Letcher County Special Education Director Regina Brown said her district has more pre-school students this year with special education needs than without — a sharp and unprecedented uptick that’s reflected across the state, and many, including Brown, surmise early opioid exposure is to blame.
“We do have students that are enrolling in our school system, and so do every other school system across the state, that have kids ... with significant developmental delays,” Brown, who has taught for 31 years, said this week. Tremors wrought by the opioid epidemic, including a hike in substance use disorder among pregnant mothers and a subsequent uptrend in rates of Neonatal Abstinence Syndrome, “directly correlates with the increase in disabilities,” she believes.
Director of Advocacy for the Kentucky School Board Association Eric Kennedy agrees. Teachers across Kentucky “are seeing the... first generation[s] of children enter our schools in Kentucky in kindergarten, first grade that were born with essentially drugs in their system, that were born with that neonatal abstinence syndrome,” he said.
Babies can be born with NAS if their mothers use substances while pregnant. Once they’re born, physical symptoms in children often resemble withdrawal responses in adults, including tremors, vomiting and seizures. The syndrome first came into public view in the 1980s with the crack-cocaine epidemic and resurfaced with force again around 2009 as a pernicious outgrowth of the opioid epidemic. In 2013, the Kentucky General Assembly designated NAS a reportable disease, and a year later, mandated a statewide reporting registry to chart its prevalence. In Kentucky, the two most common drugs children are currently born exposed to are buprenorphine, found in Suboxone and used by doctors for medication-assisted treatment, and heroin.
Between 2001 and 2017, hospitals across the state treated more than 8,500 babies born with NAS, ballooning from 46 cases in 2001 to a peak 1,354 in 2015, according to 2018 state data. Due to under reporting, though, state officials believe the full amount is likely higher. 2016 brought the first slight drop in NAS birth rates in more than a decade to 1,257, and that decline continued into 2017, with 1,114 children. That means roughly 22 out of every 1,000 babies born in Kentucky that year showed symptoms of NAS. In some Appalachian parts of the state, the frequency was much higher, at 65 cases per 1,000.
Coinciding was a delayed but notable spike in the number of autistic students in Kentucky across all grades. Between 2011 and 2018, children diagnosed with autism nearly doubled, from 4,378 to 8,040, according to data from the Kentucky Department of Education. The volume of children during that time with any disability or impairment grew by nearly 7,500 -- all but 500 of whom entered the system between 2015 and 2018.
Now, as children with detectable cognitive trauma are flooding school districts, many teachers and school officials are drawing connections to NAS and the opioid epidemic. Yet because these surges are so recent, particularly with NAS, there’s little research charting it’s long-term consequences in children as they age.
Certain developmental delays and disabilities are “a consequence of the crisis, but we don’t know which piece,” said Kentucky Department of Public Health Deputy Commissioner Connie White, a former Frankfort obstetrician and gynecologist.
What is known is that the syndrome can cause a range of behavioral issues and cognitive delays, and schools, as a result, are already sensing a greater need for tailored education. Even then, it’s often impossible to parse complications from NAS with other outgrowths of the epidemic, such as family’s financial instability, incarcerated parents, abuse and whether a child spent in the state’s out-of-home-care system, White said.
It’s going to take time, in other words, to suss out what trauma is directly tied to NAS and what’s a result of the broader epidemic. And without clear causation, evidence-based responses are harder to come by, officials have said.
What many teachers and school administrators can say for certain is they’re seeing a rising number of children with learning disabilities and development delays in need of individualized education plans, placing an “unprecedented” demand on already strained resources, like a lack of special education teachers statewide, Kennedy said.
“[We] saw this need coming, and I’m afraid we’re about to see a wave of school impacts that we’re only on the cusp of now,” Kennedy said. “Like everything else, addressing this epidemic comes back to needing people, resources, and needing funding to operate programs we haven’t before.”
Rise in special education lacks a ‘root cause’
While smoking and drinking while pregnant still cause more damage to a fetus than any other substance, chronic exposure to opioids causes a constellation of other issues, some of which are more inconspicuous and are therefore harder to attribute.
“We know that it has everything to do with brain development, which we know then has to do with storage and retrieval of information,” said Michelle Antle, the past president of the Kentucky Association for Psychology in the Schools.
“I’ve talked to several school psychologists about this and everybody says we need to know more, learning more about what it is and what the effects are. But it seems to be so different from child to child.”
In Fayette County, for example, “there is a general consensus that we are serving an increasing number of students whose families have been ravaged by addiction, but we do not have a way to measure it,” spokeswoman Lisa Deffendall said. More children are qualifying for special education services across the district, she said, “but we cannot point to a particular root cause.”
Likewise, northern Kentucky’s Erlanger-Elsmere Independent School District Superintendent Kathy Burkhardt agreed: “Whether they’ve been born [drug-exposed] or they’ve just been in a traumatic home situation ... [we’re] seeing younger and younger children with not only more developmental needs, but also social and emotional.”
As a result, “What we are seeing are many, many more resources needed at those early levels,” she said.
