, 1982). The four items in this category test a com bination of
sensory, m otor, and cognitive abilities in perform ance.
MAP scores take into consideration the child's age. There are six
item score sheets, one for each age group. The child's raw scores are
noted on the front of the score sheet and the observations of behavior
during the test are recorded on the back of the score sheet.
To determ ine the child's chronological age, the child's date of birth
(DOB) should be subtracted from the date of the evaluation(DOE).
The raw score on the score sheet is used to com pare the child's
perform ance to that of other children in the sam e age group. Raw
scores in the MAP are converted into percentiles for each subscale and
for an overall developm ental score and then are color-coded (Miller,
1982.) There are three possible categories that the raw score can fall
within: red, yellow, or green. Children w hose scores fall at the fifth
percentile or below, com pared to scores from the norm ative sample of
the sam e age group, are classified as Red or at high risk for developing
academ ic problem s and, in clinical assessm ent, are recom m ended for
49
further evaluation (Miller, 1982). Children who score within the sixth
to twenty-fifth percentile are labeled yellow suggesting that they be
carefully watched as they develop to determ ine if any academic
problem s exist (Miller, 1982.) And finally, children above the 25th
percentile are classified as green which m eans that they fall within
normal limits for their age group (Miller, 1982.) These red, yellow, and
green categories were used in the analysis of the present study.
History of Test Development
The developm ent of the MAP was first initiated in 1972. Ever
since, it has been evolving and going through rigorous
standardization, reliability, and validity studies. Prior to creating the
MAP, Miller established a rationale for justifying the need to develop
an assessm ent tool like the MAP. Miller (1982) extensively reviewed
the literature on the relationship betw een developm ent and academ ic
perform ance and the legislation regarding educational services for
children with handicaps. From h er literature review Miller (1982)
found the majority of the literature to suggest that delays or problem s
in m ost areas of developm ent can lead to later academ ic problems. She
also discovered that early identification and intervention can possibly
decrease the significance of the developm ental delays.
After Miller (1982) reviewed the literature and drew a strong
rationale for the need of a test like the MAP, she began reviewing the
current tests that were targeted to identify preschoolers with
preacadem ic problem s. From reviewing existing tests she concluded
50
that although there are m any tests that are targeted for this population,
no test sufficiently exam ines these children. No developm ental
assessm ent tool looks closely at the neurological foundation of
developm ent. From her literature review and test reviews, Miller
(1982) established a set of criteria for a developm ental screening tool to
identify preschoolers with preacadem ic problem s.
First of all, she established that the tool would need to m eet the
requirem ents of PL 94-142 and the American Psychological
Association's criteria for educational and psychological testing. The
test had to be designed to screen in thirty m inutes or less children
betw een the ages of two and a half years to five and a half years. The
test m ust be easy for school personnel to administer and reflect a strong
theoretical base. Finally, the test had to m eet rigorous standardization
procedures and reliability and validity testing (Miller, 1982).
D evelopm ent of initial test items: The M AFs first edition was
created in 1974. Miller (1982) used her literature and test reviews to
create the item s on the first test. By examining previously existing tests
she adapted items to be appropriate for the age group under study and
the era in which the test was created. Miller used the existing tests to
influence the form at and content of the MAP. W hen the preliminary
drafts were created, Miller (1982) discussed the drafts with various
professionals, such as pediatricians, occupational therapists, physical
therapists, speech pathologists, and psychologists.
51
Pre-standardization test developm ent: There were four editions
of the MAP during the pre-standardization phase of the MAP
developm ent. The first edition consisted of 800 items that were
adm inistered to approxim ately 400 preschoolers in M assachusettses.
Twenty professionals adm inistered and scored the MAP. After the first
study Miller revised the MAP on the basis of the results and rewrote
the manual. New items were created and old items that did not m eet
the standards that Miller created prior to developm ent of this test were
dropped (Miller, 1982). In the second edition the MAP was
adm inistered to 486 preschoolers following the sam e procedures as in
the first edition.
The third edition was created using results of the statistical
analysis of the data from the second edition as well as clinical feedback
from the examiners. The third edition w as adm inistered to 136
children in Walpole, M assachusetts. Once again extensive
examination of the data led to the next edition of the test. The items
chosen for the fourth edition of the MAP were determ ined by the
following criteria. Each item was evaluated for its level of difficulty,
w hether the items discrim inated well using a point biserial correlation
and how each item correlated with the subtest categories. Item
difficulty was determ ined by the percent of children who passed each
item (Miller, 1982). Miller (1982) w as able to determ ine the degree to
which an item discriminated by a point biserial correlation of each
item. Then she perform ed correlational studies to show w hether each
52
item was associated with the subtest categories. All t! 1 to the MA P
research edition which will be discussed further in the next section.
Standardization of the MAP: The MAP research edition and the
MAP final edition both went through rigorous standardization
procedures. Between 1979 and 1980 Miller (1982) im plem ented the
MAP research edition. Prior to the developm ent of the MAP research
edition, Miller (1982) conducted pilot studies on a sam ple of 1,014
preschool aged children throughout the United States using thirty
occupational therapists and physical therapists to adm inister the test.
There were a total of 12 pilot studies which two to three therapists were
assigned to each study. In these studies the research sample was
ratified and random ized for age, geographical region, race, sex,
nm unity size, and socio-econom ic factors.
The results of these pilot studies were used to develop the MAP
research edition. The MAP research edition initially consisted of 530
items selected for field testing (Miller, 1982). Miller chose 600 normal
children, 70 from each of the United States nine geographical regions,
as subjects in the study of the MAP research edition. Nine field
ipervisors, all of which w ere Occupational Therapists, were trained in
ne m ethods for random ly selecting a sample, administering the test,
scoring the test, and interpreting the data (Miller, 1982). Miller was
forced to decrease the num ber of items in the MAP research edition by
half secondary to the short attention spans of this age group. In order
to determ ine w hether the MAP would be able to discriminate betw een
53
normal children and children with preacadem ic problem s, Miller
(1982) adm inistered the test to 60 children who were noted to have
preacadem ic problems.
Data analysis from the MAP research edition was used to create
the MAP final edition. Miller (1982) established criteria for the items in
order for them to be included in the final edition. First, she noted that
the item s m ust discriminate betw een age groups and betw een normal
children and children with preacadem ic problems. Items m ust be
representative of various behavioral variables and m ust be easy to
administer. She also consulted with pediatricians, neurologists,
ophthalm ologists, speech pathologists, and occupational therapists in
choosing the final item s for the MAP.
The end result was the MAP final edition which consists of 27
items and a series of structured observations (Miller, 1982). At this
stage new test kits were constructed and new procedures were taught
for administration. To standardize the test, Miller (1982) used the sam e
concepts of random izing and stratifying the sam ple as used in the MAP
research edition. The standardization sam ple size was (N= 1,200).
Children selected for the norm ative sam ple did not show any
noticeable physical, mental, or em otional disorders. No children who
were previously tested were perm itted to participate in the study of the
MAP final edition.
Miller (1982) also had the MAP final edition adm inistered to 90
children with preacadem ic problem s. In this phase of her research she
54
developed a score sheet that would be quick to use, would provide
clear information regarding child's status of performance, and would
easily differentiate betw een children who need assistance and those
who do not. This was developed by using a raw score frequency
distribution table to determ ine cutoff points. It was also at this point
that Miller (1982) chose the three color classifications for children's
scores: red, yellow, and green.
Reliability studies of the MAP: Reliability refers to the consistency
of scores on a test when the test has been administered on different
occasions or by different people or in different variable conditions
(Anastasi, 1986). There are many types of reliability, however, not all
types of reliability pertain to the MAP. The reliability studies which are
m ost relevant to the MAP are inter-rater reliability, test-retest
reliability, and internal reliability. In addition to these reliability
studies, Miller (1982) calculated the standard error of m easurem ent
which is an estim ate of the am ount of variation in an individual
child's test score.
