Prenatal smoking and internalizing and externalizing problems in children studied from childhood to late adolescence

Social determinants of mental health: a Finnish nationwide follow-up study on mental disorders

BACKGROUND

Most mental disorders start in childhood and adolescence. Risk factors are prenatal and perinatal, genetic as well as environmental and family related. Research evidence is, however, insufficient to explain the life-course development of mental disorders. This study aims to provide evidence on factors affecting mental health in childhood and adolescence.

DATA AND METHODS

The 1987 Finnish Birth Cohort covers all children born in Finland in 1987 (N=59 476) who were followed up until the age of 21 years. The study covers detailed health, social welfare and sociodemographic data of the cohort members and their parents from Finnish registers.

RESULTS

Altogether, 7578 (12.7%) cohort members had had a diagnosed mental disorder. Several prenatal, perinatal and family-related risk factors for mental disorders were found, with sex differences. The main risk factors for mental disorders were having a young mother (OR 1.30 (1.16 to 1.47)), parents' divorce (OR 1.33 (1.26 to 1.41)), death of a parent (OR 1.27 (1.16 to 1.38)), parents' short education (OR 1.23(1.09 to 1.38)), childhood family receiving social assistance (OR 1.61 (1.52 to 1.71)) or having a parent treated at specialised psychiatric care (OR 1.47 (1.39 to 1.55)). Perinatal problem (OR 1.11 (1.01 to 1.22)) and prenatal smoking (OR 1.09 (1.02 to 1.16)) were risk factors for mental disorders, even after controlling for background factors. Elevated risk was seen if the cohort member had only basic education (OR 3.37 (3.14 to 3.62)) or had received social assistance (OR 2.45 (2.30 to 2.60)).

CONCLUSIONS

Mental disorders had many social risk factors which are interlinked. Although family difficulties increased the risk for mental disorders, they were clearly determined by the cohort member's low education and financial hardship. This study provides evidence for comprehensive preventative and supporting efforts. Families with social adversities and with parental mental health problems should be supported to secure children's development.

Questioning the causal link between maternal smoking during pregnancy and offspring use of psychotropic medication: a sibling design analysis

A recent population-based, longitudinal study from Finland observed a dose-response association between smoking during pregnancy (SDP) and use of psychotropic medications in exposed children and young adults. However, this association may be confounded by unmeasured familial characteristics related to both SDP and offspring mental health. Consequently, we aim to investigate the effect of SDP by means of a sibling design that to some extent allows controlling for unknown environmental and genetic confounders. Using the Swedish Medical Birth Register (1987–1993), which was linked to the Swedish Prescribed Drugs Register (July 2005–December 2008), we investigated 579,543 children and among them 39, 007 were discordant for use of psychotropic medication and 4,021 siblings discordant for both use of psychotropic medication and for smoking exposure. Replicating the Finnish study using traditional logistic regression methods we found an association between exposure to ≥10 cigarettes per day during pregnancy and psychotropic drug use (odds ratio = 1.61, 95% confidence interval 1.56, 1.66). Similar in size to the association reported from Finland (odds ratio = 1.63; 95% confidence interval 1.53, 1.74). However, in the adjusted sibling analysis using conditional logistic regression, the association was considerably reduced (odds ratio 1.22; 95% confidence interval 1.08, 1.38). Preventing smoking is of major public health importance. However, SDP per se appears to have less influence on offspring psychotropic drug use than previously suggested.

Trajectories of psychosocial problems in adolescents predicted by findings from early well-child assessments

PURPOSE

To describe trajectories of emotional and behavioral problems in adolescents and to identify early indicators of these trajectories using data from routine well-child assessments at ages 0-4 years.

METHODS

Data from three assessment waves of adolescents (n = 1,816) of the TRAILS were used (ages: 11-17 years). Information on early indicators (at ages 0-4 years) came from the records of the well-child services. Trajectories of emotional and behavioral problems were based on the parent-reported Child Behavior Checklist and the adolescent-reported Youth Self-Report, filled out at ages 11, 14, and 17 years. Multinomial logistic regression analysis was used to examine the predictive value of these early indicators on trajectories.

