Negative emotionality and cortisol during adolescent pregnancy and its effects on infant health and autonomic nervous system reactivity

Prenatal paternal stress predicts infant parasympathetic functioning above and beyond maternal prenatal stress

BACKGROUND

Paternal stress is often assessed by maternal report and is posited to influence infant development indirectly by contributing to a mother's stress and experiences during pregnancy. Far less is known about how direct effects of prenatal paternal stress, as described by fathers themselves, are related to an infant's physiological functioning. We assessed fathers' own experiences of stress and examined its direct impact on infant respiratory sinus arrhythmia (RSA), a biological index of self-regulation, at seven-month postpartum.

METHOD

During the third trimester of pregnancy, the UCLA Life Stress Interview was conducted to assess chronic stress in mothers and fathers (N = 90). Infant baseline RSA and RSA reactivity in response to the Still-Face paradigm were assessed at seven-month postpartum.

RESULTS

Infants of fathers with high prenatal stress showed lower baseline RSA, possibly reflective of poor infant psychophysiological regulation. The predictive role of paternal stress remained significant after controlling for maternal stress.

CONCLUSIONS

Our findings provide emerging empirical evidence to support the influence of prenatal paternal stress on infant RSA, highlighting the important role of fathers for child development.

Cortisol levels versus self-report stress measures during pregnancy as predictors of adverse infant outcomes: a systematic review

Systematically review existing evidence to (1) identify the association between self-report stress and cortisol levels measured during pregnancy; and, (2) assess their association with adverse infant outcomes to determine which is the better predictor. A systematic review was conducted in accordance with PRISMA guidelines. Search terms focused on pregnancy, psychological stress and cortisol. Nine electronic databases were searched, in addition to reference lists of relevant papers. Eligibility criteria consisted of studies that included measurement of self-reported psychological stress, cortisol and assessed their associations with any infant-related outcome. Further limits included studies published in English or Spanish with human female participants. A meta-regression was not feasible due to differences in study samples, measurement tools employed, types of cortisol assessed and outcomes reported. A narrative synthesis was provided. 28 studies were eligible for inclusion. Convergent validity between self-report measures and cortisol was reported by three studies (range r = 0.12-0.41). Higher levels of self-report stress were significantly associated with intrauterine growth restriction (fetal biparietal diameter, low fetal head circumference, abdominal circumference), low gestational age at birth, low anthropometric measures (birth length, head circumference, length of the neonate), poor infant neurodevelopment (cognitive development) and potentially pathogenic gut microbiota (Clostridiaceae Clostridium, Haemophilus) in six studies. Higher cortisol levels were significantly associated with intrauterine growth restriction (fetal biparietal diameter, low fetal head circumference, abdominal circumference), low gestational age at birth, low infant birth weight, poor infant neurodevelopment (attention scores on the Network Neurobehavioral Scale) and low levels of potentially protective gut microbiota (Lactobacillus, Slackia and Actinobaculum) in 13 studies. Of the studies that assessed which type of measure was a better predictor of infant outcomes (n = 6), there was agreement that cortisol levels were statistically better at predicting adverse outcomes than self-reported stress. Self-report stress measures appear to be modest predictors of adverse infant outcomes in comparison to cortisol. A number of methodological limitations need to be addressed in future studies to help understand the relationship between cortisol and self-reported stress and how they are related to adverse infant outcomes.

Sex-Specific Effects of Stress on Respiratory Control: Plasticity, Adaptation, and Dysfunction

As our understanding of respiratory control evolves, we appreciate how the basic neurobiological principles of plasticity discovered in other systems shape the development and function of the respiratory control system. While breathing is a robust homeostatic function, there is growing evidence that stress disrupts respiratory control in ways that predispose to disease. Neonatal stress (in the form of maternal separation) affects "classical" respiratory control structures such as the peripheral O₂ sensors (carotid bodies) and the medulla (e.g., nucleus of the solitary tract). Furthermore, early life stress disrupts the paraventricular nucleus of the hypothalamus (PVH), a structure that has emerged as a primary determinant of the intensity of the ventilatory response to hypoxia. Although underestimated, the PVH's influence on respiratory function is a logical extension of the hypothalamic control of metabolic demand and supply. In this article, we review the functional and anatomical links between the stress neuroendocrine axis and the medullary network regulating breathing. We then present the persistent and sex-specific effects of neonatal stress on respiratory control in adult rats. The similarities between the respiratory phenotype of stressed rats and clinical manifestations of respiratory control disorders such as sleep-disordered breathing and panic attacks are remarkable. These observations are in line with the scientific consensus that the origins of adult disease are often found among developmental and biological disruptions occurring during early life. These observations bring a different perspective on the structural hierarchy of respiratory homeostasis and point to new directions in our understanding of the etiology of respiratory control disorders. © 2021 American Physiological Society. Compr Physiol 11:1-38, 2021.