In the inter-rater reliability studies 30 children were tested by two
field supervisors who were trained in the administration and scoring
of the MAP. One supervisor adm inistered the test to the child and
scored while the second supervisor independently observed and scored
the sam e test (Miller, 1982). Each supervisor adm inistered half of the
tests (N=20).
55
Miller (1982) com puted the Pearson Product M om ent Correlation
Coefficient to determ ine the relationship betw een the two
adm inistrators' scores for each child. The total MAP scores were highly
reliable, with a .978 correlation coefficient. The Foundations, Verbal,
Non-verbal, and Complex-Tasks Indices also dem onstrated high inter
rater reliability with coefficients of .97, .98, .99, and .98, respectively.
The only Index with a reliability coefficient below .90 was the
Coordination index (.84) which required m ore subjective interpretation
for scoring. Overall the MAP can be considered to have high inter
rater reliability. In other words, the scores on the MAP are not expected
to vary greatly from one adm inistrator to the next.
The next type of reliability which was evaluated in the reliability
studies of the MAP was test-retest reliability. Test-retest reliability
refers to w hether the test scores will be consistent from one
administration of the test to the next over time (Anastasi, 1986). Miller
(1982) used (N=90) children and three field supervisors in the test-retest
studies. Each supervisor adm inistered the test twice to 30 children.
The second administration was not less than one week later, nor
longer than four weeks later than the first administration.
Miller (1982) did not, however, com pute correlation coefficients
for test-retest reliability. Instead she com puted percentages of children
that scored within the sam e category (red, yellow, or green) for both
adm inistrations of the test. For these studies 81% in the total MAP
score , 80% in the foundations index, 72% in the coordination index,
56
80% in the Verbal index, 94% in the Non-verbal index, and 91% in the
Complex-tasks index scored within the sam e categories during the first
and second administrations. Although Miller (1982) did not com pute
correlation coefficients for test-retest reliability, she claims, based on
her results, that this test can be considered to be a reliable tool. Because
of the results of the test-retest reliability studies, test users can assum e
that the test can be adm inistered by any trained professional and will
yield similar scores.
The final reliability study that Miller (1982) conducted was the
internal reliability study in which 1,204 children were adm inistered the
test. Internal reliability determ ines how much an item contributes to
the entire score (Anastasi, 1986). Miller (1982) did not expect there to be
high internal reliability in the MAP because the behaviors being
examined in the MAP are so heterogeneous. Miller (1982) used two
statistical techniques to assess internal reliability: the Spearman-Brown
formula, which yielded a coefficient of .79263, and the Guttman which
produced a coefficient of .79245.
Miller (1982) also com puted standard error of m easurem ent
(SEM), which is used to estim ate the am ount of variation in an
individual child's score. The SEM for the MAP is 0.5. This is a
desirable standard error of m easurem ent, as it is small. However,
Miller (1982) used the inter-rater reliability coefficient for the
determ ination of the M A Fs SEM rather than the test-retest reliability
coefficient. Generally, the inter-rater reliability of a test such as the
57
MAP is higher than the test-retest reliability. This is because in a test,
such as the MAP, the instructions for scoring are specific and
behavioral ratings are easily agreed upon, leaving little room for
interpretation. Test-retest reliability is likely to be lower because
extraneous factors, such as environment, m ood, attention, and health
status can cause test results to fluctuate m ore than the effects of
different test administrators, particularly when test subjects are young
children. From the SEM that Miller (1982) found it is clear that on any
given day a child's score should not vary significantly producing a
different conclusion regarding the child's developm ental status.
Validity studies of the MAP; Validity is referred to as the extent to
which the content of a test m easures what it says it m easures (Isaac &
Michael, 1990). The MAP was tested for three types of validity: content
validity, criterion-related validity, and construct validity. Content
validity was evaluated through a MAP specification table which
explained the developm ental dom ains of the MAP and he each item
contributed to the dom ains of the test (Miller, 1982). The s ific ion
table was used to determ ine w hether the items represente re
behaviors that were being assessed.
Although the MAP is a unique test and not completely
com parable it to other developm ental tests, it correlated highly
enough, but not too high with other developm ental tests, indicating
criterion-related validity. Miller (1982) adm inistered several different
developm ental tests to thirty children. The tests that were
58
adm inistered were: W echsler Preschool and Primary Scale of
Intelligence ( non-significant correlation with the MAP total score =
.27), Illinois Test of Psycholinguistic abilities (correlation to MAP =
.312), Southern California Sensory Integration Tests (score not
obtained), and Denver Developmental Screening Test (MAP identified
24% m ore children at risk).
For construct validity Miller (1982) also determ ined w hether there
was a relationship betw een the item perform ance and chronological
age of the child. Any items that did not discriminate well betw een age
groups w ere eliminated. In addition, through factor analysis, Miller
(1982) determ ined w hether the item s shared similar attributes so that
they could be clustered into categories. Miller (1982) identified three
subgroups: verbal, coordination, and non-verbal, and discovered that
items in these subgroups contributed accurately to the total score of the
MAP with no overlap.
In assessing construct validity of the MAP Miller (1982)
determ ined w hether the MAP was accurate in identifying subjects with
known preacadem ic problem s (n=90). These problem s were identified
by parents, teachers, and physicians. Out of the 90 children 75% of
these children scored within the red or yellow zone on the MAP. Fifty
percent of those children were classified within the red category. This
leaves the reader questioning why the rem aining 25% percent of
children w ere not included in the red or yellow category. This leads
the reader to believe that m any children with preacadem ic problem s
59
run the possibility of not being referred w hen truly they need further
assistance. However, from the M A Ps concurrent validity studies, one
can not determ ine w hether the MAP is correctly identifying children
w ho are at risk for later academ ic problem s. This was later studied
through the predictive validity studies.
Three studies have been conducted on the M APs predictive
validity with respect to identification of children w ho are at risk for
preacadem ic problem s (Cohn, 1986; Lemerand, 1985; Miller, 1986). Each
study found m oderate, positive correlations betw een the MAP scores
and criterion m easurem ents. Because each study was designed
differently and m easured preacadem ic risk, as well as outcom es, with
different criteria, com parisons across the three studies different
(Hum phry & King-Thomas, 1993).
Miller (1987) conducted a follow-up study of children (n=338) who
participated in the original MAP standardization project (N=l,204)
from 1980. Miller (1987) obtained correlations betw een the MAP scores
and four year follow-up criteria m easures including verbal
perform ances and full-scale intelligence quotients from the W eschler
Intelligence Scale for Children-Revised, WISC-R, (Weschler, 1974) and
reading math, and language achievem ent subtests of the W oodcock-
Johnson Psychoeducational Battery, Part II (W oodcock & Johnson,
1977). In addition Miller (1987) used school records as a m eans of
determ ining the M APs predictive ability.
60
Pearson correlations were determ ined betw een the MAP scores
and the scores on the selected assessm ents. Although Miller (1987)
calculated correlation coefficients betw een the MAP subscales and the
criterion m easurem ents, the highest correlations were betw een the
MAP total scores and the WISC-R Full Scale IQ (r=.50) and the
W oodcock-Johnson Language standard scores (r=.35). Miller (1987)
concluded that results indicated that the MAP dem onstrated strong
predictive validity with respect to standardized instrum ents that are
sensitive to problem s in school-aged children.
Miller (1988) also tested the MAP for sensitivity and specificity of
the fifth and twenty-fifth percentile cutoff points for identification of
preacadem ic problems. Sensitivity is referred to as the "percent of
children with problem s w ho are correctly identified by the screening"
(Miller, 1988, p.811). Specificity refers to the "percentage of children
with no problem s w ho are correctly identified" (Miller, 1988, p. 811).
Miller (1988) refers to over-referrals as false positives and under
referrals as false negatives.