RESULTS

For boys and girls, we found four trajectories for each outcome: one with high problem levels, and three with middle-high, middle-low, and low levels. For emotional problems, the type of trajectory was predicted by parental educational level and parental divorce or single parents, for both genders. Moreover, sleep problems were predictive in boys and language problems in girls (odds ratios between 1.53 and 7.42). For behavioral problems, the type of trajectory was predicted by maternal smoking during pregnancy, parental educational level, and parental divorce or single parents, for both genders. Moreover, for boys, early behavioral problems and attention hyperactivity problems were predictive (odds ratios between 1.64 and 5.43).

CONCLUSIONS

Trajectories of emotional and behavioral problems during adolescence are rather stable and can be predicted by a parsimonious set of data from early well-child assessments.

Smoking during pregnancy and psychiatric disorders in preschoolers

The overall objective of this study was to determine whether smoking during pregnancy is related to psychiatric disorders in 4-year-olds while controlling for a wide range of potential confounding variables (i.e. parental anxiety, depression, personality disorders, drug abuse, and socio-economic characteristics). Parents of a community sample of 4-year-olds (N = 995) residing in the city of Trondheim, Norway were interviewed using the Preschool Age Psychiatric Assessment, which includes information on prenatal smoking. After adjusting for potential confounding variables using the propensity score, smoking during pregnancy was found to increase the odds for attention-deficit/hyperactivity disorder (ADHD) OR = 2.59 (CI 1.5-4.34, p < 0.001), oppositional defiant disorder (ODD) OR = 2.69 (CI 1.84-3.91, p = 0.02) and comorbid OR = 2.55 (CI 1.24-5.23, p < 0.001). Prenatal smoking during pregnancy is associated with an increased risk for symptoms of ADHD and ODD independently of each other, in 4-year-olds.

Prognosis and continuity of child mental health problems from preschool to primary school: results of a four-year longitudinal study

In a four-year longitudinal study, changes in and continuity of behavioral and emotional problems were examined in 814 subjects from kindergarten to primary school. Mental health problems were assessed by means of the Child Behavior Checklist (CBCL). The distribution of the CBCL broadband groups revealed a high level of continuity of internalizing symptoms over the four-year period and a shift from externalizing symptoms at baseline towards a combination of internalizing and externalizing symptoms at follow-up. The presence of mental health problems at follow-up was correlated with gender (higher amongst boys), pre-existing mental health problems at baseline, and separation or divorce of the parents, but not with single-family status or the age and educational level of the mother. The increasing number of children with a combination of internalizing and externalizing symptoms demonstrates the increasing complexity of child mental health problems in the developmental span from preschool age to school age.

Pathways to children's externalizing behavior: a three-generation study

In this study, based on Family Interactional Theory (FIT), the authors tested a longitudinal model of the intergenerational effects of the grandmothers' parent-child relationships and the grandparents' smoking on the grandchildren's externalizing behavior via parents' psychological symptoms, tobacco use, and child rearing. Using Mplus, the authors obtained a structural equation model that demonstrated generational associations from grandmothers (G1) to parents (G2) to their oldest children (G3) and thus was in accord with FIT. They identified a pathway from the grandmothers' parenting to the grandchildren's externalizing behavior via the parents' psychological symptoms, their smoking, and their child rearing. Parents' psychological symptoms in adolescence were associated with their tobacco use in their late twenties, controlling for the continuity of their psychological symptoms and their tobacco use. This 3-generational model adds to the literature on parent-child relationships (G1), smoking from adolescence to early adulthood (G2), and externalizing behavior in the G3 child.

Early mental health morbidity and later smoking at age 17 years

BACKGROUND

We examined the relationship between the onset and pattern of childhood mental health disorders and subsequent current smoking status at age 17 years.

METHOD

Data were from a prospective cohort study of 2868 births of which 1064 supplied information about their current smoking at 17 years of age. The association between the onset and pattern of clinically significant mental health disorders in the child and subsequent smoking at age 17 years was estimated via multivariable logistic regression.

RESULTS

Relative to 17 year olds who never had an externalizing disorder, 17-year-olds who had an externalizing disorder at age 5, 8 or 14 years were, respectively, 2.0 times [95% confidence interval (CI) 1.24-3.25], 1.9 (95% CI 1.00-3.65) or 3.9 times (95% CI 1.73-8.72) more likely to be a current smoker. Children with an ongoing pattern of externalizing disorder were 3.0 times (95% CI 1.89-4.84) more likely to be smokers at the age of 17 years and those whose mothers reported daily consumption of 6-10 cigarettes at 18 weeks' gestation were 2.5 times (OR 2.46, 95% CI 1.26-4.83) more likely to report smoking at 17 years of age. Associations with early anxiety and depression in the child were not found.

