Jittery babies, mistreated toddlers, strung-out mothers: Cheryll Jones' pediatric nursing practice is far from what it was when she started out 30 years ago - long before methamphetamine invaded this riverside Corn Belt town.
"If anybody told me my primary caseload would be kids exposed to illicit drugs, I'd have said they were crazy," said Jones, who now runs a local task force helping the most helpless victims of the nation's meth epidemic - small children whose parents make and use the highly addictive drug.
The scars are inflicted in myriad ways: Exposure to the drug in the womb, contamination from toxic chemicals used in home-based meth manufacture, explosions and fires, long-term neglect from parents obsessed with their drug habits, physical abuse and sexual abuse. Many of the meth-lab homes are filthy, often strewn with drug paraphernalia and pornography; meth-making chemicals have been found in diaper bags and toy chests.
"I've been in homes where you'd find jars of meth oil in the refrigerator, but no milk, no bread for the kids," said Marvin Van Haaften, a former country sheriff who is now Iowa's drug policy coordinator.
The meth epidemic took root on the West Coast, and is now worsening in many big cities nationwide. But nowhere is its heartbreaking toll on young children more evident than in the towns and small cities of America's heartland - notably Iowa, Missouri, Tennessee, Arkansas, Oklahoma, Kentucky and Indiana.
Nationally, authorities have dismantled more than 50,000 clandestine meth labs since 2001, including some 4,000 in Iowa. Roughly 30 percent were "mom and pop" labs in homes where children live.
Thousands of children across the country have been taken away from their meth-abusing parents in recent years, placed with relatives or shifted into already overloaded foster care systems. Scores have been injured, a dozen or more killed; thousands have been born with traces of meth in their bodies.
Dr. Rizwan Shah, a pediatrician at Blank Children's Hospital in Des Moines, encountered her first meth-exposed child in 1993 and has studied more than 500 of them since, becoming a respected expert on the phenomenon.
She stresses that the prognosis for meth-exposed kids varies widely, and strives to prevent them from being stereotyped. Some suffer serious brain damage and others experience long-lasting development problems, while many will grow into adults without serious health consequences, she said.
But what's beyond doubt, Shah says, is that pregnant women using meth are harming their babies.
"The brain gets hijacked by the drug," she said, describing patterns of overstimulation and disrupted sleep cycles among infants, as well as hyperactivity and attention-deficit disorder among meth-exposed school children.
One 2-year-old boy Shah treats must be fed through a tube to his stomach because meth exposure left him unable to swallow properly.
The mothers Shah meets often evoke meth's powerful lure - an initial burst of energy, a sudden and welcome ability to lose weight.
"Some of these women are trying to be good mothers," she added. "But when you're high on meth, you don't take of yourself or your family. The older kids are parenting the younger ones and also parenting the parent. They lose their childhood to become caretakers."
Ottumwa, a meatpacking and slaughterhouse town of 25,000 in southeast Iowa, has become a focal point of the state's efforts to aid meth-affected children, both because of the steady caseload at Cheryll Jones' clinic and because it is home to the country's first Moms Off Meth group - a self-help program for mothers trying to confront their addiction and reorder their lives.
Sue Armstrong's children were ages 9, 4 and 3 when she started heavy meth use seven years ago.
"It made me feel able to do everything," she said. "Then it stopped working, but I kept using it to cover up the shame I felt."
Armstrong's children were placed with relatives for 18 months. Now she has them back after kicking her habit and getting a job at a battered women's shelter.
Kris Salisbury, another Moms Off Meth participant, had a 2-year-old daughter when she started using meth in 1986. She bore twins in 1988, but used meth 10 more years until police raided her home where she and her live-in boyfriend operated a meth lab.
"There I was, sometimes, thinking I was a wonderful parent because my oldest daughter would have hundreds of dollars I'd given her and could take the twins to the movies," Salisbury said.
The reality was less rosy. She recalled the boyfriend abusing her in the children's presence, grabbing her daughter by the hair, smashing the kids' games with a hammer.
"I was an awful parent," said Salisbury, now a substance abuse counselor.
Salisbury and Armstrong were luckier than the many meth-abusing parents who permanently lose custody of their children.
Iowa courts have handled scores of meth cases recently in which parental rights were terminated. In one case, a father was arrested and a brick of meth seized as authorities evacuated two dirty, lice-infested girls - aged 3 1/2 and 2 1/2 - who had not been potty trained and still drank from baby bottles.
Carol Gutchewsky, a regional supervisor of state social workers, said addict parents trying to keep their children sometimes run out of time - if a child's temporary relocation stretches past 22 months, the state is obligated by federal regulations to seek termination of parental rights.
"It takes a long time to beat meth," Gutchewsky said. "While parents are going through the treatment process, and maybe having a relapse, the clock is ticking. The best interests of the child may be on a collision course with the parents' treatment."
The coordinator of Iowa's year-old Drug Endangered Children program, assistant attorney general Mary Chavez, empathizes with parents in such predicaments and hopes politicians provide funds to expand and improve treatment programs.
"But we want to keep the focus on the children," Chavez said. "You'll find that no matter how horrendous their lifestyle, no matter how neglectful they are, parents always think their kids are best off with them. We have solid findings otherwise."
Under Iowa's current policies, the Department of Human Services has some discretion as to removing meth-exposed children from home or giving addicted parents a chance to kick the habit.
The number of meth-affected kids in the United States is difficult to calculate; experts say it is many thousands per year.
In Iowa, 5,887 children since 2001 have figured in abuse cases that directly involve illegal drugs, mostly meth - either traces of drugs were found in their bodies or they were present while their parents manufactured meth. But that figure does not cover a range of other cases in which the abuse was classified as neglect, even though the parents' conduct stemmed from meth use.
An ominous barometer was provided by Gutchewsky, who calculated that meth played a role in roughly half the serious child-abuse cases in her 16-county region - 720 of 1,469 active, long-term cases. If that ratio applied statewide, Iowa would be experiencing more than 6,000 meth-related child abuse cases per year.
Iowa officials are blunt about the difficulties of properly caring for meth-exposed children and combating the underlying drug epidemic. An effective response requires coordinated action by law enforcement officers, hazardous-material cleanup crews, health and social service agencies, substance-abuse programs, the courts and legislature.
Yet the problem is growing at a time of tight budgets and perennial scarcity of foster homes. Many children are now taken in by grandparents who may lack the stamina and savvy to handle troubled youngsters.
Another thorny issue is whether Iowa should screen more newborn babies for drug exposure. Policies vary among hospitals; some test only a small fraction of newborns.
Several states have toughened sentences in cases where meth is manufactured in the presence of minors, but not all children are saved.
A 1-year-old Des Moines girl, Brooklyn Petithory, died from a bathtub accident suffered as her father was coming down from his meth high. A Riverside, Calif., mother received a life sentence because her infant son ingested meth from breast milk or tainted baby bottles.
Mary Chavez tries hard to be optimistic, insisting that - with proper resources - Iowa's meth-exposed children have bright futures. The alternative, she admits, is bleak.
"All they've been is neglected. All they've ever seen is the unacceptable," she said. "If we don't do something, they're going to be filling up Iowa's prisons in a few years."
By David Crary