Miller (1988) used a 2 x 2 contingency table to determ ine the
sensitivity and specificity of the M APs cutoff points. Miller (1988)
found that 2.4% of the children w hose scores fell at the fifth percentile
or below were falsely identified as at risk for developing preacadem ic
problem s (false positives). In addition, she found that 7.7% of the
children who w ere not identified as being at risk for academ ic problem s
at the fifth percentile cutoff were later identified as having academ ic
61
problem s (false negatives). At the 25th percentile cutoff the false
positive rate was slightly higher at 8.4% and the false negative rate was
slightly low er at 4.2%.
Lemerand used 273 children from Michigan who were being
screened for admission into a kindergarten to assess the predictive
abilities of the MAP (Miller, Lemerand, & Cohn, 1986). One year after
the initial screening Lemerand com pared MAP scores to three criterion
measures: the Kindergarten Performance Profiles (KPP), referral for
special services, and grade placem ent for the following year (Miller,
Lemerand, & Cohn, 1 6). Lemerand also used the fifth and twenty-
fifth percentile cutoft ints to identify children at risk for pre
academ ic problem s. ; er findings were that the M APs 25th percentile
cutoff point had sensitivity and specificity rates of .70 and higher for
predicting which children will have difficulty in kindergarten using
the previously stated criteria. Lemerand also reported the M APs over
referral tendencies, but did not thoroughly discuss its under-referral
tendencies (Miller, Lemerand, & Cohn, 1986).
In Cohn's study t-tests were used to analyze the relationship
betw een the MAP scores of 134 children from Colorado and their scores
on later criterion m easures (Miller, Lemerand, & Cohn, 1986). There
was a 1.25 to 2.5 year span betw een the initial administration of the
MAP and the scores of the criterion m easures. In Cohn's study the
criterion m easures included an author-designed teacher rating scale,
report card grades, and the need for supportive services (Miller,
62
Lemerand, & Cohn, 1986). The results of the t-tests suggested that the
m ean scores of the MAP differed significantly betw een groups of
"problem" children and "no problem" children as indicated by teachers
ratings and referrals for support services. However, Cohn did not find
a significant difference betw een MAP scores and first grade report card
grades (Miller, Lemerand, & Cohn, 1986).
Because the predictive validity of the MAP was investigated by
people other than only the author of the test, these additional studies
add credibility to the studies on the M APs predictive abilities (Miller,
Lemerand, & Cohn, 1986). The three researchers feel that these studies
offer encouraging results regarding the MAP and its accuracy in
identifying preschool aged children with pre-academ ic risks (Miller,
Lemerand, &Cohn, " ! ^86). On the the other hand, critics feel that there
are weaknesses in t se studies and that attention m ust be drawn to
these weaknesses before accepting the tool as having strong predictive
validity (Shouten & Kirkpatrick, 1993).
Miller, Lemerand, and Cohn (1986) stress the am ount of over
referrals in their studies as being problematic. However, they do not
discuss the significance of under-referrals. On the other hand, Shouten
and Kirkpatrick (1993) criticize the MAP for its percentage of under
referrals which is "more relevant to the aims of the screening process
than over-referrals" (p.13). This is a critical problem which needs to be
researched further, not only with the MAP, but with all developm ental
assessm ent screening tools (Shouten & Kirkpatrick, 1993).
63
Miller (1993) responded to these criticisms by stating that the
Shouten and Kirkpatrick (1993) focus only on one cutpoint of the test
and on only one study. In closing Miller (1993) stressed that Shouten
and Kirkpatrick (1993) did not conduct a full investigation of the MAP
studies and urged test users to review as m uch of the literature
regarding the MAP as possible before making their decision for or
against the use of the MAP as a developm ental screening tool for pre
academ ic problem s. After reviewing the literature thoroughly, the
author has decided that the MAP will be the m ost appropriate
assessm ent tool for the im plem entation of this research. The m ethods
in which this research will follow will be discussed in Chapter Three of
this proposal.
64
Methods
Research Design
This study was set up as a m atched pair design com paring the
MAP scores of prenatally drug exposed preschoolers to MAP scores of
non-drug exposed preschoolers of the sam e age, sex, geographical area,
and socioeconom ic status. The researcher then identified
developm ental strengths and w eaknesses of the prenatally drug-
exposed sam ple in com parison to non-drug exposed sample.
Participants
Inclusion and Exclusion Criteria
Children betw een the ages two years nine m onths and five years
eight m onths w ho had a docum ented history of prenatal drug exposure
were included in the drug exposed group in this study. The ethnic
background and sex of each child was noted, in addition to
socioeconom ic status of the parent or guardian. Ethnicity was defined
as Caucasian, Hispanic, Afro-American, or Asian and determ ined
through the m other's ethnicity. Sex was classified as either m ale or
female.
The participants were primarily drawn from a low socio-economic
status population. Low socioeconom ic status was defined as the lowest
three levels of the occupational scale of the Hollingshead's Index of
Social Position (Hollingshead & Redlich, 1958). The occupations of the
65
person or persons responsible for raising the child were considered in
determining the social position. All participants included in the study
were Los Angeles County residents. Children who lived with their
biological parents, adopted parents, foster parents, or in foster group
hom es were eligible to participate in this study. Those participants
who lived in group foster hom es were assum ed to com e from a low
socioeconom ical environm ent.
After the drug-exposed group was chosen, a non-drug exposed
group was chosen from various preschools within Los Angeles County.
This comparison group was matched on a case by case basis to the target
sam ple for age, gender, ethnicity, and socioeconom ic status.
Socioeconomic status for the non-drug exposed group was also defined
using the Hollingshead Index for Social Position occupational scale.
Children with a diagnosis of fetal alcohol syndrom e were not
perm itted to participate in this study, even if they had a concom itant
history of prenatal drug exposure. Fetal alcohol syndrom e (FAS) is a
serious condition characterized by a series of growth abnormalities and
functional deficits in children w ho were bom to alcoholic m others
(Pratt & Allen, 1989 ). Because fetal alcohol syndrom e has such
distinctive and dram atic sym ptom s, including children with FAS in
this study m ay have produced results that are m ore characteristic of
FAS than of illicit drug exposure.
Children with a history of prenatal exposure to psychotropic drugs
also were excluded from the study. This study was limited to children
66
of illicit drug abusing m others. In the case of identical twins only one
was allowed to be included in the study. Non-drug exposed children
who w ere receiving special therapies also were excluded from the study
in order to avoid introducing an additional variable into the study.
Informed Consent
In order for a child to participate in this research study informed
consent needed to be acquired from the legal guardian or parent.
Informed consent for children who lived with their biological parents
cam e from the parents. Children who w ere adopted received informed
consent from their adoptive parents. Children w ho lived with foster
parents or in foster group hom es received consent from the courts.
The latter obviously was the m ost time consuming process for
obtaining informed consent for a child to participate in this study.
There were two separate informed consent forms associated with
this study. First, there was an informed consent form for drug exposed
subjects which described the purpose and nature of the study, and
requested perm ission to review the child's school charts for
information regarding positive toxicity screens, the child's age, gender,
race, parents' occupations, and MAP scores (see Appendix A).
The second informed consent form was directed tow ards non-
drug exposed children in regular preschools (see Appendix B ). This
form informed the parents of the nature of the study, requested
perm ission to review the child's school file for information regarding
the parents' occupations, the child's age, race, and gender, and
67
requested a signature of a medical release form indicating that the child
was not known to have been prenatally drug exposed. This form also
described the Miller A ssessm ent for Preschoolers and requested
perm ission to test the child using the MAP and to utilize the results for
the purposes of the study.
Recruitment of participants
The drug exposed participants for this study were selected from
the therapeutic preschool affiliated with St. John's Hospital in Santa
Monica, California. Mary Rinsch, the Occupational Therapist on staff,
routinely adm inisters the Miller A ssessm ent for Preschoolers (MAP) to
children affiliated with the therapeutic preschool. Many of the
children at the preschool have a docum ented history of prenatal drug
exposure. After obtaining approval from the Human Subjects
Protection com m ittee at St. John's Hospital to conduct research at their
facility, recruiting a sam ple of six drug exposed participants began.