Exposures influencing the developing central autonomic nervous system

Autonomic nervous system function is critical for transition from in-utero to ex-utero life and is associated with neurodevelopmental and neuropsychiatric outcomes later in life. Adverse prenatal and neonatal conditions and exposures can impair or alter ANS development and, as a result, may also impact long-term neurodevelopmental outcomes. The objective of this article is to provide a broad overview of the impact of factors that are known to influence autonomic development during the fetal and early neonatal period, including maternal mood and stress during and after pregnancy, fetal growth restriction, congenital heart disease, toxic exposures, and preterm birth. We touch briefly on the typical development of the ANS, then delve into both in-utero and ex-utero maternal and fetal factors that may impact developmental trajectory of the ANS and, thus, have implications in transition and in long-term developmental outcomes. While many types of exposures and conditions have been shown to impact development of the autonomic nervous system, there is still much to be learned about the mechanisms underlying these influences. In the future, more advanced neuromonitoring tools will be required to better understand autonomic development and its influence on long-term neurodevelopmental and neuropsychological function, especially during the fetal period.

Culture and stress biology in immigrant youth from the prenatal period to adolescence: A systematic review

Immigration patterns over the last two decades have changed the demographic composition of the United States; children are growing up in an increasingly multicultural environment. Immigrant youth may face culture-related stressors and leverage culture-related strengths across development that may influence their mental and physical health. Responses to early life stressors may differ across children at the level of stress biology, which can affect how they handle cultural challenges. However, there is limited research on culture and stress biology, which may be a mediator or moderator of culture's effects on immigrant youth. The aim of the present article is to systematically review research that examines the roles of both culture and stress biology from the prenatal period to adolescence in immigrant youth. Specifically, we review articles that examine how stress-sensitive biological systems (hypothalamic pituitary adrenal axis and the autonomic nervous system) and culture-related constructs have been modeled together in immigrant youth. Based on these findings, we note remaining questions and recommendations for future research in integrating measures of cultural processes and stress biology in children.

Maternal Pregnancy Diet Quality Is Directly Associated with Autonomic Nervous System Function in 6-Month-Old Offspring

BACKGROUND

Many pregnant women are consuming diets of poor overall quality. Although many studies have linked poor prenatal diet quality to an increased risk of specific diseases in offspring, it is not known if exposure to poor prenatal diet affects core neurophysiological regulatory systems in offspring known to lie upstream of multiple diseases.

OBJECTIVE

We aimed to examine the association between prenatal diet quality and autonomic nervous system (ANS) function in infants at 6 mo of age.

METHODS

Data from 400 women (aged >18 y, with uncomplicated pregnancies) and their infants participating in the Maternal-Infant Research on Environmental Chemicals-Infant Development cohort were used to investigate links between prenatal diet quality and infant ANS function at 6 mo of age. Prenatal diet quality was assessed using the Healthy Eating Index (2010), calculated from a validated FFQ completed by women during the first trimester. Infant ANS function was measured using 2 assessments of heart rate variability (HRV) including root mean square of successive differences (RMSSD) and SD of N-N intervals (SDNN). Associations were analyzed before and after adjustment for socioeconomic status, maternal depression symptoms, maternal cardiometabolic dysfunction, breastfeeding, and prenatal smoking.

RESULTS

Poorer prenatal diet quality was associated with lower infant HRV assessed using RMSSD (B: 0.07; 95% CI: 0.01, 0.13; R2 = 0.013) and SDNN (B: 0.18; 95% CI: 0.02, 0.35; R2 = 0.011). These associations remained significant after adjustment for confounding variables [RMSSD: B: 0.09; 95% CI: 0.003, 0.18; squared semipartial correlation (sp2) = 0.14 and SDNN B: 0.24; 95% CI: 0.0, 0.49; sp2 = 0.13].

