oversight

Parental Substance Abuse: Implications for Children, the Child Welfare System, and Foster Care Outcomes

Published by the Government Accountability Office on 1997-10-28.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                            United States General Accounting Office

GAO                         Testimony
                            Before the Subcommittee on Human Resources,
                            Committee on Ways and Means, House of Representatives




For Release on Delivery
Expected at 3:00 p.m.
Tuesday, October 28, 1997
                            PARENTAL SUBSTANCE
                            ABUSE

                            Implications for Children,
                            the Child Welfare System,
                            and Foster Care Outcomes
                            Statement of Jane L. Ross, Director
                            Income Security Issues
                            Health, Education, and Human Services Division




GAO/T-HEHS-98-40
Parental Substance Abuse: Implications for
Children, the Child Welfare System, and
Foster Care Outcomes
               Mr. Chairman and Members of the Subcommittee:

               Each year, nearly 1 million children in this country are the victims of
               abuse and neglect by their parents or other caregivers, and parental
               substance abuse is very often a contributing factor in these cases.
               Although estimates vary widely, there is considerable literature that
               suggests that parental substance abuse is involved in the majority of foster
               care cases in some locations. It is not surprising, therefore, that the nature
               and effects of parental substance abuse are of concern to this
               Subcommittee, particularly in light of the dramatic increase in the foster
               care population, which was estimated to be almost half a million by the
               end of 1995.

               Because of your concern, you asked us to discuss the implications of
               parental substance abuse for children and the child welfare system. You
               also asked us to comment on permanency planning for foster care cases
               involving parental substance abuse, given the importance of family
               reunification.

               My testimony today is based on our ongoing work for the Senate
               Committee on Finance and previous work we have done in the child
               welfare and substance abuse areas. (See Related GAO Products at the end
               of this statement.) Our ongoing work on the implications of parental
               substance abuse for foster care primarily consists of reviews of the
               substance abuse histories and drug treatment experiences of parents, as
               well as the initiatives that might help achieve timely exits from foster care
               for cases involving parental substance abuse. Most of the previous work I
               refer to here involved an extensive review of the case files of
               representative samples of young foster children—those under 3 years of
               age—who were in foster care in Los Angeles County, New York City, and
               Philadelphia County in 1986 and 1991. These locations accounted for a
               substantial portion of their respective states’ populations of young foster
               children in 1991.1 Furthermore, over 50 percent of the nation’s foster
               children were under the jurisdiction of these three states in that year.

               Let me briefly summarize our findings. For many children, it is parental
               substance abuse that brings them to the attention of the child welfare
               system. When a newborn has been found to have been prenatally exposed
               to drugs or alcohol, this often triggers an investigation of suspected child
               abuse and neglect. In some states, prenatal substance exposure itself

               1
                In 1991, these locations accounted for 44 percent of young foster children in California; 81 percent of
               young foster children in New York; and 29 percent of young foster children in Pennsylvania.



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                 Parental Substance Abuse: Implications for
                 Children, the Child Welfare System, and
                 Foster Care Outcomes




                 constitutes neglect and is grounds for removing a child from its parents.
                 Substance abuse can damage a parent’s ability to care for older children as
                 well, and can lead to child abuse or neglect. As a result, some of these
                 children are removed from the custody of their parents and placed in
                 foster care.

                 Furthermore, once a child is in the system, parental substance abuse is a
                 significant hurdle in their path out of the system—a hurdle that requires
                 drug or alcohol treatment for the parent in addition to other services for
                 the family. The nature of drug and alcohol addiction means a parent’s
                 recovery can take a considerable amount of time. Other problems these
                 parents face, such as mental illness and homelessness, further complicate
                 these cases. Foster care cases that involve parental substance abuse,
                 therefore, place an additional strain on a child welfare system already
                 overburdened by the sheer number of foster care cases.

                 Child welfare agencies are charged with ensuring that foster care cases are
                 resolved in a timely manner and with making reasonable efforts to reunite
                 children with their parents. Ideally, both of these goals are to be achieved.
                 However, even for parents who are able to recover from drug or alcohol
                 abuse problems, recovery can be a long process. Child welfare officials
                 may have difficulties making permanency decisions within shorter time
                 frames before they know whether the parent is likely to succeed in drug
                 treatment. So, when parental substance abuse is an issue in a foster care
                 case, it may be difficult to reconcile these two goals. The foster care
                 initiatives and laws that some states and localities are instituting may help
                 reconcile the goals of family reunification and timely exits from foster care
                 for the cases involving parental substance abuse.


