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Placing an emphasis on neonatal abstinence syndrome’s (NAS) potential for negative developmental outcome dismisses the larger, more complex factors of a child’s life that contribute to a long-term trajectory for development. Such a singular focus on NAS can be a source of harm for the child and family, and it neglects an opportunity to help the family fully heal and thrive, according to research published in the Journal of Addiction Medicine this fall (October 2018).

Hendrée Jones, PhD, professor of obstetrics and gynecology at the UNC School of Medicine’s Department of Obstetrics and Gynecology, is lead author of the commentary “Prenatal Opioid Exposure, Neonatal Abstinence Syndrome/Neonatal Opioid Withdrawal Syndrome, and Later Child Development Research: Shortcomings and Solutions.” Jones is also executive director of the UNC Horizons Program, a substance use disorder treatment program for pregnant and parenting women.

In this commentary, Jones and her team identify the shortcomings in the methodology of research that relates NAS to child development. They also make recommendations for a new framework through which researchers can study developmental problems in later childhood that had been previously attributed to NAS.

Many studies have grouped children together under the umbrella term of ‘children-with-NAS’ to describe a population of children who have either been known opioid-exposed and/or experienced withdrawal symptoms at birth, sometimes based on Diagnostic and Statistical Manual/International Statistical Classification of Diseases and Related Health Problems-9/10 codes (DSM IV and X). Jones and colleagues say this research method is missing too much information to relate NAS to developmental outcomes because prenatal exposure to opioids, type(s) of opioids, exposure length, amount, documented diagnosed with NAS, and treatment methods given for NAS are all unknown. The resulting samples are too poorly defined.

NAS also can fall into what is known as the ‘single-cause fallacy’ – developmental delay is related to NAS, therefore NAS causes developmental delay – when children who experience developmental problems do so for a variety of reasons.

“Policy makers, researchers and health care providers need to help support mothers with opioid use disorders and their children as a dyad in more holistic ways that address the underlying issues of health disparities and work to prevent adverse childhood experiences. Such a focus holds a higher promise of reducing risk for future generations than does a narrow focus on NAS.”

Jones says there is little evidence of a linear cause-and-effect relationship between either NAS diagnosis or prenatal opioid exposure and adverse developmental outcomes. A focus on multiple variables and their roles with the child and his/her environment can give a more complete picture and lead to targeted treatment for children and families.

To more accurately study this group, the team recommends researchers adopt methods identified in reviews of literature on the 1980s crack-cocaine epidemic. Research should (1) include an appropriate comparison group; (2) recruit samples prospectively in the perinatal period; (3) use masked assessment; and (4) exclude participants exposed in utero to other substances.

Jones says that this new framework is needed to prevent the harm caused to children and families when NAS is used as the main indicator of adverse developmental outcomes. Such a focus is likely to overlook and exclude what are very complex interpersonal, intrapersonal and environmental factors that contribute to long-term developmental trajectories of children.

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