CONCLUSIONS

In a large cohort study, poorer prenatal diet quality was associated with lower offspring HRV, a marker of decreased capacity of the ANS to respond adaptively to challenge. Therefore, poor prenatal diet may play a significant role in the programming of multiple organ systems and could increase general susceptibility to disease in offspring.

Stress during pregnancy affected neonatal outcomes and changed cortisol and leptin levels both in mothers and newborns

BACKGROUND

The present study aimed to determine the effect of perceived stress during pregnancy on neonatal outcomes and cortisol and leptin levels in mothers and their newborns.

METHODS

This longitudinal study was carried out on 110 pregnant women in Miandoab city, Iran. Mothers, who had singleton pregnancies and gestational age of 24 to 28 weeks, were included in the study. The participants were asked to fill out Cohen's Perceived Stress Scale (PSS). The mothers were then tracked in gestational ages of 28-32 weeks, 32-36 weeks, and the time of delivery. The maternal and umbilical cord blood samples were obtained during labor in order to measure leptin and cortisol levels.

RESULTS

Umbilical cortisol level was significantly higher in newborns who had meconium stained amniotic fluid than those who did not. Maternal blood leptin levels at delivery were significantly higher in the mothers whose neonates had respiratory distress, low birth weight, low head circumference, low Apgar score, and were premature than those whose neonates did not have such problems. The level of leptin in umbilical cord blood was significantly higher in neonates who had respiratory distress than those who did not. The results also showed a significant correlation between maternal cortisol levels and PSS during weeks 24-28 and the entire pregnancy. A significant relationship was observed between umbilical leptin and maternal leptin levels.

CONCLUSIONS

It can be concluded that stress during pregnancy is accompanied by fetal distress. The probable reason for newborns distress may be related to increased maternal leptin levels.

Effects of pre- and postnatal maternal stress on infant temperament and autonomic nervous system reactivity and regulation in a diverse, low-income population

We examined the prospective associations of objective and subjective measures of stress during pregnancy with infant stress reactivity and regulation, an early-life predictor of psychopathology. In a racially and ethnically diverse low-income sample of 151 mother-infant dyads, maternal reports of stressful life events (SLE) and perceived stress (PS) were collected serially over gestation and the early postpartum period. Infant reactivity and regulation at 6 months of age was assessed via maternal report of temperament (negativity, surgency, and regulation) and infant parasympathetic nervous system physiology (respiratory sinus arrhythmia [RSA]) during the Still Face Paradigm. Regression models predicting infant temperament showed higher maternal prenatal PS predicted lower surgency and self-regulation but not negativity. Regression models predicting infant physiology showed higher numbers of SLE during gestation predicted greater RSA reactivity and weaker recovery. Tests of interactions revealed SLE predicted RSA reactivity only at moderate to high levels of PS. Thus, findings suggest objective and subjective measures of maternal prenatal stress uniquely predict infant behavior and physiology, adjusting for key pre- and postnatal covariates, and advance the limited evidence for such prenatal programming within high-risk populations. Assessing multiple levels of maternal stress and offspring stress reactivity and regulation provides a richer picture of intergenerational transmission of adversity.

Salutary effects of an attention bias modification mobile application on biobehavioral measures of stress and anxiety during pregnancy

Stress and anxiety during pregnancy are associated with a range of adverse health outcomes, but there is an unmet need for low-barrier treatments that target stress and anxiety. One such treatment approach, attention bias modification training (ABMT), targets the anxiety-related threat bias, a disruption in attention to and neural processing of threat-related information. It remains unclear, however, whether reducing treatment barriers via mobile delivery of ABMT is effective and whether ABMT efficacy varies depending on individual differences in neural processing of threat. The present study tested whether mobile, gamified ABMT reduced prenatal threat bias, anxiety and stress, and whether ABMT efficacy varied with individual differences in neural responses to threat. Participants were 29 women in their 19th-29th week of pregnancy, randomized to four weeks of an ABMT or placebo training (PT) version of the mobile app using a double-blind design. Self-report of anxiety, depression, and stress were obtained; salivary cortisol was collected at home and in lab in response to stressors to index biological stress reactivity. Threat bias was measured using a computerized attention assay during which EEG was recorded to generate event-related potentials (ERPs) to threat cues. Results showed lower levels of lab cortisol following ABMT versus PT. Although the main effect of ABMT on subjective anxiety was not significant, the magnitude of cortisol reduction was correlated with lower levels of subjective anxiety and threat bias. Those receiving ABMT also reported less anxiety when showing smaller ERPs to threat (P1, P2) prior to training, but, conversely reported more anxiety when showing larger ERPs to threat. Use of gamified, mobile ABMT reduced biobehavioral indices of prenatal stress and anxiety, but effects on anxiety varied with individual differences in cortisol response and neurocognitive indices of early attention to threat.

