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Alcohol and Substance

Water by the spoonful - Children of addiction

Gideon Koren, MD, FRCPC, FACMT

March 2013



I just saw for the first time a 7-year-old boy with severe attention deficit hyperactivity disorder and oppositional defiant disorder. He came with his grandmother, who has been his guardian for the past 2 years. His mother is addicted to cocaine and is in rehabilitation. There is no paternal involvement. What is known about the long-term effects of being raised by parents with addictions?


Being raised by parents addicted to cocaine, other drugs, or alcohol confers high risk of neglect, physical and mental abuse, poverty, and a long list of psychological and psychiatric disorders. These children must be considered to be at very high risk and should be followed appropriately; both the children and their families must be supported.


Je viens de rencontrer pour la première fois un garçon de 7 ans qui souffre d'un grave trouble d'hyperactivité avec déficit de l'attention et d'un trouble oppositionnel avec provocation. Il est venu avec sa grand-mère, qui est sa tutrice depuis 2 ans. Sa mère est cocaïnomane et est en cure de désintoxication. Il n'y a pas de présence paternelle. Que sait-on des effets à long terme d'être élevé par des parents toxicomanes?


Être élevé par des parents qui ont une dépendance à la cocaïne, à d'autres drogues ou à l'alcool comporte des risques élevés de négligence, de violence physique et mentale, de pauvreté et d'une longue liste de problèmes psychologiques et psychiatriques. Ces enfants doivent être considérés comme étant &0224; risque très élevé et devraient être suivis de manière approprié; tant les enfants que leur famille doivent recevoir du soutien.

Being raised by parents addicted to cocaine, other drugs, or alcohol confers high risk of neglect, physical and mental abuse, poverty, and a long list of psychological and psychiatric disorders. These children must be considered to be at very high risk and should be followed appropriately; both the children and their families must be supported.

When I went to see the 2012 Pulitzer prize–winning play Water by the Spoonful, written by Quiara Alegría Hudes, I was very curious about how it got its name. The answer was powerful.

In one of the climaxes of the play, the main character, Eliot, reminds his natural mother of the day his "life was cut into two." He was a young child of a Puerto Rican family in New York. He and his younger sister contracted "stomach flu" and had frequent diarrhea. His crack-addicted mother took them to the local emergency department, which was overflowing with similar cases. They were sent home with a brochure instructing the parents to give the children water by the spoonful every 5 minutes. A short time after they returned home, their mother fled. Many hours later, a neighbour found the 2 children totally dehydrated. The sister was already dead. Eliot says to his now-sober mother: "When you are so dehydrated, you do not even have water for tears." At that moment, I had plenty of water turning into tears.

In 1994 I was privileged to help create Toronto's Breaking the Cycle, a program aimed at mothers with addictions and their young children. During the past 2 decades I have seen a lot of brave women trying to break the cycle of addiction, and a small group of committed professionals trying to help them overcome their terrible odds. The statistics at Breaking the Cycle are encouraging, maybe because the team there mixes tenderness, love, and care with straightforward realism.

Existing evidence creates a very harsh picture of the risks faced by children of addiction. Without considering these risks, the chance to rescue the children is marginal. Children exposed in utero to drugs of abuse or alcohol tend to have higher rates of intrauterine growth restriction, premature birth, and small head circumference than healthy control subjects. 1 Due to vertical transmission, these babies are more likely to have positive test results for hepatitis, HIV, and other sexually transmitted infections.

There are serious concerns about the neuropsychological achievements of these children—they achieve lower scores on screening tests than children of healthy mothers and than children of women who discontinued their drug use in early pregnancy. 2 Studies showed that children born to mothers addicted to heroin had substantially lower cognitive achievements compared with healthy control subjects. However, if they were given up for adoption at a very young age, their achievements were not different from those of control subjects. 3 These data strongly suggest that much of this damage is secondary to disrupted childhood experience, characterized by neglect, physical and emotional abuse, emotional instability, and many other markers of aggression and instability.

Just as concerning, studies have shown high prevalence rates of psychiatric morbidity among these children, with up to two-thirds having at least 1 psychiatric diagnosis, and almost half having at least 1 affective or anxiety disorder, with boys at higher risk.4 High prevalence rates of attention deficit hyperactivity disorder and oppositional defiant disorder are consistently reported. Studies have also repeatedly shown that the more foster homes these children attend, the worse their outcomes are.

Sadly, the window for intervention is relatively narrow, and many of these children experience lower academic achievement, drop out of school, have high rates of psychiatric morbidity, and exhibit delinquency. As shown by Streissguth et al in the context of fetal alcohol spectrum disorder, the earlier these children are diagnosed and interventions are initiated, the better the predicted outcomes are. 5

Motherisk questions are prepared by the Motherisk Team at The Hospital for Sick Children in Toronto, ON. Dr. Koren is Director of the Motherisk Program and is supported by the Research Leadership for Better Pharmacotherapy during Pregnancy and Lactation. He holds the Ivey Chair in Molecular Toxicology in the Department of Medicine at the University of Western Ontario in London.

Do you have questions about the effects of drugs, chemicals, radiation, or infections in women who are pregnant or breastfeeding? We invite you to submit them to the Motherisk Program by fax at 416 813-7562; they will be addressed in future Motherisk Updates.

Published Motherisk Updates are available on the Canadian Family Physician website (www.cfp.ca) and also on the Motherisk website.

View abstract »»

Competing interests
None declared

Copyright © the College of Family Physicians of Canada
Can Fam Physician
Vol. 59, No. 3, March 2013 e141-e142
Copyright © 2013 by The College of Family Physicians of Canada


  1. Vucinovic M, Roje D, Vucinovic Z, Capkun V, Bucat M, Banovic I. Maternal and neonatal effects of substance abuse during pregnancy: our ten-year experience. Yonsei Med J 2008;49(5):705-13. Medline
  2. Hjerkinn B, Lindbaek M, Skogmo I, Rosvold EO. Neuropsychological screening of children of substance-abusing women attending a special child welfare clinic in Norway. Subst Abuse Treat Prev Policy 2010;5:17. Medline
  3. Ornoy A, Michailevskaya V, Lukashov I, Bar-Hamburger R, Harel S. The developmental outcome of children born to heroin-dependent mothers, raised at home or adopted. Child Abuse Negl 1996;20(5):385-96. CrossRef | Medline
  4. Luthar SS, Cushing G, Merikangas KR, Rounsaville BJ. Multiple jeopardy: risk and protective factors among addicted mothers' offspring. Dev Psychopathol 1998;10(1):117-36. CrossRef | Medline
  5. Streissguth AP, Bookstein FL, Barr HM, Sampson PD, O'Malley K, Young JK. Risk factors for adverse life outcomes in fetal alcohol syndrome and fetal alcohol effects. J Dev Behav Pediatr 2004;25(4):228-38. CrossRef | Medline
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