Originally, it was believed that ten to twelve drug exposed subjects
would be recruited. However, due to various complications only six
drug exposed subjects were successfully recruited. First of all, St. John's
Therapeutic Preschool had fewer drug exposed students available at the
time of data collection then were previously available. Two of the
drug exposed students were identical twins; only one of them was
selected for the study in order to avoid bias. Thirdly, several children
had stopped attending the preschool during the time of the study and
68
the m others could not be located to request permission to possibly
include their children in the study.
In order to recruit drug exposed subjects, an informed consent
form w as sent to the parents of the children attending St. John's
Therapeutic Preschool. If the parent agreed to sign the informed
consent, the chart was initially reviewed to determ ine w hether the
child had a docum ented history of prenatal drug exposure. Children
who clearly had a docum ented history of drug exposure were chosen to
participate in the study. Through the second chart review the
researcher was able access to the following information: the parents'
occupations, the child's age, gender, ethnicity and the child's results on
the Miller A ssessm ent for Preschoolers.
Each child was m atched as closely as possible for age in months.
Ethnicity was determ ined by the m other's ethnic background.
Classifications include Caucasian, Hispanic, Afro-American, and Asian.
Gender was identified as either m ale or female. Socioeconom ic Status
was defined through the one factor of Hollingshead index for social
position using parent occupations. If both parents were participant s in
the child's care, then both of the parents' occupations were used in
determining social position. However, if only one parent was
involved with raising the child, then the prim ary caregiver's
occupation was used to determ ine social position.
While the drug exposed subjects were being recruited, the
researcher began recruiting six non-drug exposed m atches from a
69
larger pool of children. Prior to recruitm ent of these subjects, the study
was reviewed and approved by the Research Committee of the
University of Southern California Health Sciences Campus. Each child
in this sam ple was m atched to a drug exposed child for age, race,
gender, and socioeconom ic status. Many different preschools were
contacted requesting permission to conduct this research project at
their facility. Letters explaining the purpose and nature of this study
were sent to the directors of each preschool. Preschools that were
contacted included: St. John's Regular Preschool, Long Beach City
College Preschool, Rio H ondo College Preschool, Los Angeles City
College Preschool, H eadstart Programs, and West Los Angeles City
College Preschool.
Each preschool developed different procedures to recruit subjects
to m aintain ethical codes of privacy. The first school which the
researcher approached was St. John's Regular Preschool. Jeanne Day,
the director of the regular preschool requested that the researcher
present the study at a p aren t/teach er support group meeting. During
the m eeting the researcher asked parents who were interested in
participating in the study to contact the researcher after the meeting.
Several parents approached the researcher after the m eeting providing
the researcher with the prelim inary information. However, none of
the children m atched the drug exposed children for ethnicity or
socioeconom ic status.
70
The next school contacted was Long Beach City College Preschool.
After obtaining perm ission to conduct research at the preschool, the
researcher was required to circulate a form to parents informing them
of the nature of the study and the requirem ents to be included in the
study. If the parents w ere interested in allowing their child to be a
possible participant in the study, then they were asked to provide the
prelim inary information: the child's name, birthdate, ethnicity, and
gender, and their own occupations. The sheet was then returned to the
researcher. The researcher then contacted the parents of any children
who w ere possible candidates for the study. Only one child was a
possible candidate. However, when the researcher contacted the parent
it was discovered that the child had been receiving speech therapy,
therefore, the child w as elim inated from the study.
The third school that was contacted was Rio H ondo College
Preschool. The staff at Rio Hondo College Preschool reviewed the
requirements, then approached the parents of the children they
believed would be appropriate for this study. If parents agreed to
participate, the researcher approached the parent with the informed
consent. Two children were eligible to be in the study, however, the
researcher chose not to use them because better m atches were found at
W est Los Angeles College.
Two Headstart Programs were contacted. The staff at both facilities
reviewed the requirem ents and discussed w hether any children would
be appropriate. Very few possible subjects w ere found. In som e cases,
71
children who could have been possible subjects were suspected to have
had som e prenatal drug exposure. Therefore, the researcher chose not
to use any subjects from these two headstart programs.
Then the researcher contacted Los Angeles City College Preschool.
W hen the researcher presented the study to the director of the
preschool, the director told the researcher that the class population
would not fit the criteria of the target group. However, the director of
the preschool directed the researcher towards W est Los Angeles College
Preschool, which would have a population of students that would
better m atch the sam ple of drug exposed subjects.
Finally, the researcher approached W est Los Angeles College
Preschool where Yvonne Simone, the director was very eager to
participate in this study. Dem ographics regarding the drug exposed
children including the child's ages, genders, ethnic backgrounds, and
parental occupations were presented to the director. The director of the
preschool asked the teachers to identify any children that might be
possible non-drug exposed m atches for the drug exposed subjects. The
director also requested a letter from the researcher briefly stating the
purpose and nature of the study. Concurrently, the director also
constructed a letter to accom pany the researcher's letter. Parents who
were contacted were asked to provide verbal permission for the
researcher to approach them with the informed consent form. After a
parent had supplied verbal consent, the researcher approached the
72
parent with the formal informed consent form. Ten possible subjects
were located from West Los Angeles College Preschool.
Description of Subjects
Six children in each group participated in the study. In each
group there were four male and two female subjects. The ethnic
backgrounds were determ ined by the ethnicity of the biological mother.
In each sam ple there was one Caucasian child, one Hispanic child, and
four Afro-American children. Ages ranged from three years, ten
m onths to five years, seven m onths. Initially, the Wilcoxon Signed
Rank test was used to determ ine w hether the ages of the children in
the two groups were significantly different. Mean age of the drug
exposed group was 58.33 + /- 8.26 m onths; m ean age of the non-drug
exposed group was 56.83 + /- 6.08 months. No statistically significant
difference w as discovered through the Wilcoxon signed rank test
(p=20). The largest age span betw een a m atched drug exposed and a
non-drug exposed subject was five months. The smallest age span was
one month. See Table 1 for the descriptive data.
Table 1 Descriptive Data
Match #1
CA
(years, months)
G ender Ethnicitv MO FO
PDE * 5 .2 Female Afro-Am Accountant Not in hom e
NDE * 5.1 Female Afro-Am Student N otin hom e
Match #2
PDE * 4.9 M ale Caucasian Unemployed Not in hom e
NDE * 4.5 M ale Caucasian Student Contractor
Match #3
PDE * 3.10 M ale Hispanic Valet Parking
M anager
N ot in hom e
NDE * 3.11 M ale Hispanic Student Not in hom e
73
Table 1 (continued) Descriptive Data
Match #4
PDE * 5.7 M ale Afro-Am Unemployed Student
with Com puter skills
NDE * 5.3 M ale Afro-Am Not in hom e N otin home
Match #5
PDE * 4.4 Female Afro-Am Not in hom e N otin home
NDE * 4.8 Female Afro-Am Student Not in hom e
Match tt6
PDE * 5.6 M ale Afro-Am N ot in hom e Not in hom e
NDE * 5.1 Male Afro-Am Student Not in hom e
PDE = Prenatally drug exposed; NDE = Non drug exposed; CA = Chronological Age;
MO = Mother's occupation; FO = Father's occupation
Instrumentation
As discussed in the previous two chapters, the Miller Assessm ent for
Preschoolers (MAP) was the assessm ent tool that was used in this
study. The 27-item MAP is a twenty to thirty m inute screening tool
designed to identify preschool aged children with mild to m oderate
pre-academ ic problems. In order for the MAP to m eet its intended
purpose, it would have to have good reliability and validity. Both
reliability and validity are discussed thoroughly in chapter two of this
thesis.
The MAP has been reviewed and critiqued by m any professionals.
DeGangi (1983) in her critique of the standardization of the MAP
supported Miller's tool by stating that it is a well-developed screening
tool that dem onstrates good item discrimination, good test structure
and content, good data collection on normal subjects, and good inter
rater reliability. On the other hand, she criticizes the MAP for its
w eaknesses in sam ple selection of children with delays (DeGangi, 1983).