Prediction of Postpartum Social Support and Symptoms of Depression in Pregnant Adolescents: A Pilot Study

Many pregnant adolescents remain in school, creating unique challenges for professionals to meet their educational and health needs. In this descriptive pilot study of pregnant adolescents ( n = 26), 68% demonstrated symptoms of depression as measured by the Center for Epidemiologic Studies Depression Scale (CES-D). In addition, there was an expectation by the pregnant adolescent that postpartum social support received, as measured by the Postpartum Support Questionnaire, would be different from what is important to her. As an important part of the team, school nurses are uniquely positioned to screen pregnant adolescents for depression and to assist them in learning how to negotiate for the social support that is important to them.

Worries About Labor and Birth: A Population-Based Study of Outcomes for Young Primiparous Women

BACKGROUND

Pregnancy at a young age is a continuing public health concern strongly associated with socioeconomic deprivation, social isolation, and stigma. The objectives were to see whether, compared with women aged 21 or more, women aged 20 years or younger worried more about labor and birth, and had poorer maternal outcomes. Another objective was to investigate the extent to which worries about labor and birth mediated the associations between young age and outcomes.

METHODS

A secondary analysis of data was conducted relating to 2,598 primiparous women's experience of maternity care in England in 2010. The survey collected data on care in the antenatal, intrapartum, and postnatal periods, and sociodemographic factors. A validated checklist measured worries about labor and birth.

RESULTS

Compared with women aged 21 or more, women aged 20 years or younger worried more about labor and birth. The pain and duration of labor worried all women and those aged 20 years or younger were particularly worried about the uncertainty of labor onset, cesarean section birth, and about embarrassment. In logistic regression, after adjusting for potential confounders, young age was a significant independent risk factor for worries about pain and distress in labor, and self-reported depression at 1 and 3 months. However, young age was also significantly associated with having a normal vaginal delivery.

CONCLUSIONS

It may be appropriate to focus support on women experiencing multiple disadvantage, rather than young age alone.

Cross-generational influences on childhood anxiety disorders: pathways and mechanisms

Anxiety disorders are common across the lifespan, cause severe distress and impairment, and usually have their onset in childhood. Substantial clinical and epidemiological research has demonstrated the existence of links between anxiety and its disorders in children and parents. Research on the pathways and mechanisms underlying these links has pointed to both behavioral and biological systems. This review synthesizes and summarizes several major aspects of this research. Behavioral systems include vicarious learning, social referencing, and modeling of parental anxiety; overly protective or critical parenting styles; and aspects of parental responses to child anxiety including family accommodation of the child's symptoms. Biological systems include aspects of the prenatal environment affected by maternal anxiety, development and functioning of the oxytocinergic system, and genetic and epigenetic transmission. Implications for the prevention and treatment of child anxiety disorders are discussed, including the potential to enhance child anxiety treatment outcomes through biologically informed parent-based interventions.

