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It's a little after 9 a.m.,and the steam rising from crumpled sheets of aluminum foil carries the aroma of freshly cooked sausage and toast around the playroom at the Matilda H. Theiss Health and Child Development Center. Four toddlers sit in their high chairs waiting for breakfast. One toddler, Ben, dressed in overalls, reaches eagerly toward the food, although it rests on a table across the room.

Soon, two staff members bring breakfast over. As the toddlers eat, more food lands on their clothes and trays than in their mouths. Nothing unusual about that: All babies are sloppy eaters. Yet for Ben and his companions eating is more difficult than for others their age because these toddlers' ability to grasp objects is hampered by muscle stiffness -- a stiffness that may have been caused by drugs their mothers used before the childrens' births. At the Theiss Center, breakfast does more than offer a good meal. The small pieces of toast and sausage force the children to practice picking up objects and thus improve their grasp.

The use of breakfast as a therapeutic tool is indicative of the center's thorough, comprehensive approach to treatment. A part of the University of Pittsburgh Medical Center, the Theiss Center is located in the midst of Terrace Village, a housing project in Pittsburgh's Hill District. Most of Terrace Village's 1,500 residents are African American, and single women head the majority of households. Median family income is under $6,000 a year. The Theiss Center's mission is to link its surrounding community to medical, psychiatric, and social services. To do so, Pitt physicians and other professionals there have developed multi-faceted responses to the problems people in poverty face -- complex problems that defy easy answers.

The center is unique, for instance, because of its location. Many of the families enrolled in its programs -- which range from day care to preventive medicine, from dental care to literacy support -- live within walking distance of the center's doors. That's important since transportation difficulties can keep single mothers with limited income from getting services and treatment.

It is with similar insight that the Theiss Center approaches Ben and the other toddlers. Through the Program for At-Risk Kids (PARK), in which these children are enrolled, the Theiss Center addresses issues that go beyond the toddlers' physical symptoms. The program, heading into its third year, was developed by Susan Burns, an assistant professor of psychiatry at Pitt. PARK helps families with children from six months to three years of age whose mothers used drugs while pregnant. Yet it sees prenatal exposure to drugs as only a part of the larger problem of poverty.

In fact, doctors have no way of knowing whether drugs caused problems in the children at PARK, says Claire Cohen, the medical director of child development programs at the Theiss Center. "There is a lot of hysteria about prenatal drug use, which has clouded the issues," she asserts.

Some hysteria has stemmed from news coverage of the rise of crack cocaine. Recent stories on the "crack baby" phenomenon have linked cocaine exposure to a number of problems in newborns, including premature birth and low birth weight, as well as hypersensitivity, irritability, and fine motor defects. "There's an idea that there is a definitive scientific syndrome for 'crack babies.'" Cohen says. "And there isn't." In truth, she insists, crack cocaine exposure in babies has never been proven to cause anything.

The reason is that scientists cannot isolate the effects of prenatal exposure to crack. Most pregnant women who use crack cocaine during pregnancy live in devastating poverty. Thus, they suffer from other conditions that have been proven to contribute to low birth weight: poor health, inadequate nutrition, and poor prenatal care. Because of these confounding variables, there's no way to determine exactly which factors were the cause of an infant's problems.

The drugs proven to contribute to problems in newborns include alcohol and tobacco, which can be studied in otherwise healthy and well-cared-for pregnant women. Cohen acknowledges that if scientists could study crack this way, they might very well find that the drug does play a role in some disorders, such as hyperactivity. But for now the effects of crack remain ill-understood.

Many women in PARK have also been struggling with addictions to other drugs. Most have used some combination of cocaine, marijuana, alcohol, or heroin. The effects of prenatal heroin exposure, like those of crack, are difficult to study. Research has indicated only tentatively that marijuana may have harmful effects on newborns.

"In that case," says Cohen, "you may ask, 'Why does our program target children who have been exposed to illegal drugs?'" The answer is that PARK, which gets clients through referrals from drug treatment programs and hospitals, employs illegal drug use as a "tag" to identify women who are likely to have suffered from problems that are known to endanger infants -- problems such as poor prenatal care.