74
She also criticizes the MAP for its arbitrary cutoff points for
classification of children at risk (DeGangi, 1983). Through the MAP
predictive validity studies which were discussed in chapter two
stronger support has been established for the 5% and 25% cutoff points
designed to classify children as "at risk" for pre-academ ic problem s
(Miller, Lemerand, & Cohn, 1986).
Miller and Sprang (1986) critiqued the MAP by com paring it to
four preschool screening instrum ents using ten psychom etric criteria
for norm referenced tests (McCauley and Swisher, 1984). In their
review, the MAP, along with the Developm ental Indicators for the
A ssessm ent of Learning - Revised (DIAL-R), m et the m ost of the ten
criteria (Miller & Sprang, 1986). Overall, the MAP is supported and
utilized by m any child developm ent professionals. According to The
Ninth Mental Measurements Yearbook, "the MAP appears to be the
best available screening test for identifying preschool children with
m oderate 'preacadem ic' problem s" (Mitchell, 1985, p.976).
Research Protocols
Procedures began with searching for drug exposed subjects.
Informed consent forms were sent to parents of children at St. John's
therapeutic preschool which perm itted the researcher to review the
child's records for selection of the drug-exposed subjects following the
criteria discussed earlier in this chapter. W hen the drug exposed
subjects were chosen the researcher obtained the child's MAP results
and any necessary information to choose m atching non-drug exposed
75
subjects from their charts. Because the MAP is an assessm ent tool
routinely adm inistered by the occupational therapist on staff at St.
John's therapeutic preschool, the drug exposed subjects chosen from
this school had already been tested.
At that point the researcher approached parents from regular
preschools described earlier in this chapter to request permission to
review charts in order to identify children who might be appropriate
m atches for any of the drug exposed subjects. Non-drug exposed
children who could be paired with a drug exposed subject for age,
ethnicity, gender, and socioeconom ic status were invited through
informed consent to participate in the study. After the appropriate
party had given consent for the child to participate in the study, the
researcher adm inistered the MAP to the non-drug exposed child.
The test took approxim ately an hour to administer. In som e cases the
researcher was forced to break the testing situation up into two
sessions. This was due to the lack of space available to the researcher at
the facilities and to the schedules of the children in the preschools.
A limitation of this study is that the data were collected by two
different individuals, the researcher and the occupational therapist at
St. John's Hospital. However, the MAP has been shown to have good
inter-rater reliability. This increases confidence in the reliability of the
data. However, it is possible that the results m ay be affected by
investigator bias, because the researcher tested all of the non-drug
exposed subjects and was aware of their group placement.
76
Statistical Analysis
Initially, the plan was to use percentile scores of the Total MAP
and MAP Indices for statistical analysis. However, MAP percentile
scores are not sensitive at high levels of performance. For example, a
child who falls betw een the 8th and 9th percentile receives a percentile
score of 9, whereas a child who falls betw een the 63rd percentile and
the 99th percentile receives a percentile score of 99.
It was decided by the researcher and her consulting statistician,
therefore, to assign ranks to each score using the MAP green, yellow,
and red criteria. For example, if a child's percentile score fell within
Miller's green range, the num ber three was assigned to that score. The
num ber two was assigned to a yellow score, and the num ber one was
assigned to a red score. This was done for the total MAP score and for
each of the five index scores for each pair. In order to provide a m ore
sensitive m ethod for exploring the d ata the researcher also tallied the
num ber of items that received green scores, yellow scores, and red
scores for each subject's total MAP score and subscale scores. The
Wilcoxon signed rank test was conducted to detect group differences.
One-tailed tests were conducted with the expectation that the drug
exposed group would perform lower on Total MAP and the subtests.
The results of the statistical tests will be reported in the results chapter
and interpreted and discussed in the discussion chapter of this thesis.
77
Results
Percentile Scores of Subjects
The percentile scores for the MAP were not used in the statistical
analysis because the percentile scores are m ore discriminating of low
than average or high performance. For example, on the Coordination
Index, a child w ho receives a percentile score of 99 truly perform ed
som ew here betw een the 53rd and 99th percentiles, whereas, a child
who receives a score of 4 perform ed betw een the 3rd and 4th
percentiles. The lower the derived percentile score, the m ore accurate
the percentile score would be for that particular child. Despite the
limitations that this type of scoring presents, it provides a general
picture of the child's perform ance, and targets children who are
performing below expectations. Table 2 depicts the percentile scores.
Table 2 Percentile Scores
Percentile Scores
Subjects Found Coord Verbal Nverbal Complex Tc
Match #1
PDE 29 53 48 7 9 9
NDE 99 99 99 53 99 92
Match #2
PDE 31 33 10 99 1 9
NDE 99 33 99 53 99 74
Match #3
PDE 53 99 99 9 55
NDE 33 99 99 99 83
Match #4
PDE
4
99 99 31 83
NDE > 9 99 48 30 16 47
Match #5
PDE 1 4 1 1 1 1
NDE 63 99 99 53 99 83
Match It6
PDE 42 33 6 53 1 8
NDE 99 99 48 99 99 92
TotaI= Total MAP Found= Foundations Coord= Coordination Verbal= Verbal
Nverbal= Non-verbal Complex= Complex Tasks
78
Wilcoxon Signed Rank Results
The researcher analyzed the data with the Wilcoxon signed rank
test, first using scale scores, then using item scores. The total MAP
score and each subscale score were analyzed by assigning a one to a
score classified as red (below the fifth percentile), a two to a score
classified as yellow (between the fifth and 25th percentile), and a three
to a score classified as green (above the twenty-fifth percentile). See
Table 3 for results. Although there was no statistical significance in the
com parison of these two groups, the p-values on the total MAP, the
Verbal Index and the Complex Tasks Index indicate a trend in the
direction suggesting that the drug exposed preschoolers scored lower
on the MAP in these areas than the non-drug exposed preschoolers.
To analyze item scores, the researcher counted the num ber of
red, yellow, and green items each child scored in the Total MAP score
and each subscale, and analyzed w hether there w ere any significant
differences betw een the two groups. See Table 4 for details.
Table 3 Wilcoxon Results for Total MAP and Subscales
Var M ean+ /-S D
Drue Exposed
(Ranee) M edian
Non-drue Exposed
M ean + /-S D (Ranee) M edian p-value
Found
2.67+/-.82 (1-3) 3.0 3.0+/-0.0 (3-3) 3.0 p=.50
Coord
2.67+/-.82 (1-3) 3.0 3.0+/-0.0 (3-3) 3.0 p=.50
Verbal
2.33+/-.82 (1-3) 2.5 3.0+/-0.0 (3-3) 3.0 p=.12
Nverbal
2.5+/-.82 (1-3) 3.0 3.0+/-0.0 (3-3) 3.0 p=.25
Complex
1.67+/-.82 (1-3) 1.5 2.83+/-.41 (2-3) 3 p=,06
Total
2.17+/-.75 (1-3) 2.0 3.0+/-0.0 (3-3) 3.0 p=.06
79
Table 4 Wilcoxon Analysis of Red. Yellow. & Green Scores Between The Two Groups
Drug Exposed Non-drug Exposed
Var Mean + /- SD M edian Mean + /- SD M edian p-value
Found
It reds .67+/-1.63 0.0 0.0+/-0.0 0.0 p=.50
tt yellows 2.0+/-1.67 2.5 .17+/-.41 0.0 p=.50
tfgreens 7.33+/-2.66 7.5 9.83+/-.41 10 p=.06
Coord
it reds .33+/-.82 0.0 0.0+/-0.0 0.0 p=.50
tt yellows 1.17+/-.75 1.0 .67+/-1.03 0.0 p=.25
tfgreens 5.5+/-1.05 5.5 6.33+/-1.03 7.0 p=.19
Verbal
tt reds 67+/-.82 .50 0.0+/-0.0 0.0 p=.13
tt yellows .83+/-.98 .50 .33+/-.52 0.0 p=.25
tt greens 2.5+/-1.64 3.0 3.67+/-52 4.0 p=.05
Nverbal
tt reds .17 + /- .41 0.0 0.0+/- 0,0 0 .0 p=.50
tt yellows 1.5+/-1.97 .50 .83+/-.75 1.0 p=.28
tt greens 3.33+/-223 4.5 4.17+/-.75 4.0 p=.25
Complex
tt reds 1.33+/-.82 1.5 .17+/-.41 0.0 p=.06
tt yellows 1.0+/-.89 1.0 0.0+/-0.0 0.0 p=.06
tt greens 1.67+/ -.82 2.0 3.83+/-.41 4.0 p=.02
Total
tt reds 2.83+/-3.25 2.0 .17+/-.41 0.0 p=.06
tt yellows 6.17+/-4.17 5.5 2.0+/ -.89 2.0 p=.09
tt greens 18+/-6.63 18.5 24.8+/-1.17 25 p=,05
Total= Total MAP Found= Foundations Coord= Coordination Verbal= Verbal
Nverbal= Non-verbal Complex= Complex Tasks
The results from the Wilcoxon signed rank test dem onstrated
no statistical significance in com paring the red and yellow scores
betw een the two groups. However, the p-values on the Total MAP, the
Verbal Index, and the Complex Tasks Index indicate a strong trend
suggesting that the prenatally drug exposed preschoolers perform ed
lower on these subscales of the MAP. In addition, the p-values for the
com parison of the green scores on these sam e indices indicate that the
non-drug exposed preschoolers scored a statistically significantly higher
80
num ber of greens on the items in these indices than the prenatally
drug exposed preschoolers.