It’s clear many schools across Kentucky are bowing under the weight of greater specialized education needs. School officials interviewed for this story conceded that while they cannot point to NAS with certainty in all cases, shifting trends in student populations are strong enough to lead them to believe it’s a primary contributor.
Morgan County Superintendent C. Thomas Potter, said his district has an uptick in students with developmental delays in elementary schools. NAS could be a “premier cause,” he said, one that has forced the district to employ more special education teachers “than I’ve seen in my career” -- a hiring momentum that will be “increasingly difficult” to maintain without additional funding.
Increased special education resources have also been needed in Martin, Harlan, Letcher, Garrard counties, and the Jackson Independent school districts.
In Letcher County, Brown’s district, numbers of students “with developmental delays has increased tremendously in the last four to six years and it can be directly correlated to [NAS],” she said.
Garrard’s population of students requiring special education has increased by 10 percent since the 2017-2018 school year, Director of Special Education and Preschool Wendy Congleton said. And of the 3,717 students in Harlan County, more than 20 percent of them require some sort of special education, according to Eric Bowling, who oversees the preschool and special education programs for the Eastern Kentucky district. Tumult at home, such as parental absence and domestic violence are also likely to blame for Harlan County’s surge in its specialized needs students, Bowling said.
Congleton said she sees a range of NAS symptoms in her student population, from the more obvious attention and alertness deficit and reactive detachment disorders, to more discrete characteristics, such as lack of self-help skills and general learning deficits.
Adjusting resources to better serve this growing student population is another challenge, they said.
School officials in Eastern Kentucky’s Jackson Independent district met last week to discuss how best to support its high volume of special education pre-K and first grade students this school year , Superintendent Paul Green said. Causation aside, increased student demand is sure make a dent in already scant resources for the district that serves only 320 students.
“As small as we are, if we have a couple of kids that come in that require extra resources to support their learning needs, the funding is just not there,” he said.
‘Following that baby’
As Kentucky’s abuse and overdose rates among adults climbed, so too have NAS rates. But drugs contributing to the syndrome have shifted, particularly in recent years as medical professionals have become more unanimous in their call for medication-assisted treatment (MAT) to treat substance use disorder. Though most are exposed to more than one substance, 60 percent of children in 2017 with the syndrome were exposed to buprenorphine, a drug found in Suboxone, given by physicians as part of a drug treatment plan. Suboxone, like other prescription drugs, is also illegally trafficked and abused.
Suboxone and methadone are opioids but don’t cause a high the way heroin or prescription painkillers do. Doctors prescribe these medications to reduce cravings and withdrawal symptoms in hopes of weaning patients off opioid use entirely.
The trouble, though, is that any exposure to these drugs, even as part of a treatment plan, is shown to impair children’s development in some way, according to a new article in the American Academy of Pediatrics co-authored by University of Kentucky Neonatologist Dr. Henrietta Bada, who also leads the state public health department’s Division of Maternal and Child Health.
Complicating matters, the study explains, is the “potential lag between birth and when deficits manifest later in childhood.” Even if a child doesn’t show impairments early in life, that doesn’t rule out later onset.
Children between the ages of 3 and 6 who were born with NAS caused by opioids are much more likely have a lower IQ and emotional or intellectual delays or disabilities, are slower to mature, and have trouble regulating their emotions. Across the board, mental abilities were “lower in all children” exposed to opioids, compared with those who weren’t.
Other research compiled by Bada shows virtually no differentiation between the risk involved with taking heroin while pregnant, compared with Suboxone or methadone. Kids exposed to methadone or buprenorphine had more trouble than their peers with short-term memory and behavioral inhibitions. In some cases, children exposed to methadone performed worse than those exposed to heroin. Strained or troubled living situations are likely to exacerbate these problems, generally.
Even with the known risks, medication-assisted treatment is still the best option for a pregnant mother on opioids, Bada and White said. The alternative could trigger fetal withdrawal symptoms that could be fatal, or have “more detrimental to the development of the nervous system,” said Bada said. In part because visiting a clinic for treatment also ensures a pregnant patient will receive prenatal care, persisting with a controlled prescription of opioids through MAT “minimizes the risk in the long run,” Bada said.
But that long run could be years, and the state’s approach to solutions will need to be “fluid,” White said. Though NAS rates are slowing, the reduction is nominal, so much so that it could be chalked up to under reporting, according to the 2019 report. The five- to six-year delay for an NAS infant to reach pre-K and Kindergarten age means districts across Kentucky are likely facing at least a decade of tailored resources to accommodate this new population of students.
Both she and Bada agree that increased coordination of wrap-around services is crucial. That includes working to reduce stigma.
“Do we even want to start telling people these kids are NAS babies? If we start telling teachers, are they going to be treated differently?” she said, wondering if labeling will do more harm than good.
The Cabinet for Health and Family Services, using medical claims data, will soon begin tracking how often children born with NAS are readmitted into a health care facility and why. In addition to helping the state track these cases, it could help inform decisions made by the state’s child welfare system later in the child’s life, should their family have contact with the agency, White said.
“How can we make sure when that mom goes home that somebody is going to be following that baby?” White said. “Right now, that’s not anyone’s particular job. In my opinion, that’s everyone’s job.”