Juanita Menendez walks into the playroom at the Theiss Center carrying a tub of snow. Instantly, all play among the toddlers stops. Menendez, a developmental specialist at Pitt's Western Psychiatric Institute and Clinic, places the tub on the floor,and a chorus of oohs and ahs comes from the group as they feel the snow against their tiny palms.

Making the best of one of the winter's many blizzards, Menendez uses the snow as a tool to get a physical and mental reaction from the wide-eyed children, all of whom have problems with both speech and motor skills. As she motions them to grasp the snow, she encourages them to say "snow" and "cold." Playtime, like mealtime,is therapy in disguise. Encouraging the children to say these words helps to compensate for difficulties the children are having in learning to speak. Grasping the snow, like picking up the sausage, improves the use of hand muscles.

It's worth noting that these children's problems are not dramatic. Instead,the difficulties are more subtle. Ben, who is two, moves with a rigid stride as he runs across the floor. His twin sister, Jenny, has weak back muscles and has had trouble standing erect. Much of the play structured at Theiss, such as grasping the snow or pushing "infant-sized" go-carts across the floor, helps kids to work through these developmental problems.

Such therapy may be helpful, of course, but the child's future also depends on the parents moving away from drug abuse. Vaughn Stagg, a Pitt psychologist and the clinical administrator for the Theiss Center, says even after a child is born, a parent's addiction can contribute to poor development in that child. "Even if there is no biological damage to the child, many of the caretaker responsibilities may have been siphoned off by the substance abuse," he says. Sometimes, a parent under the influence of drugs cannot perform even simple acts of care, such as cuddling the newborn. Says Stagg, "You may have a parent who can't respond when the baby cries, who can't pick up and feed the kid." Children who are neglected may be late to learn to speak or walk.

Many of the women in PARK who are recovering from addictions also have some form of mental illness. Clinicians at the Theiss Center believe some mothers use a combination of barbiturates or "downers" to self-medicate for untreated mental health problems such as depression or schizophrenia. One goal of PARK is to help the mothers in the program better understand and manage problems with mental illness. The Theiss Center's comprehensive approach goes a long way to building successful families. In an era where single parents are raising children alone, the network of family members to pass on parenting tips may be absent. PARK fills that void with its parenting classes.

In a meeting room in the Theiss Center, Samantha, a single mother enrolled in PARK, agrees to discuss her experiences. Her voice is just above a whisper: "I used heroin, cocaine, and I used to drink." She now believes that abuse she suffered during childhood contributed to problems with depression that later led to drugs. Looking back, she says drugs offered only short periods of relief: "When I came down, my problems were still there."

The parenting skills Samantha picked up in Theiss Center classes have helped her care for her new daughter. "I don't have any other children," she says, "and when I first brought Lisa home from the hospital, I didn't know how to take care of a baby."

Mothers in the program learn coping skills, such as how to handle a temperamental two-year-old. They receive reassurance about their children's behavior. Some new mothers, for instance, were relieved to hear something as everyday as the fact that it is normal for a 10-month-old baby to pull at earrings. Samantha says, "If it wasn't for this place I would go crazy. It really helps me out a lot because I am taking care of her by myself."

The aftermath of drug use makes basic survival a challenge for mothers like Samantha and their children. PARK tries to bridge the gap between failure and success by offering many layers of help -- from breakfasts that are both nourishing and therapeutic to recreation that is fun and helps to improve motor skills. But there is a deeper aspect to PARK, one that goes beyond efforts to address physical problems such as poor diet or muscle weakness. The central aim of PARK and of the Theiss Center is to enable family members to offer one another the support they need. "We help mothers get over the hump," concludes Cohen. "Infants need a lot of holding, a lot of love, a lot of involvement. That is not some whimsical thing. That is important for physical and psychological well being."

Editor's note: The names of the clients of the Theiss Center have been changed to preserve confidentiality.

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