Discussion
81
The data analysis indicates that there were statistically significant
differences betw een the num ber of green scores of the drug-exposed
preschoolers and the non-drug exposed preschoolers on the Total
MAP, the Verbal Index, and the Complex Tasks Index using the
Wilcoxon signed rank test. Although there were no statistical
differences in the num ber of red and yellow scores betw een the two
groups using the Wilcoxon signed rank test, the p-values indicate a
strong trend suggesting that the drug exposed children m ore frequently
scored red or yellow on items in the Total MAP, the Verbal Index, and
the Complex Tasks Index.
On the Wilcoxon Signed Rank test the indices scores and the
overall MAP scores were assigned a one, two, or three depending on
w hether they w ere red, yellow, or green. There were only six subjects
in each sample. Because the sam ple sizes were so small, it was difficult
to obtain a statistically significant difference betw een the two groups on
the red and yellow scores. However, the p-values on the on the Total
MAP, the Verbal Index, and the Complex Tasks Index are very close to
dem onstrating a statistical significance. Perhaps, if the sam ple sizes
were larger, there m ay be a m ore dram atic difference betw een the drug
exposed group and the non-drug exposed group in these areas of the
MAP.
82
vever, one m ust not overlook, despite the small sam ple size,
thr indices on the MAP show a statistically significant difference
ii ihe num ber of green scores betw een the drug exposed group and the
non-drug exposed group. The drug exposed preschoolers scored
statistically significantly fewer green scores on the Total MAP, the
Verbal Index, and the Com plex Tasks Index, than the non-drug
exposed preschoolers, indicating that these truly represent areas of
difficulty for the drug exposed children. The researcher also noted a
trend suggesting that the drug exposed group scored fewer greens in the
Foundations Index than the non-drug exposed group. After analyzing
the data and discovering that there was a statistically significant
difference betw een the two groups on these particular indices and trend
in others, the researcher explored clinical and theoretical explanations
for these results.
The Foundations Index of the MAP assessed the neurological
developm ent of the children involved in the study . For example, it
tested the children's sense of position and m ovem ent, sense of touch
and com ponents of basic m ovem ent patterns. The tw o item s in this
section which had the highest frequency of low scores am ong the
prenatally drug exposed preschoolers included Supine Flexion and
Rapid Alternating M ovements.
The Supine Flexion item exam ined the children's ability to
perform the basic m ovem ent pattern of abdom inal flexion. A child
with low muscle tone or dyspraxia may perform poorly on this item.
83
According to Ayres (1972), low tone could be indicative of poor flow of
proprioceptive feedback which could lead to poor body schem e and
m otor control. In addition, she hypothesized that body schem e which
provides the foundations for praxis is closely related to the integration
of sensory information (1972). Ayres (1972) hypothesis suggests that a
child w ho perform s poorly on this item m ay have a dyspractic disorder.
The Rapid Alternating M ovem ents item reflects the children's
bilateral m otor and sequencing skills and kinesthetic proprioception.
Children who scored below average on this item m ay dem onstrate
po o r body schem e and poor ability to perform activities that require
alternating or bilateral coordination. The results that several drug
exposed preschoolers scored below average on both the supine flexion
item and the rapid alternating m ovem ents item support the theory
that there is a connection betw een proprioceptive feedback and m otor
perform ance.
One m ay ask why the drug exposed children as a whole scored
below average on the Foundations Index, yet did not score below
average on the Coordination Index. Many of the items in the
Foundations Index require perform ance without visual feedback.
However, only one item on the Coordination Index requires the child
to close h is/h er eyes during the perform ance of that item. Because
som e item s in the Foundations Index limit the use of vision to provide
feedback, the child m ust rely m ore on his or her proprioceptive,
84
vestibular, and tactile sensory receptors to be able to perform
successfully on these test items.
Some examples of items in this index that restrict visual
feedback include a stereognosis test, a Romberg test, and a marching in
place test. If children have delays in the developm ent of their
som atosensory and vestibular processing they m ay perform poorly in
these tests. However, when vision is available to guide the task,
children do not have to rely as heavily on their proximal sensory
systems to perform a task, as with m any of the items in the
Coordination Index.
Because the items in the Foundations Index test the child's m ost
basic sensory processing and m otor skills, a child who scores below
average on this index probably will dem onstrate poor body schem e and
ability to perform m ore complex tasks that require these basic skills.
This rationale offers an explanation as to why the drug exposed
children also scored below average on the Complex Tasks Index in
addition to the Foundations Index. The Complex Task Index requires
coordination of two or m ore skills from all of the other indices. The
two items in which every drug exposed child scored below average
included the Draw-A-Person test and the Block Designs item.
Satisfactory perform ance on the Draw-A-Person test requires the
child to have a developed body scheme, adequate fine m otor skills,
visual-spatial manipulation, and visualization (Miller, 1988). Because
m any of the drug-exposed children scored below average on items that
examined their proprioceptive feedback, it is not a surprise that these
sam e children would score below average on the Draw-A-Person test
which examines the child's sense of body scheme. According to Ayres
(1972) po o r kinesthetic processing limits the developm ent of not only
body scheme, but also visual perception and praxis. Visual-spatial
m anipulation and visualization skills are skills that are necessary for
good perform ance on both the Draw-A-Person and the Block Designs
items in the Complex Tasks Index A child w ho has a dyspractic
disorder m ay have difficulty m otor planning how to stack blocks
accurately into a design or to draw appropriate body parts when
drawing a picture of a person.
As stated above, an argument has been established to explain the
connection betw een the Foundations Index and the Complex Tasks
Index and why the drug exposed children scored statistically
significantly lower than the non-drug exposed children on both of
these indices. But, why did the drug exposed children also lower on
the Verbal Index?
The Verbal Index included four item s which either tested
language com prehension or auditory memory. The tw o items that
tested language com prehension were the General Information and the
Follow Directions tests. In the General Information test the child was
asked three simple questions in which he or she was required to
answer appropriately. In the Following Directions test the child was
given a series of com m ands to perform. The two items that tested
86
auditory m em ory included the Sentence Repetition and Digit
Repetition. In these test items the exam iner says either a sentence or a
series of num bers and the child is asked to repeat exactly what the
exam iner said. All four item s in this index require the ability to
process auditoty information.