CONCLUSIONS

Current smoking in 17-year-olds may be underpinned by early emergent, and then, ongoing, externalizing disorder that commenced as young as age 5 years as well as exposure to early prenatal maternal smoking. The associations documented in adults and adolescents that link tobacco smoking and mental health are likely to be in play at these early points in development.

Exposure to environmental and lifestyle factors and attention-deficit / hyperactivity disorder in children — A review of epidemiological studies

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders in children. Although the mechanisms that lead to the development of ADHD remain unclear, genetic and environmental factors have been implicated. These include heavy metals and chemical exposures, nutritional and lifestyle/psychosocial factors. The aim of this review was to investigate the association between ADHD or ADHD-related symptoms and widespread environmental factors such as phthalates, bisphenol A (BPA), tobacco smoke, polycyclic aromatic hydrocarbons (PAHs), polyfluoroalkyl chemicals (PFCs) and alcohol. Medline, PubMed and Ebsco search was performed to identify the studies which analyze the association of prenatal and postnatal child exposure to environmental toxicants and lifestyle factors and ADHD or ADHD-related symptoms. The review is restricted to human studies published since 2000 in English in peer reviewed journals. Despite much research has been done on the association between environmental risk factors and ADHD or ADHD symptoms, results are not consistent. Most studies in this field, focused on exposure to tobacco smoke, found an association between that exposure and ADHD and ADHD symptoms. On the other hand, the impact of phthalates, BPA, PFCs, PAHs and alcohol is less frequently investigated and does not allow a firm conclusion regarding the association with the outcomes of interest.

A three-generational study of risk factors for childhood externalizing behavior among African Americans and Puerto Ricans

This is the first prospective study to examine the precursors of child externalizing behavior across three generations of African Americans and Puerto Ricans. Participants comprised a community cohort of male and female African Americans and Puerto Ricans (N = 366, X⁻ age = 29.4 years), who are part of an ongoing study of drug use and problem behaviors, and who had a child. Data were collected at four time waves, spanning the participants' adolescence to adulthood. Questionnaires were initially self-administered in schools in East Harlem, NY, USA (time 1). Subsequently, structured interviews were conducted by trained interviewers (times 2 and 3), and self-administered via mail (time 4). The independent variables consisted of the participants' prospective reports of their (a) relationships with their parents during adolescence, (b) depressive mood and drug use (adolescence to adulthood), (c) relationship with their oldest child between the ages of 6-13, and (d) perceptions of neighborhood crime and deterioration (in adulthood). The dependent variable was externalizing behavior in the participant's oldest child (X⁻ age = 9.6 years; SD = 2.0). Structural equation modeling showed that the parent-child relationship during participants' adolescence was linked with the participants' depressive mood and drug use which, in turn, were associated with the participants' relationship with their own child, as well as with neighborhood crime and deterioration when participants were adults. The participants' depressive mood, and relationship with their own child, as well as neighborhood crime and deterioration, each had a direct pathway to externalizing behavior in the participant's child. Findings suggest that intervention programs and public policy should address parental attributes, neighborhood factors, and, especially, parenting skills, to reduce risk factors for the intergenerational transmission of externalizing behavior.

Unpacking the association: Individual differences in the relation of prenatal exposure to cigarettes and disruptive behavior phenotypes

Prenatal exposure to cigarettes has been robustly associated with disruptive behavior in diverse samples and across developmental periods. In this paper we aim to elucidate exposure related behavioral phenotypes and developmental pathways by testing: (a) differential associations of exposure and four disruptive behavior dimensional phenotypes: Aggression, Noncompliance, Temper Loss and Low Concern for Others; and (b) moderation of these pathways including sex differences and moderation by parental responsive engagement. Participants were 211 teens and their parents from the East Boston Family Study (EBFS), an adolescent follow-up of a pregnancy cohort over-sampled for exposure. A best estimate serum cotinine corrected score was used to characterize exposure. In multivariate models controlling for parental antisocial behavior, family adversity and secondhand exposure, exposure uniquely predicted Aggression and Noncompliance. Paternal responsiveness moderated exposure effects on disruptive behavior. There were no sex differences in these patterns. Phenotypic findings suggest the possibility of specific neural mechanisms. In conjunction with prior research, protective effects of parental responsiveness occurring as late as adolescence point to the potential benefit of parenting-based prevention efforts to reduce risk to exposed offspring.