                 The child welfare system encompasses a broad range of activities,
Background       including

             •   child protective services (CPS), which investigates reports of child abuse
                 and neglect;
             •   services to support and preserve families; and
             •   foster care for children who cannot live safely at home.

                 States and localities provide the majority of funds for foster care and child
                 welfare services, but federal funds are provided to states for the food,
                 housing, and incidental expenses of foster children whose parents meet
                 federal eligibility criteria. Federal funding for the administration and



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                         Parental Substance Abuse: Implications for
                         Children, the Child Welfare System, and
                         Foster Care Outcomes




                         maintenance expenses of foster care was estimated at about $3.6 billion in
                         1997. Additional federal funds are provided to states for a wide range of
                         other child welfare and family preservation and support services, and
                         these were estimated at about $500 million in 1997.

                         As an integral part of the child welfare system, foster care is designed to
                         ensure the safety and well-being of children whose families are not caring
                         for them adequately. Beyond food and housing, foster care agencies
                         provide services to children and their parents that are intended to address
                         the problems that brought the children into the system. Agencies are also
                         required to develop a permanency plan for foster children to make sure
                         they do not remain in the system longer than necessary. Usually, the initial
                         plan is to work toward returning the children to their parents. If attempts
                         to reunify the family fail, the agency is to develop a plan to place the
                         children in some other safe, permanent living arrangement, such as
                         adoption or guardianship. According to federal statute, the court must
                         hold a permanency planning hearing no later than 18 months after a child
                         enters foster care.2 Proposed federal legislation would shorten this time
                         frame to 12 months,3 in the hope of reducing the time a child spends in
                         foster care. Some states have already adopted this shorter time frame.


                         Children come to the attention of the child welfare system in two
Parental Substance       ways—either shortly after birth because they were exposed to drugs or
Abuse Often Brings       alcohol in-utero or sometime later because they have been abused or
Children to the          neglected. Children with substance abusing parents enter foster care in
                         either way.
Attention of the Child
Welfare System           Many state statutes require that drug- or alcohol-exposed infants be
                         reported, and some of these children are subsequently removed from the
                         custody of their parents if an investigation determines that they have been
                         abused or neglected. In some states, prenatal substance exposure itself
                         constitutes neglect and is grounds for removing children from the custody
                         of their parents. Large numbers of children in foster care are known to
                         have been prenatally substance exposed. In an earlier study, we estimated
                         that close to two-thirds of young foster children in selected locations in
                         1991 had been prenatally exposed to drugs and alcohol, up from about
                         one-quarter in 1986.


                         2
                          42 U.S.C. 675(5)(C).
                         3
                          Adoption Promotion Act of 1997 (H.R. 867); Promotion of Adoption, Safety, and Support for Abused
                         and Neglected Children (S. 1195).



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Parental Substance Abuse: Implications for
Children, the Child Welfare System, and
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In both years, cocaine was the most prevalent substance that young foster
children were known to have been exposed to, and the incidence of this
exposure increased from about 17 percent of young foster children in 1986
to 55 percent in 1991. Moreover, among those who had been prenatally
exposed who were in foster care in 1991, about one quarter had been
exposed to more than one substance. The actual number of young foster
children who had been exposed to drugs or alcohol in-utero may have
been much higher because we relied on the mother’s self-reporting of drug
or alcohol use or toxicology test results of the mother or infant to
document prenatal exposure. Yet, not all children or mothers are tested at
birth for drugs, and even when they are tested, only recent drug or alcohol
use can be confirmed.

Older children of substance abusing parents also may enter foster care
because they have been abused or neglected as a result of their parents’
diminished ability to properly care for them. Abuse and neglect of children
of all ages, as reported to CPS agencies, more than doubled from 1.1 million
to over 2.9 million between 1980 and 1994, and a Department of Health and
Human Services (HHS) report found that the number of CPS cases involving
substance abuse can range from 20 to 90 percent, depending on the area of
the country. For example, we recently found that about 75 percent of
confirmed cases of child abuse and neglect in New York City involved
substance abuse by at least one parent or caregiver. Many of these parents
live in drug-infested and poor neighborhoods that intensify family
problems.