Prenatal depression and adverse birth outcomes: an updated systematic review

Complications related to preterm birth (PTB) and low birth weight (LBW) are leading causes of infant morbidity and mortality. Prenatal depression is a hypothesized psychosocial risk factor for both birth outcomes. The purpose of this systematic review was to examine evidence published between 1977 and 2013 on prenatal depression and risks of these primary adverse birth outcomes. A systematic search of the PUBMED and PsycINFO databases was conducted to identify studies testing the associations between prenatal depressive symptoms, or diagnoses of depression, and risk of PTB or LBW. We systematically selected 50 published reports on PTB and length of gestation, and 33 reports on LBW and BW. Results were reviewed by two independent reviewers and we evaluated the quality of the evidence with an established systematic review method, the Newcastle Ottawa Scale. We then undertook a narrative synthesis of the results following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Less than a quarter of 50 published reports found that prenatal depression was significantly associated with PTB or gestational age. In contrast, slightly more than half of the 33 reports found that prenatal depression was associated with LBW or BW. When weighing methodological features, we determined that the effects of prenatal depression on LBW are more consistent than effects on length of gestation or PTB. Although the evidence may not be strong enough to support routine depression screening for risk of adverse outcomes, screening to enable detection and timely treatment to reduce risk of postpartum depression is warranted. Further rigorous research on prenatal depression and adverse birth outcomes is needed.

Pregnancy distress gets under fetal skin: Maternal ambulatory assessment & sex differences in prenatal development

Prenatal maternal distress is associated with an at-risk developmental profile, yet there is little fetal evidence of this putative in utero process. Moreover, the biological transmission for these maternal effects remains uncertain. In a study of n = 125 pregnant adolescents (ages 14-19), ambulatory assessments of daily negative mood (anger, frustration, irritation, stress), physical activity, blood pressure, heart rate (every 30 min over 24 hr), and salivary cortisol (six samples) were collected at 13-16, 24-27, 34-37 gestational weeks. Corticotropin-releasing hormone, C-reactive protein, and interleukin 6 from blood draws and 20 min assessments of fetal heart rate (FHR) and movement were acquired at the latter two sessions. On average, fetuses showed development in the expected direction (decrease in FHR, increase in SD of FHR and in the correlation of movement and FHR ("coupling")). Maternal distress characteristics were associated with variations in the level and trajectory of fetal measures, and results often differed by sex. For males, greater maternal 1st and 2nd session negative mood and 2nd session physical activity were associated with lower overall FHR (p < .01), while 1st session cortisol was associated with a smaller increase in coupling (p < .01), and overall higher levels (p = .05)-findings suggesting accelerated development. For females, negative mood, cortisol, and diastolic blood pressure were associated with indications of relatively less advanced and accelerated outcomes. There were no associations between negative mood and biological variables. These data indicate that maternal psychobiological status influences fetal development, with females possibly more variously responsive to different exposures.

Pregnancy anxiety: A systematic review of current scales

BACKGROUND

Depression in pregnancy is a serious health issue; however, anxiety in pregnancy, with a reported higher prevalence, may also be a serious issue. Anxiety symptoms in pregnancy can relate to several anxiety types, such as general anxiety, anxiety disorders, and pregnancy-related anxiety (PrA), anxiety characterised by pregnancy specific fears and worries. Awareness of these distinctions however, is not always widespread. Both general anxiety and PrA are associated with maternal negative outcomes (e.g. increased nausea) however; PrA is more often associated with negative outcomes for the child (e.g. preterm birth). Furthermore, PrA is potentially a risk factor for postnatal depression with assessment of PrA potentially affording important intervention opportunities. Currently several different instruments are used for PrA however their psychometric properties are unclear. To our knowledge a review of current instruments and their psychometric properties is lacking, this paper aims to fill that gap.

METHODS

Studies, which assessed PrA, published between 1983 and 2013 in peer-reviewed journals, were identified.

RESULTS

Sixty studies were identified after applying inclusion/exclusion criteria, and classified as: pregnancy-related anxiety specific, scales for other constructs, sub scales of another instrument and general anxiety scales. Each scale's strengths and limitations were discussed.

LIMITATIONS

Our findings may be limited by restricting our review to peer-reviewed journals. This was done however as we sought to identify scales with good psychometric properties.

CONCLUSIONS

Currently no scales are available for pregnancy-related anxiety with sound theoretical and psychometric properties. Clinically the need for such a scale is highlighted by the potential intervention opportunities this may afford. Future research should be directed towards the development of such a scale.

Maternal cortisol during pregnancy is related to infant cardiac vagal control

BACKGROUND

Prenatal exposure to maternal psychological distress and glucocorticoids result in neurobiological adaptations within the fetus that increase risk for developing exaggerated emotional, behavioral, and stress responses to novelty and challenges in childhood. The current study investigated the influence of maternal depressed mood and cortisol during pregnancy on infant cardiac vagal control (CVC) to standardized laboratory challenge tasks.