Prenatal smoking exposure and the risk of behavioral problems and substance use in adolescence: the TRAILS study

AIMS

To study the prospective relationship between maternal smoking during pregnancy (MSP) and behavioral problems, heavy alcohol use, daily smoking, and ever use of cannabis in the offspring, and to assess the role of confounding and mediating factors in a systematic way.

METHODS

Population-based cohort study of 2,230 respondents, starting in 2001 when respondents were around the age of 11 years, and two follow-up measurements at intervals of about 2.5 years (response rates of 96.0 and 81.4%).

RESULTS

Almost one third of the respondents' mothers had smoked tobacco during pregnancy. These respondents were at an increased risk for all outcomes except internalizing problems (significant odds ratios ranged from 1.40 to 2.97). The successive models showed that the potential confounding factors reduced the strength of all relationships. In the full model, the strongest relationship was found for mothers who smoked more than 10 cigarettes a day during pregnancy and daily smoking in early adolescence (odds ratio: 1.56), but none of the relationships were statistically significant.

CONCLUSIONS

MSP is a marker for future behavioral outcomes in the offspring, but reducing the prevalence of MSP is unlikely to make a meaningful contribution to the prevention of these problems in adolescents.

Early Health Risk Factors for Violence: Conceptualization, Review of the Evidence, and Implications

Violence and aggression are public health problems that can benefit from ongoing research into risk reduction and prevention. Current developmental theories of violence and aggression emphasize biological and psychosocial factors, particularly during adolescence. However, there has been less focus on understanding the interactive, multiplicative effects of these processes. Furthermore, little attention has been given to the pre-, peri-, and postnatal periods, where prevention and intervention may yield effective results. Early health risk factors that influence negative behavioral outcomes include prenatal and postnatal nutrition, tobacco use during pregnancy, maternal depression, birth complications, traumatic brain injury, lead exposure, and child abuse. There is an ample literature to suggest that these early health risk factors may increase the likelihood of childhood externalizing behaviors, aggression, juvenile delinquency, adult criminal behavior, and/or violence. This paper proposes an early health risk factors framework for violence prediction, built on existing developmental theories of criminal behavior and supported by empirical findings. This framework addresses gaps in the adolescent psychopathology literature and presents a novel conceptualization of behavioral disturbance that emphasizes the pre-, peri-, and post-natal periods, when a child's development is critical and the opportunity for behavioral and environmental modification is high. Implications for such a framework on violence prevention programs are discussed.

Association of clinical characteristics and cessation of tobacco, alcohol, and illicit drug use during pregnancy

Pregnancy is a time of relative urgency and opportunity for the treatment of substance use disorders in women, yet little is known about modifiable factors that contribute to successful abstinence. We examined self-worth, depression, anxiety, and novelty seeking in the context of substance use cessation during pregnancy in a sample of women with a high prevalence of substance abuse. Subjects were 448 birth mothers who participated in a prospective adoption study. Discontinuation rates were: tobacco 22.2%, alcohol 64.7%, marijuana 77.2%, and other drugs, 73.7-100%. Depression, anxiety, and novelty seeking were lower among women who discontinued substance use, compared to those who did not. Self-worth was higher in women who discontinued substance use. Among 110 polysubstance users, the number of substances discontinued during pregnancy was correlated with depression, anxiety, and self-worth in the hypothesized direction. Possible clinical implications are discussed. 

CYP1A1 modifies the effect of maternal exposure to environmental tobacco smoke on child behavior

INTRODUCTION

Maternal environmental tobacco smoke (ETS) has been identified as a key risk factor for problem behavior in children, but the role of genetic susceptibility is not clear. The purpose of this study was to examine the metabolic genetic modification effect of exposure to ETS in nonsmoking mothers on child behavior at 2 years of age.

METHODS

A prospective cohort study was conducted among 191 mothers who gave births between 2004 and 2005 and their infants in Taiwan. The mothers completed a questionnaire before delivery in which they provided information on exposure to ETS during pregnancy. Four metabolic genes, CYP1A1 MspI, CYP1A1 Ile462Val, GSTT1, and GSTM1 were isolated from both maternal and infant DNA samples. Children's behavior problems at 2 years of age were reported by their mothers using the Child Behavior Checklist/1.5-5. Multiple linear models were used to estimate the effects of ETS and genotype on child behavior.