Neglect is most frequently cited as the primary reason children are
removed from the custody of their parents and placed in foster care.
According to the Office of Child Abuse and Neglect, the children of
parents who are substance abusers are often neglected because their
parents are physically or psychologically absent while they seek, or are
under the influence of, alcohol and other harmful drugs. Sixty-eight
percent of young children in foster care in California and New York in
1991 were removed from their parents as a result of neglect or caretaker
absence or incapacity. No other reasons for removal accounted for a large
portion of entries of young children into foster care. Physical, sexual, and
emotional abuse combined accounted for only about 7 percent of
removals of these young children.




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                       Parental Substance Abuse: Implications for
                       Children, the Child Welfare System, and
                       Foster Care Outcomes




                       Parental substance abuse not only adversely affects the well-being of
Parental Substance     children, it also places additional strain on the child welfare system. The
Abuse Places           foster care population increased dramatically between 1985 and 1995 and
Additional Strain on   is estimated to have reached about 494,000 by the end of 1995. As a
                       consequence, foster care expenditures have risen dramatically. Between
the Child Welfare      1985 and 1995, federal foster care expenditures under title IV-E of the
System                 Social Security Act increased from $546 million to about $3 billion. We
                       found that a greater portion of foster care expenditures in some locations
                       shifted to the federal government between 1986 and 1991 because much of
                       the growth in the population of young foster children involved poor
                       families who were eligible for federal funding.

                       Parental substance abuse is involved in a large number of cases. We have
                       previously reported that an estimated 78 percent of young foster children
                       in 1991 in selected locations had at least one parent who was abusing
                       drugs or alcohol. Our recent interviews with child welfare officials in Los
                       Angeles County, California, and Cook County, Illinois, have confirmed that
                       the majority of foster care cases in these counties for children of all ages
                       involve parental substance abuse. Officials in these locations stated not
                       only that cocaine use among parents of foster children is still pervasive but
                       that the use of other highly addictive and debilitating drugs, such as heroin
                       and methamphetamines, appears to be on the rise. In addition, officials
                       confirmed that use of multiple substances is common.

                       In addition to the large number of foster care cases involving parental
                       substance abuse, the complexities of these family situations place greater
                       demands on the child welfare system. Most of the families of the young
                       foster children in selected locations whose case files we reviewed had
                       additional children in foster care, and at least one parent was absent.
                       About one-third of the families were homeless or lacked a stable
                       residence. Some had at least one parent who had a criminal record or was
                       incarcerated, and in some families domestic violence was a problem. In
                       addition, child welfare officials in Los Angeles and Cook Counties recently
                       told us that dual diagnosis of substance addiction and mental illness is
                       common among foster parents. The National Institute of Mental Health
                       reported in 1990 that most cocaine abusers had at least one serious mental
                       disorder such as schizophrenia, depression, or antisocial personality
                       disorder.

                       To illustrate the complexities of these cases and the influences the
                       complexities can have on outcomes from foster care, let me describe a
                       case we recently reviewed as part of our ongoing work. This case involves



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Children, the Child Welfare System, and
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a woman with four children, all of whom were removed from her custody
as a result of neglect related to her cocaine abuse. The youngest child
entered foster care shortly after his birth. By that time, the three older
children had already been removed from their mother’s custody. All four
of the children were placed with their grandmother. The mother had a long
history of cocaine abuse that interfered with her ability to parent. At least
two of her four children were known to have been prenatally exposed to
cocaine. She also had been convicted of felony drug possession and
prostitution, lacked a stable residence, and was unemployed. The father
was never located, although it was discovered that he had a criminal
record for felony drug possession and sales.

