however these behavioral effects seem to be mild. Children exposed to cocaine in the first trimester are less sociable, more withdrawn, and show more anxious and depressed behaviors. Those exposed to higher doses of cocaine have been reported to show aggressive and disruptive behaviors. PCE girls are seven times more likely to have delinquent behavioral problems, but PCE boys are no more likely than other boys. Studies from the 2000s and 2010s are conflicted on whether PCE adolescents are at greater risk for use of drugs such as cocaine, alcohol, and marijuana. A 2010 study found that PCE adolescent girls were have anxiety than their non-exposed peers. Physical outcomes Slowed growth is well documented in fetuses, but it is not as clear whether older children remain smaller or catch up to their peers. Some studies show that growth remains slowed for as many as ten years. PCE may also interfere with the way the motor system matures. Motor effects that have been documented include poorer reflexes and quality of movement in infants. PCE may have an effect on the neuroendocrine system, but more study is needed to determine whether it does and what the effects are. A review of the literature reported that cocaine use causes congenital defects between 15 and 20% of the time; however another large-scale study found no difference in rates of birth anomalies in PCE and non-PCE infants. It has been suggested that some birth defects could be due to cocaine's disruption of blood vessel growth. Most PCE-related congenital defects are found in the brain, heart, genitourinary tract, arms and legs. Cocaine use by pregnant mothers may directly or indirectly contribute to defects in the formation of the circulatory system and is associated with abnormalities in development of the aorta. Heart malformations can include a missing ventricle and defects with the septum of the heart, and can result in potentially deadly congestive heart failure. Genital malformations occur at a higher-than-normal rate with PCE. The liver and lungs are also at higher risk for abnormalities. Cloverleaf skull, a congenital malformation in which the skull has three lobes, the brain is deformed, and hydrocephalus occurs, is also associated with PCE. Like birth defects, small head size, and stroke are risks in PCE. Epidemiology Of all cocaine users, women of childbearing age comprise 15–17%. An estimated 0.6 to 3% of pregnant women in the developed world use cocaine. A