By Douglas J. Besharov

This article originally appeared in The Washington Post, August 6, 1989.

LAST WEEK in this city, Greater Southeast Community Hospital released a 7-week-old baby to her homeless, drug-addicted mother even though the child was at severe risk of pulmonary arrest. The hospital's explanation: "Because [the mother] demanded that the baby be released."

The hospital provided the mother with an apnea monitor to warn her if the baby stopped breathing while asleep, and trained her in CPR. But on the very first night, the mother went out drinking and left the child at a friend's house -- without the monitor. Within seven hours, the baby was dead. Like Dooney Waters, the 6-year-old living in his mother's drug den, whose shocking story was reported in The Washington Post last week, this child was all but abandoned by the authorities.

Why aren't we protecting these children? One major reason is that, paradoxically, we continue to entrust their care to the very parents who are threatening their well-being. Instead of tackling head-on the tenet of prevailing social welfare policy that holds that children are almost always better off with their mothers, discussion has focused on options for dealing with the drug-addicted mothers: whether to concentrate on drug-treatment services or prosecution. These are important concerns, but they do not go to the heart of what must be done -- now -- to protect these children.

The first thing to understand in this debate is that crack is uniquely dangerous. Other drugs have plagued our society since the 1960s, but cocaine, and especially its derivative, crack, poses a threat to many more young children -- because mothers use it. According to Dr. David Bateman, director of perinatology at New York's Harlem Hospital, "Heroin was a man's drug and we just didn't see as much of it in pregnant women. Many more women are on crack than ever were on heroin."

Almost 20 years ago, as director of the New York State Assembly Select Committee on Child Abuse, I studied heroin-withdrawal babies in New York City. Nothing I learned then prepared me for the devastating damage cocaine is doing to children.

Cocaine is very harmful to the fetus. Some infants are born with deformed hearts, lungs, digestive systems or limbs; others suffer what amounts to a disabling stroke while in the womb. The problem isn't of intractable proportions: The most widely cited estimate -- up to 375,000 fetally exposed babies (or "crack-babies") born per year -- is much too high. A more realistic estimate is 30,000 to 50,000. But the incidence is rising in cities, suburbs and even rural areas. In New York City, for example, there are about 7,000 such births each year. In the District, about 1,500.

Crack is a mean drug that can induce parents to neglect and even violence. "These mothers don't care about their babies and they don't care about themselves," says Dr. Jing Ja Yoon, chief of neonatology at Bronx Lebanon Hospital. "Crack is destroying people -- I've never seen mothers like this before. Children aren't being fed. Mothers sell their food stamps. Young women sell their bodies, and that's done in front of the children. Even when heroin was at its worst, it wasn't like this."

Older children are often battered by their crack-crazed parents. In one highly publicized case, a 5-year-old girl was found dead in her parents' apartment with a broken neck, broken arm, large circular welts on her buttocks, and cuts and bruises on her mouth. Her 9-year-old brother was found the next day huddled in a closet. Both his legs were fractured; he had eight other broken bones, and bruises covered his body. Less dramatic, but still hideous cases are far from uncommon.

Cases like these lead to proposals to expand treatment services for crack-addicted mothers. But at least for now, such services would probably make little difference. Crack addicts typically show little or no interest in prenatal care and are unlikely to seek it until very late in their pregnancy, if ever. Often they present themselves at the hospital only in time to give birth. Some new mothers abandon their sick babies in the hospital -- not returning, even if the infant dies, to help bury it.

In fact, according to Dr. Elizabeth Brown of Boston City Hospital, "It is not extraordinary for a woman, bored and uncomfortable, to take crack purposely to induce labor."

Similarly, an expansion of drug-treatment services for women is long overdue but unlikely to produce quick or substantial results. Years of effort have yielded no widely applicable therapeutic program for treating heroin addicts. "Crack is new enough that no one has yet figured out an effective treatment," according to Peter Reuter, a Rand Corp. expert on drugs.

The other popularly debated alternative -- "getting tough" with crack mothers -- is equally unpromising. True, in the past few months there have been a number of criminal prosecutions of mothers: In Illinois a jury refused to convict a mother whose daughter died of fetal exposure to cocaine, and two weeks ago, a Florida mother was convicted of delivering cocaine to her baby through the umbilical cord. In addition, some have suggested that pregnant drug addicts be placed in custody to make sure that they stop using drugs. D.C. Judge Peter Wolf, for example, ordered a pregnant woman to remain in jail until she delivered her baby after she tested positive for cocaine use while awaiting trial on theft charges.

But there are not enough prison cells for serious criminals, and what new ones are built will not go to drug mothers. Moreover, there is a real danger that, faced with the possibility of incarceration, many pregnant women will not come in for prenatal care. In any event, this approach provides no protection for the child once born, since its mother is only too likely to return to her addiction when released.