Despite the mother’s long history of drug use and related criminal activity,
she eventually completed a residential drug treatment program that lasted
about 1 year, participated in follow-up drug treatment support groups, and
tested clean for over 6 months. In addition, she completed other
requirements for family reunification, such as attending parenting and
human immunodeficiency virus (HIV) education classes, and she was also
able to obtain suitable housing. Although the mother was ultimately
reunified with her youngest child, it took a considerable amount of time
and an array of social services to resolve this case. The child was returned
to his mother on a trial basis about 18 months after he entered foster care.
The child welfare system retained jurisdiction for about another year,
during which family maintenance services were provided.

In addition, many foster children have serious health problems, some of
which are associated with prenatal substance exposure, which further add
to the complexity of addressing the service needs of these families. We
found that over half of young foster children in 1991 had serious health
problems, and medical research has shown that many of the health
problems that these children had, such as fetal alcohol syndrome,
developmental delays, and HIV, may have been caused or compounded by
prenatal exposure to drugs or alcohol.

Special supportive services and treatment will be needed by many of these
children. Early identification of children who are HIV positive is
particularly critical because medical advances in identification and
treatment can enhance and prolong the lives of these children. Some of
these children require foster care either in institutions that can
accommodate their medical needs or in foster family homes where the
caregivers are specially trained. Reunifying families can also be more
difficult because of the additional strains that caring for medically fragile



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                       Parental Substance Abuse: Implications for
                       Children, the Child Welfare System, and
                       Foster Care Outcomes




                       children places on parents, who are at the same time recovering from drug
                       or alcohol addictions.

                       Some caseworkers find it difficult to manage the high caseloads involving
                       families with increasingly complex service needs. Some states have
                       experienced resource constraints, including problems recruiting and
                       retaining caseworkers, shortages of available foster parents, and
                       difficulties obtaining needed services, such as drug treatment, that are
                       generally outside the control of the child welfare system. Caseworkers are
                       also experiencing difficulties resolving cases. Once children are removed
                       from the custody of their parents, they sometimes remain in foster care for
                       extended periods.


                       The problem of children “languishing” or remaining in foster care for many
Parental Substance     years has become a great concern to federal and state policymakers. While
Abuse Adds to the      most children are reunified with their parents, adopted, or placed with a
Difficulty of Making   guardian, others remain in foster care, often with relatives, until they age
                       out of the system. The circuitous and burdensome route out of foster
Permanency             care—court hearings and sometimes more than one foster care
Decisions              placement—can take years, be extremely costly, and have serious
                       emotional consequences for children.

                       Yet, making timely decisions about children exiting foster care can be
                       difficult to reconcile with the time a parent needs to recover from a
                       substance abuse problem. Current federal and state foster care laws
                       emphasize both timely exits from foster care and reunifying children with
                       their parents. However, even for those who are able to recover from drug
                       and alcohol addictions, it can be a difficult process that generally involves
                       periods of relapse as a result of the chronic nature of addiction. Achieving
                       timely exits from foster care may sometimes conflict with the realities of
                       recovering from drug and alcohol addictions. The current emphasis on
                       speeding up permanency decisions will further challenge child welfare
                       agencies.

                       Current federal law requires that states conduct a permanency planning
                       hearing within 18 months after a child enters foster care to determine
                       whether family reunification should continue to be the goal, or whether
                       some other permanent living arrangement, such as adoption or
                       guardianship, should be pursued. The current emphasis on speeding up
                       permanency hearings reflects concerns about children spending long
                       periods of time in foster care. Pending federal legislation would shorten



                       Page 7                                                       GAO/T-HEHS-98-40
Parental Substance Abuse: Implications for
Children, the Child Welfare System, and
Foster Care Outcomes




the time allowed before holding a permanency planning hearing from 18 to
12 months. As of early 1996, 23 states had already enacted shorter time
frames for holding a permanency planning hearing than required under
federal law. In two of these states, the shorter time frames apply only to
younger children. It should be emphasized, however, that while a
permanency planning hearing must be held within these specified time
frames, the law does not require that a final decision be made at this
hearing as to whether family reunification efforts should be continued or
terminated.