METHODS

The sample comprised 194 women and their infants. Maternal reports of depressed mood and salivary cortisol were assessed at 14 and 32 weeks gestational age. Linear regression was used to examine associations between maternal measures during early and late pregnancy, and infant CVC indexed via respiratory sinus arrhythmia (RSA) at rest and in response to laboratory tasks designed to elicit frustration when infants were 6 months of age. It was hypothesized that maternal depressed mood and cortisol would be associated with lower basal RSA and smaller decreases in RSA from baseline to challenge.

RESULTS

A significant decrease in infant RSA from baseline to frustration tasks indicated that laboratory tasks elicited a reliable decrease in RSA from baseline to frustration among infants which is characterized by reduction in vagal efferent activity on the heart in response to challenge. Higher maternal cortisol, but not depressed mood, was associated with lower basal RSA and greater decrease in RSA from baseline to frustration. Associations between maternal cortisol and infant basal RSA were observed for both early and late pregnancy whereas the associations between prenatal cortisol and decrease in RSA from baseline to frustration were observed for early, but not late, pregnancy.

CONCLUSIONS

Maternal cortisol during pregnancy was associated with infant CVC at 6-months of age. Such influences may have enduring impacts on the child and important implications for the development of physical and mental health outcomes.

Effect of maternal job strain during pregnancy on infant neurodevelopment by gender at 6 and 12 months: Mothers and Children's Environmental Health (MOCEH) study

OBJECTIVES

Limited evidence is available regarding the association between prenatal job strain and infant neurodevelopment. Most studies used stress indicators other than job strain to explain the relationship between prenatal maternal stress and child development. The objective of this study was to investigate the association between maternal job strain during pregnancy and neurodevelopment in infancy.

METHODS

Mothers and Children's Environmental Health (MOCEH) study, an on-going prospective birth cohort study, has been conducted in South Korea since 2006. Job strain during pregnancy was measured using Korean version of Job Content Questionnaire (JCQ). Infant neurodevelopment was assessed using Korean Bayley Scale of Infant Development II (K-BSID-II) at 6 and 12 months of age. A total of 343 mother-child pairs that completed JCQ and K-BSID-II more than once were included. Mental Developmental Index (MDI) and Psychomotor Developmental Index (PDI) defined in the K-BSID-II were used as outcome variables.

RESULTS

Compared to infants from mothers with low job strain, significant (p < 0.05) decreases in PDI were found in infants from mothers with active and passive job at 6 months of age. After stratification by infant sex, boys in the high strain group had a lower MDI score than boys in the low job strain group at 12 months. On the other hand, girls in the high strain and active groups had higher MDI scores than girls in the low job strain group at 12 months. PDI at 12 months also showed different results by sex. Boys in the high strain and passive job groups had lower PDI scores than boys in the low job strain group. However, such difference was not observed in girls.

CONCLUSIONS

The findings of this study suggest that prenatal job strain affects infant neurodevelopment in a gender-dependent manner.

Selection and the marriage premium for infant health

Previous research has found a positive relationship between marriage and infant health, but it is unclear whether this relationship is causal or a reflection of positive selection into marriage. We use multiple empirical approaches to address this issue. First, using a technique developed by Gelbach (2009) to determine the relative importance of observable characteristics, we show how selection into marriage has changed over time. Second, we construct a matched sample of children born to the same mother and apply panel data techniques to account for time-invariant unobserved characteristics. We find evidence of a sizable marriage premium. However, this premium fell by more than 40 % between 1989 and 2004, largely as a result of declining selection into marriage by race. Accounting for selection reduces ordinary least squares estimates of the marriage premiums for birth weight, prematurity, and infant mortality by at least one-half.