RESULTS

Maternal ETS exposure was associated with the anxious score. The ETS-exposed group with both the CYP1A1 MspI and the CYP1A1 Ile462Val variants had higher scores, as reflected in total CBCL score as well as scores on the internalizing scale and its emotional subdomain, the anxious scale, and the externalizing scale and its aggressive subdomain.

CONCLUSIONS

Child behavioral problems may be associated with prenatal ETS exposure, and this effect may be modified by infant CYP1A1 MspI and CYP1A1 Ile462Val genes.

Early findings of preventive child healthcare professionals predict psychosocial problems in preadolescence: the TRAILS study

OBJECTIVE

To develop and validate a prediction model for psychosocial problems in preadolescence using data on early developmental factors from routine Preventive Child Healthcare (PCH).

STUDY DESIGN

The data come from the 1692 participants who take part in the TRacking Adolescents' Individual Lives Survey, a longitudinal study. Information on early developmental factors (ages 0 to 4 years) was collected from the PCH file. Parents complete the Child Behavior Checklist when their child is age 11. To examine the predictive value of PCH-registered developmental factors on preadolescent problems, several multiple logistic regression analysis were performed, in a derivation sample (n = 1058). The predictive performance of the models was then assessed with area under the curve (AUC) in a validation sample (n = 643) to evaluate the validity of these models.

RESULTS

PCH-registered behavioral problems, attention/hyperactivity problems, enuresis, education level of the father, and being male were found to significantly predict externalizing problems (odds ratios [OR] between 1.4 and 3.7). Internalizing problems were predicted by maternal smoking during pregnancy, sleep problems, and being male (ORs between 1.7 and 3.0). The model for externalizing problems had a modest discriminatory power (AUC 0.66, 95% confidence interval 0.59-0.72). However, for internalizing problems the AUC was 0.54 (95% confidence interval 0.47-0.60), indicating poor discriminatory power.

CONCLUSIONS

Findings on early development as registered by PCH are modestly predictive for externalizing problems in preadolescents, but only slightly for internalizing problems.

Is smoking during pregnancy a risk factor for psychopathology in young children? A methodological caveat and report on preschoolers

OBJECTIVE

While studies of the effects of prenatal smoking on child psychopathology have found positive relationships, most studies (1) failed to control for a range of correlates of maternal smoking that could affect children's behavior; (2) have been conducted with school-age rather than younger children, so it is not clear when such problems emerge; and (3) have not examined the effects on internalizing problems.

METHOD

This study examined the effects of prenatal smoke exposure on behaviors associated with externalizing and internalizing behavior problems and negative temperament in a diverse community sample of 679 4-year-olds.

RESULTS

After controlling for correlates that include socioeconomic status, life stress, family conflict, maternal depression, maternal scaffolding skills, mother-child attachment, child negative affect and effortful control, smoking during pregnancy was no longer associated with child behavior or emotional problems.

CONCLUSIONS

Future studies need to control for a wide range of covariates of maternal smoking.

Fetal origins of mental health: evidence and mechanisms

The concept of fetal programming states that changes in the fetal environment during sensitive periods of organ development may cause long-lasting changes in the structure and functioning of these organs later in life and influence the risk for chronic diseases such as coronary heart disease and type 2 diabetes. Fetal growth is a summary marker of the fetal environment and is reflected by relatively easy-to-obtain measures of size at birth such as birth weight. In the last two decades, a body of evidence emerged linking fetal growth with behavioural and mental health outcomes later in life. Cognitive functioning and behavioural problems in childhood, in particular inattention/hyperactivity, have been shown to be inversely related to fetal growth. Although results are mixed, risk for personality disorders and schizophrenia seems to be linked with fetal growth and adversity, while the evidence for mood disorders is weak. Vulnerability for psychopathology may also be influenced by prenatal adversity. There is evidence for associations of fetal growth with temperament in childhood as well as stress reactivity and distress. The associations of fetal growth with mental health later in life are potentially caused by specific prenatal factors such as maternal smoking, alcohol, toxins/drugs, nutrition, psychosocial stress and infection during pregnancy. The mechanisms likely involve changes in neurodevelopment and in the set point of neuroendocrine systems, and there is evidence that prenatal adversity interacts with genetic and postnatal environmental factors. Future studies should examine the effects of specific prenatal factors and attempt to disentangle genetic and prenatal environmental effects.