Some drug treatment administrators and child welfare officials in these
same locations believe that shorter time frames might help motivate a
parent who abuses drugs to recover. However, expedited time frames4
may require that permanency decisions be made before it is known
whether the parent is likely to succeed in drug treatment. While one
prominent national study found that a large proportion of cocaine addicts
failed when they attempted to stay off the drug, we previously reported
that certain forms of treatment do hold promise. In addition, progress has
been made in the treatment of heroin addiction through traditional
methadone maintenance programs and experimental treatments. However,
even when the parent is engaged in drug treatment, treatment may last up
to 1 or 2 years, and recovery is often characterized as a lifelong process
with the potential for recurring relapses.

Some drug treatment administrators in Los Angeles and Cook Counties
believe that treatment is more likely to succeed if the full range of needs of
the mother are addressed, including child care and parenting classes as
well as assistance with housing and employment, which help the transition
to a drug-free lifestyle. These drug treatment administrators also stressed
how important it was for parents who are reunited with their children to
receive supportive services to continue their recovery process and help
them care for their children.

Determining the potential for an individual’s success in drug treatment is
extremely difficult given the variety of substances abused, types of
treatment and program quality, differences in addiction and readiness for
recovery, and definitions of what constitutes “recovery.” However, the
longer an individual is in treatment, the greater the potential for improved

4
 Recently, both California and Illinois enacted expedited time frames for holding a permanency
planning hearing within 12 months. In addition, California enacted an even shorter time frame of 6
months for children entering foster care under the age of 3. The changes to Illinois’ permanency
legislation are currently in effect only in Cook County; they will go into effect throughout the rest of
the state beginning January 1, 1998.



Page 8                                                                              GAO/T-HEHS-98-40
Parental Substance Abuse: Implications for
Children, the Child Welfare System, and
Foster Care Outcomes




behavior. Some caseworkers in Los Angeles and Cook Counties said that
shorter time frames for holding a permanency planning hearing may be
appropriate in terms of the foster child’s need for a permanent living
arrangement. However, they also said that the likelihood of reunifying
these children with their parents when permanency decisions must be
made earlier may be significantly reduced when substance abuse is
involved. In their view, the prospects of reunifying these families may be
even worse if the level of services currently provided to them is not
enhanced.

In our ongoing work, we have found that states and localities are
responding to the need for timely permanency for foster children through
programmatic initiatives and changes to permanency laws. Most of these
initiatives and changes to permanency laws are very new, so there is little
experience to draw upon to determine whether they will help achieve
timely exits from foster care for cases involving parental substance abuse.
Furthermore, some of these initiatives and changes are controversial and
reflect the challenge of balancing the rights of parents with what is in the
best interest of the child, within the context of a severely strained child
welfare system.

For example, California and Illinois have enacted statutory changes that
specifically address permanency for foster care cases involving parental
substance abuse. The Illinois legislature recently enacted new grounds for
terminating parental rights. Under this statute, a mother who has had two
or more infants who were prenatally exposed to drugs or alcohol can be
declared an unfit parent if she had been given the opportunity to
participate in treatment when the first child was prenatally exposed.
California has enacted new statutory grounds for terminating family
reunification services if the parent has had a history of “extensive, abusive,
and chronic” use of drugs or alcohol and has resisted treatment during the
3-year period before the child entered foster care or has failed or refused
to comply with a program of drug or alcohol treatment described in the
case plan on at least two prior occasions, even though the programs were
available and accessible. While such laws may help judges make
permanency decisions when the prospects for a parent’s recovery from
drug abuse seem particularly poor, these changes are not without
controversy. Some caseworkers and dependency court attorneys in Los
Angeles and Cook Counties expressed concerns that a judge may closely
adhere to the exact language in the statutes without considering the
individual situation, and may disregard the extent to which progress has
been made toward recovery during the current foster care episode.



Page 9                                                       GAO/T-HEHS-98-40
               Parental Substance Abuse: Implications for
               Children, the Child Welfare System, and
               Foster Care Outcomes




               States and localities are undertaking programmatic initiatives that may
               also help to reconcile the goals of family reunification and timely exits
               from foster care, which may conflict, particularly when parental substance
               abuse is involved. New permanency options are being explored as are new
               ways to prevent children from entering foster care in the first place. We
               previously reported on Tennessee’s concurrent planning program that
               allows caseworkers to work toward reunifying families, while at the same
               time developing an alternate permanency plan for the child if family
               reunification efforts do not succeed. Under a concurrent planning
               approach, caseworkers emphasize to the parents that if they do not adhere
               to the requirements set forth in their case plan, parental rights can be
               terminated. Tennessee officials attributed their achieving quicker exits
               from foster care for some children in part to parents making more
               concerted efforts to make the changes needed in order to be reunified
               with their children.