Research indicates that language developm ent is dependent
upon auditory processing (Ayres, 1972). The primitive structures for
audition are located in the m esencephalic reticular formation of the
brainstem (Ayres, 1972). This structure is also the area in which
vestibular and proprioceptive stimuli are sent (Ayres, 1972). Perhaps
the children who dem onstrated po o r proprioceptive functioning
through their perform ances on the Supine Flexion and the Rapid
Alternating M ovem ents items also had p o o r auditory processing
which affected their language developm ent.
In this section the researcher has attem pted to offer a
theoretical explanation for the statistical results of this study.
However, these explanations do not provide direct suggestions for its
relevance to the field of occupational therapy. The following section
will discuss how these findings can be related to the field of pediatric
occupational therapy.
Additional Observations
Throughout the study, observations were m ade regarding the
two samples. The m ost prom inent observation w as that m any of the
drug exposed preschoolers had been administered the MAP at younger
87
ages; however, their functioning was so low that they were unable to
com plete the test. Despite their previous exposure to this particular
evaluation and special school-based intervention, the majority of the
drug-exposed children still perform ed below average on the MAP. On
the other hand, all of the non-drug exposed children were able to
perform within a green zone on the Total MAP and the MAP Indices
the first time they were adm inistered the test.
A dram atic observation was that the drug exposed children often
took twice as long to be adm inistered the MAP than did the non-drug
exposed children. Due to time restraints within the school setting and
the child's inability to sustain attention, the occupational therapist
often was forced to break the evaluation process up into two to three 45
m inute sessions in order to com plete the evaluation. However, the
researcher was able to administer the MAP to the non-drug exposed
children within one forty-five m inute to one hour session.
It was also reported by the occupational therapist that it was very
difficult 'O sustain the drug exposed children's attention to the task.
Although the testing occurred in a quiet, private room, m ost of the
drug exposed children were very distracted throughout the session and
had difficulty transitioning from one task to the next. To the contrary,
the non-drug exposed children listened to verbal com m ands and often
were eager to perform the next task despite the lack of a private room
for testing.
88
Relevance to Occupational Therapy
Because the prenatally drug-exposed children were currently
receiving supportive services, this sam ple m ay not truly represent the
entire population of prenatal drug exposed preschoolers. Instead, this
sam ple m ay represent the types of children that m ay be referred to
occupational therapy due to their severe level of involvement. Many
drug exposed children will never be identified nor referred for special
services. This sam ple m ay represent the m ost developmentally
com prom ised cases of drug exposed children. Because these children
are m ore severe cases, they would m ore likely to be referred for special
services such as occupational therapy.
Sensory integration is a theory and a treatm ent approach that is
used by occupational therapists who work with children with sensory
processing deficits. In the previous section, the explanations regarding
the study results were m ostly based from the sensory integration (SI)
theory of developm ent. After examining the results, the researcher
hypothesized that these prenatally drug exposed preschoolers
dem onstrated po o r kinesthetic processing po o r body scheme, and poor
visual-spatial m anipulation often associated with dyspractic disorder.
It was also hypothesized, based on the SI theory, that the drug exposed
children have p o o r auditory processing which interfered with their
perform ance on the verbal index of the MAP.
Occupational therapists often treat children with learning
disabilities in school settings. These deficits noted in the previous
89
section can greatly effect the child's functioning within a classroom
setting. The child who cannot copy block designs m ay also have
difficulty copying letters which is crucial for handwriting developm ent.
The child who has poor body schem e and poor proprioceptive feedback
m ay have difficulty with m otor planning which would be crucial for
participating in physical education or playground activities. Children
with poor auditory processing m ay dem onstrate language and auditory
com prehension impairm ents.
Limitations
Although this study was designed to control for som e variables,
there are m any factors that limit the ability of this study to identify
developm ental characteristics representative of drug exposed
preschoolers. The m ost obvious limitation of this study is that is not a
true experiment. Many factors m ay influence outcom e, such as
unknown variations in econom ic and social environm ent. In
addition, som e subjects in the non-drug exposure group m ay have
been exposed to drugs in-utero, but do not have a docum ented history
of such. Although in this study there is docum entation of drug
exposure for the drug exposed group, there is no way of knowing the
length of time, the types of drugs , nor the frequency for which the
m other abused drugs during pregnancy. Some children in both groups
m ay have been exposed to excessive alcohol abuse during the prenatal
phases of their life, however, their medical records do not yield
information regarding their alcohol exposure. Despite the limitations
90
of studying this population, it is crucial to perform research in this
area in order to better understand and service these children.
Some limitations in the structure of this study could have
affected the final findings in this research. The m ost obvious
limitation of this study is the fact that the sam ple sizes were so small.
A larger sam ple could have offered m ore reliable analysis of the
results. However, for practical reasons this was not possible.
Suggestions for Further Research
Because this study included such a small sam ple size, the
reliability and the validity of the study was seriously com prom ised.
Therefore, the biggest suggestion for further research in this area would
be to repeat the sam e study v-ith at least thirty subjects in each group.
This would create a rm ;ch str nger base for statistical analysis.
However, a study of this nature would require support from the child
protection services, local preschools, parents of possible subjects, and
governm ental funds.
A nother suggestion to improve this study would be to use the
sam e type of study design, but have at least one blind rater scoring the
test. This would limit any researcher bias that may have occurred in
this study. The final suggestion for further research is that the MAP be
adm inistered in conjunction with the supplem ental observations of
behavior. This would allow for a m ore thorough analysis of the
qualitative observations that were not recorded in this study.
91
References
American Psychological Association (1974). Standards for educational
and psychological tests. W ashington, D.C.: APA.
Anastas., A. (1986). Psychological testing. New York: Macmillian.
Ayres, J. (1972). Sensory integration and learning disorders (9th Ed.).
Los Angeles, California: W estern Psychological Services.
Bauman, P. & Daugherty, F . (1983). Drug-addicted m others' parenting
and their children's developm ent. The International Tournal of
Ac! :tions. 18 (3). 2° ■ 302.
Bauman, P. & Levine, (198*:;. The Developm ent of children of drug
addicts. The International [oumal of Addictions. 21 (8). 849-863.
ow, R . & Fletcher, A. (Eds.). (1987) The Merck m anual (15th Ed.).
vahv ay, New Jersey: Merck & Co., Inc..
Billing L, Eriksson, M., Steneroth, G., & Zetterstrom , R.(1985).
Pre-school children of am phetam ine ddicted mothers: somatic
and psychom otor developm ent. Act Paediatrica Scandinavia. 74.
179-184.
Chasnoff, I.J. (1989). Cocaine and pregnancy - Implications for the
child . The W estern [ournal of Medicine. 150 (4), 456-458.
Chasnoff, I.J. (1989). The incidence of cocaine use. Special Currents:
Cocaine Babies. ( Available from [Ross Laboratories, 625 Cleveland
Avenue, Columbus, Ohio, 43216]).
92
Chavkin, W. (1990). Drug addiction and pregnancy: policy crossroads.
The lournal of Public Health. 80 (4). 483-487.
Ciccone, C.D. (1990). Pharm acology in rehabilitation. Philadelphia:
F.A. Davis Company.
Cohn, S.H. (1986). An Analysis of the Predictive Validity of the Miller
A ssessm ent for Preschoolers in a Suburban Public School District.
Unpublished Doctorial Dissertation, University of Denver.
Currier, D. (1984). Elements of research in physical therapy (2nd Ed.).
Baltimore, Maryland: Williams & Wilkins.
DeGangi, G. (1983). A Critique of the standardization of the Miller
A ssessm ent for Preschoolers. The American Tournal of
Occupational Therapy. 36 (7). 407-411.
Eriksson, M., Billing, L ., Steneroth, G., & Zetterstrom , R. (1985).
Pre-school children of am phetam ine-addicted mothers.
Acta Paediatrica Scandinavia. 74: 185-190.
Fisher, A., Murray, E ., & Bundy, A. (1991). Sensory integration: theory
and practice. Philadelphia, Pennsylvania: F.A. Davis Company.