If neither punishment nor treatment for mothers is likely to improve things for the children of drug addicts, what can be done?

One obvious step is for government and community leaders to expand their currently impoverished efforts to get out the message that drugs and parenthood do not mix. Hard as it may be to imagine, some young mothers do not believe that crack is bad for their babies. In this crisis, public-service ads that use such euphemisms as "Beautiful Babies: Right From the Start" are no longer enough. The message needs to be blunt: "Using drugs while pregnant is wrong. It cripples and sometimes kills babies."

But sterner measures are also needed. To start with, hospitals should be given the legal power to care for drug babies until they are medically ready for discharge. About half the states have laws that allow hospitals to hold endangered children against parental wishes. These laws protect children when there is no time to apply for a court order or obtain police assistance. All states should have them.

Recent amendments to the federal Medicaid program guarantee that hospitals will be reimbursed for the added and sometimes extraordinary costs of caring for these children. But word has been slow to get out and many cost-conscious hospital administrators have been releasing children before they are medically ready for discharge. Again, an educational effort is needed.

Public authorities must also face up to the fact that concern must not stop with a hospital discharge. The simple truth is that children should not be left with drug-addicted parents who cannot or will not care for them. Most children of addicts -- even those living in dreadful conditions like Dooney's -- are allowed by public authorities to remain at home where they suffer serious abuse and neglect. In 1987, of New York's child-abuse fatalities involving children previously known to the authorities, two-thirds were drug-related. What's going on? Why don't judges and caseworkers remove more of these obviously endangered children from the custody of their drug-addicted parents?

Part of the problem is money. Foster care, especially for children who often need special treatment, is expensive -- depending on the child's condition, from $ 5,000 to $ 20,000. The District, for example, seems determined to save money by ignoring the plight of these children. Recently, nurses at D.C. Children's Hospital notified the District's Department of Human Services each of the two times that a 1-year-old child was sent home after testing positive for PCP, and both times he was returned to the hospital with a higher level of drugs. Typically, the District's child protective agency will not become involved unless the mother abandons her newborn.

Another problem concerns attitudes. Permeating all child-welfare decisions are deeply felt -- but unrealistic -- social attitudes about the importance of preserving families. In recent years, much has been learned about diagnosing and treating abusive and neglectful parents; programs in all parts of the nation are helping parents to take better care of their children, thus avoiding the need for foster-care placement. So it is natural to believe that these addicted mothers can be helped.

Reflecting attitudes of society at large, judges and caseworkers are unable to accept the realities of addiction. Instead, they convince themselves that, somehow, this parent will make it. Thus, any sign of improvement in the mother's functioning is seen as an indication that the child can be left at home or returned, even though there is no reason to think that her drug problem has been licked.

One repeatedly sees admirable -- but misplaced -- efforts to give parents chance after chance to turn their lives around. Four months after one infant was discharged from a six-month foster-care placement and returned to her mother and grandmother, she was found to have serious burns on her back, possibly made by an iron. The child was immediately returned to foster care. Subsequently, the mother admitted using crack to her social worker, and six months later, despite being enrolled in a drug treatment program, she gave birth to a baby with cocaine symptoms. Yet the agency's goal is still to return the older child, now almost 3 years old, as well as the newborn, to their mother.

We must face the implications of the mother's addiction -- and our inability to break her habit. If parents cannot care for their children, the children should be removed from their care. This may require the overhaul of federal foster-care and adoption laws which have been wrongly interpreted to preclude early removal of these children.

Adoption should be a real option for children whose parents show little prospect for improvement even though this means terminating parental rights. Drug children should not be allowed to get lost in a foster-care limbo, as is now so frequently the case. Courts and agencies are notoriously unwilling to free children for adoption. One crack baby's father had served four months in jail for killing the boy's baby sister six months earlier. The mother, who was frequently beaten by her husband, was in touch with the foster-care agency only sporadically. In early 1987 she gave birth to another cocaine-exposed child. Now more than 3 years old, he still lives in a temporary foster home. Nationwide, fewer than 10 percent of the children in foster care are freed for adoption.

To make the termination of parental rights easier, the D.C. Mayor's Advisory Board on Maternal and Infant Health has proposed to reduce the "complexities" of the District's adoption procedures. The issue runs deeper, though. Laws and attitudes must also change. No one likes to give up on parents, to label them as "hopeless," especially since many are themselves victims of broader social problems. But their children deserve a chance -- even if we must assume long-term responsibility for their care and upbringing.

These are not total solutions -- but they would do more to protect the children of addicts than wishful thinking about drug treatment or arguments about criminal prosecution. Each day that we fail to take decisive action means suffering, even death, for thousands of children.

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