               In addition, both California and Illinois have federal waivers for subsidized
               guardianship, under which custody is transferred from the child welfare
               agency to a legal guardian. In Illinois, CPS cases involving prenatally
               substance exposed infants can be closed by the child welfare agency
               without removing the child from the mother’s custody if the mother can
               demonstrate sufficient parental capacity and is willing to participate in
               drug treatment and receive other supportive services.

               One jurisdiction is developing an approach to deliver what its officials
               describe as enriched services to the parent. Illinois’ new performance
               contracting initiative provides an incentive for private agencies to achieve
               timely foster care exits for children by compensating these agencies on the
               basis of their maintaining a prescribed caseload per caseworker. This
               necessitates that an agency find permanent living arrangements for a
               certain number of children per caseworker per year, or the agency absorbs
               the cost associated with managing higher caseloads. A component of this
               initiative is the provision of additional resources for improved case
               management and aftercare services in order to better facilitate family
               reunification and reduce the likelihood of reentry. Providing enriched
               services may make it less likely that judges will rule that the child welfare
               agency has failed to make reasonable efforts to reunify parents with their
               children and thereby reduce delays in permanency decisionmaking.


               In summary, children with substance abusing parents often come to the
Observations   attention of the child welfare system either at birth, because of prenatal



               Page 10                                                      GAO/T-HEHS-98-40
Parental Substance Abuse: Implications for
Children, the Child Welfare System, and
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substance exposure, or later in life when they are found to have been
abused or neglected. The families of these children have increasingly
complex service needs. Many are dually diagnosed with drug or alcohol
addictions and mental illnesses, some are involved in criminal activities,
some are homeless, and most have additional children in foster care.
Burgeoning foster care caseloads entailing these complex family situations
have placed enormous strains on the child welfare system.

In seeking to achieve what is in the best interest of children, foster care
laws emphasize both family reunification and achieving timely exits from
foster care for children. Given the time it often takes a person to recover
from drug and alcohol addictions, and the current emphasis on speeding
up permanency decisions for foster children, these goals may conflict.
Reconciling these goals for children whose parents have a substance
abuse problem presents a tremendous challenge to the entire child welfare
system in determining how to balance the rights of parents with what is
truly in the best interest of children. New state and local initiatives may
help address this challenge. Through our ongoing work, we are continuing
to explore the impact of parental substance abuse on foster care, by, for
example, examining parents’ substance abuse histories and their drug
treatment experiences, as well as exploring initiatives that might help
achieve timely foster care exits for cases involving parental substance
abuse.


Mr. Chairman, this concludes my prepared statement. I would be happy to
respond to any questions from you or other Members of the
Subcommittee.




Page 11                                                    GAO/T-HEHS-98-40
Related GAO Products


              Child Protective Services: Complex Challenges Require New Strategies
              (GAO/HEHS-97-115, July 21, 1997).

              Foster Care: State Efforts to Improve the Permanency Planning Process
              Show Some Promise (GAO/HEHS-97-73, May 7, 1997).

              Cocaine Treatment: Early Results From Various Approaches
              (GAO/HEHS-96-80, June 7, 1996).

              Child Welfare: Complex Needs Strain Capacity to Provide Services
              (GAO/HEHS-95-208, Sept. 26, 1995).

              Foster Care: Health Needs of Many Young Children Are Unknown and
              Unmet (GAO/HEHS-95-114, May 26, 1995).

              Foster Care: Parental Drug Abuse Has Alarming Impact on Young Children
              (GAO/HEHS-94-89, Apr. 4, 1994).

              Drug Abuse: The Crack Cocaine Epidemic: Health Consequences and
              Treatment (GAO/HRD-91-55FS, Jan. 30, 1991).

              Drug-Exposed Infants: A Generation at Risk (GAO/HRD-90-138, June 28, 1990).




(116008)      Page 12                                                    GAO/T-HEHS-98-40
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