Free, T., Russell, F ., Mills, B ., & Hathaway, D. (1990). A descriptive
study of infants and toddlers exposed to substance abuse.
M aternal Child Nursing. 15. 245-249.
Giacoia, G. (1990). Cocaine in the cradle: A hidden epidemic.
Southern Medical Journal. 83 (8). 947-951.
93
Goodwin, D.W., & Guze, S.B. (1989). Psychiatric diagnosis (4th Ed).
New York: Oxford University Press.
Hayford, S.M., Epps, R.P., & Dahl-Regis, M. (1988). Behavior and
developm ent patterns in children bom to heroin-addicted and
m ethadone-addicted m others, loum al of the National Medical
Association. 80 (11). 1197-1200.
Hollingshead, A.B., & Redlich, F.C. (1958). Social class and m ental
illness. New York: Wiley.
Howard, J. (1989). Long-term developm ent of infants exposed
prenatally to drugs. Special Currents: Cocaine Babies. (Available
from [ Ross Laboratories, 625 Cleveland Ave., Columbus, Ohio,
43216.]).
Hurt, H. (1989). Medical controversies in evaluation and m anagem ent
of cocaine-exposed infants. Special currents: cocaine babies.
(Available from [Ross Laboratories, 625 Cleveland Avenue,
Columbus, Ohio, 43216]).
Illingworth, R, (1987). The developm ent of the infant and young
child (9th Ed.). New York, New York: Churchill Livingstone.
Isaac, S. & Michael, W. (1990). H andbook in research and evaluation
(2nd Ed). San Diego, California: Ed ITS Publishers.
Johnson, H., Classman, M., Fiks, K ., & Rosen, T. (1989). Resilient
children: individual differences in developm ental outcom e
of children born to drug abusers. The loum al of Genetic
Psychology, 151(4). 523-539.
94
Kaltenbach, K, Graziani, L.J., & Finnegan, LP. (1978). Developm ent
of children bom to w om en who received m ethadone during
pregnancy. Pediatric Research. 12. 372.
Kimble, GA. (1961). Hilgard and Marquis' conditioning and learning.
(2nd Ed.). New York, New York: A ppleton-Century Crofts.
Knoben, J. & Anderson, P. (1988). The handbook of clinical drug data
(6th Ed.). Hamilton, Illinois: Drug Intelligence Publication, Inc..
Lemerand, P.A. (1985). Predictive Validity of the Miller A ssessm ent for
Preschoolers. Unpublished doctorial dissertation. University of
Michigan.
McCauley, R, & Swisher, L (1984). Psychometric review of language
and articulation tests for preschool children. loumal of Speech
and Hearing Pis orders. 49. 34-41.
Miller, L.J. (1982). Miller assessm ent for preschoolers. Littleton,
Colorado: Foundation for Knowledge In Development.
Miller, L.J. (1986). The Predictive Validity of the Miller A ssessm ent for
Preschoolers. Unpublished doctorial dissertation, University of
Denver.
Miller, LJ. (1987). Longitudinal validity of the Miller A ssessm ent for
Preschoolers: study I. Perceptual and M otor Skills. 65. 211-217.
Miller, L.J. (1988). Longitudinal validity of the Miller A ssessm ent for
Preschoolers: study II. Perceptual and M otor Skills. 66. 811-814.
Miller, LJ. (1993). Response to 'questions and concerns about the
Miller A ssessm ent for Preschoolers'. The Occupational Therapy
loum al of Research. 13 (1). 29-33.
95
Miller, L.J., Lemerand, P.A., & Cohn, S.H. (1986). A sum m ary of three
predictive studies with the MAP. The Occupational Therapy
loum al of Research 7(6). 378-381.
Miller, LJ. & Sprong, T.A (1986). Psychometric and qualitative
com parison of four preschool screening instruments.
Toumal of Learning Disabilities. 19 (8). 480-484.
Mitchell, J.V. (Ed.). (1985). The Ninth m ental m easurem ents yearbook.
Lincoln, NE: University of Nebraska Press.
Moore, D., Forgatch, M., Mukai, L ., & Toobert, D. (1979). Interactional
coding system. Unpublished Manual, Oregon Social Learning
Center.
Neuspiel, D.R. & Hamel, S.C. (1991). Cocaine and infant behavior.
loum al of Developm ental and Behavioral Pediatrics. 12 (1). 55-63.
Olofsson, M., Buckley, W., Andersen, G.E., & Friis-Hensen, B . (1983).
Investigation of 89 children b o m by drug-dependent mothers.
Acta Paediatrica Scandinavia. 72. 407-410.
Pratt, P. N. & Allen, A.S.. (1989). Occupational therapy for children
(2nd E d.). St. Louis, Missouri: The C.V. M osby Company.
Pruitt, AW., Jacobs, E.A., Schydlower, M., Stands, B.O., & Sutton, J.M..
(1990). Committee on substance abuse: drug-abuse infants.
Pediatrics. 86 (4). 639-642.
96
Rist, M.C., (1990). The shadow children. The American School Board
journal Available from Los Angeles County Office of Education,
9300 East Imperial Highway, Downey, California, 90242-2890.
Ryan,L., Ehrlich,S., & Finnegan, L . (1987). A buse in pregnancy: effects
on the fetus and newborn. Neurotoxicology and Terotology. 9.
295-299.
Schydlower, M. (1989). Current issues affecting drug-exposed infants
and their m others. Special Currents: Cocaine Babies. (Available
from [Ross Laboratories, 625 Cleveland Ave., Columbus, Ohio,
43216]).
Short-DeGraff, M. (1988). Human developm ent for occupational and
physical therapists. Baltimore, Maryland: Williams & Wilkins.
Shouten, P.G., & Kirkpatrick, L.A. (1993). Questions and concerns
about the Miller A ssessm ent for Preschoolers. The Occupational
Therapy loumal of Research. 13 (1). 7- 28.
Silverman, S. (1989). Interaction of drug-abusing m other, fetus, types
of drugs exam ined in num erous studies. loum al of the American
Medical Association. 216,(12). 1689,1693.
Silverman, S. (1989). Scope, specifics of m aternal drug use, effects on
fetus are beginning to em erge from studies. loumal of the
American Medical Association. 216. (12). 1688-1689.
Sowder, B. & Burt, M. (1980). Children of heroin addicts: An
assessm ent of health, learning, behavioral, and adjustm ent
problem s. New York, New York: Praeger Publishers.
97
Stolberg, S. (1991, N ovem ber 21). N um ber of drug-addicted babies
decreases. Los Angeles Times. B-l, B-8.
Udell, B . (1989). Crack cocaine. Special Currents: Cocaine Babies.
(Available from [Ross Laboratories, 625 Cleveland Avenue,
Columbus, Ohio,43216]).
Wechsler, n -1974). W echsler intelligence scale for children, manual.
New Yc Psychological Corporation.
Wilson, G., McCreary, R., Kean, J., & Baxter, J. (1979). The developm ent
of preschool children of heroin-addicted mothers: a controlled
study. Pediatrics. 63:135-141.
W oodcock, R.W., & Johnson, M.B. (1977). W oodcock-fohnson Psycho-
Educational Battery. Hingham, PA: Teaching Resources Corp.
Zehrbach, R. (1975). Com prehensive identification process: screening
adm inistrator's m anual. Urbana-Champaign, University of
Illinois.

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Asset Metadata

Creator Persic, Angela Marie (author)

Core Title A Comparison Of Prenatally Drug Exposed Preschoolers To Non-Drug Exposed Preschoolers Using The Miller Assessment For Preschoolers

Degree Master of Arts

Degree Program Occupational Therapy

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag education, early childhood,education, special,health sciences, public health,health sciences, rehabilitation and therapy,OAI-PMH Harvest,psychology, developmental

Language English

Contributor Digitized by ProQuest (provenance)

Advisor Parham, Linda Diane (committee chair), Clark, Howie A. (committee member), Hedricks, Cynthia A. (committee member)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c18-9368

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