Effects of an early intervention on perceived stress and diurnal cortisol in pregnant women with elevated stress, anxiety, and depressive symptomatology

The goal of the present investigation was to examine effects of a cognitive-behavioral group intervention for pregnant women with subclinically elevated stress, anxiety and/or depression on perceived stress and salivary cortisol levels. Expectant mothers were recruited in gynaecologist practices. They participated in a screening, a standardized diagnostic interview (Munich-Composite Diagnostic Interview, M-CIDI), and were randomly assigned to an intervention (N = 21) and treatment as usual control group (N = 40). The intervention consisted of a manualized cognitive-behavioral group program for expectant mothers with subclinically elevated stress, depression, and/or anxiety symptoms. Stress questionnaire (prenatal distress (PDQ), perceived stress (PSS)) as well as diurnal salivary cortisol assessment took place at T1 (antenatal, preintervention), at T2 (antenatal, post-intervention) and T3 (3-month postpartum). Subjects that participated in the intervention exhibited a significant post-treatment change in morning cortisol (cortisol awakening response, CAR) in contrast to control subjects, F(8,51) = 2.300, p = 0.047. Intervention participants showed a smaller CAR subsequent to the intervention, displaying a lessened stress reaction. This effect was not observed in the control group. In contrast, we failed in discovering a significant difference between the research groups regarding the cortisol area under curve parameter (AUC) and the applied subjective stress questionnaires. Evaluation results were thus heterogeneous. Nevertheless, intervention effects on the CAR are promising. Our results suggest that a cognitive-behavioral intervention might lead to an improvement in the biological stress response of pregnant women with subclinically elevated stress, anxiety, or depressive symptoms.

Stress, glucocorticoids and liquorice in human pregnancy: programmers of the offspring brain

A suboptimal prenatal environment may induce permanent changes in cells, organs and physiology that alter social, emotional and cognitive functioning, and increase the risk of cardiometabolic and mental disorders in subsequent life ("developmental programming"). Although animal studies have provided a wealth of data on programming and its mechanisms, including on the role of stress and its glucocorticoid mediators, empirical evidence of these mechanisms in humans is still scanty. We review the existing human evidence on the effects of prenatal maternal stress, anxiety and depression, glucocorticoids and intake of liquorice (which inhibits the placental barrier to maternal glucocorticoids) on offspring developmental outcomes including, for instance, alterations in psychophysiological and neurocognitive functioning and mental health. This work lays the foundations for biomarker discovery and affords opportunities for prevention and interventions to ameliorate adverse outcomes in humans.

Impact of a prenatal cognitive-behavioral stress management intervention on salivary cortisol levels in low-income mothers and their infants

Recent findings suggest that elevated stress levels during the pre- and postpartum period are related to poor maternal and infant health outcomes; yet, few studies have prospectively examined the efficacy of stress management interventions on regulating stress levels among mothers and their infants. The current study examined whether a prenatal cognitive behavioral stress management (CBSM) intervention would be effective in regulating salivary cortisol (a biological marker of stress) and self-reported stress levels among mothers and their infants at six and 18 months postpartum, relative to two control groups. Our sample was comprised of predominantly Spanish-speaking, low-income women (80%; mean age=25±5 years) who were screened for depression during their second trimester of pregnancy (M=16±5 weeks of gestation). Women at high risk for depression [i.e., having either a past history of major depression or current elevated symptoms of depression (≥16 on CES-D)] were randomized to either a CBSM group (n=24) or a usual care (UC) group (n=33), while a low risk comparison (LRC) group (n=29) was comprised of women not meeting either depression criteria. ANCOVA analyses demonstrated that: (1) infants of women in the CBSM and LRC groups had significantly lower cortisol levels than infants of women in the UC group at six months postpartum (p<.001); and (2) women in the CBSM group had lower cortisol levels than women in the UC group at 18 months postpartum (p<.01). These results suggest that prenatal CBSM interventions may be efficacious in regulating biological markers of stress among mothers and their infants, thereby decreasing their risk for developing health complications over time.

Effects of maternal prenatal stress on offspring development: a commentary

Pregnancy is associated with major physiological changes and adaptation to these changes is crucial for normal fetal development. Heightened emotional stress during pregnancy may interfere with the necessary adaptation and lead to dysregulation of the two major stress response systems: the Hypothalamic-Pituitary-Adrenal (HPA) Axis and the Autonomic Nervous System (ANS). Negative effects on the fetus of such maladaptation have been documented in both animals and humans and range from poor birth outcomes to negative impacts on neurodevelopment, as well as long term emotional and behavioural disturbances. Conversely, it has been hypothesized that low levels of maternal prenatal stress may actually have an adaptive value for the offspring. Investigation of these associations employing physiological markers and repeated measures throughout pregnancy and postpartum of both the mother and the offspring, is required in order to understand the various effects of prenatal stress on the development of the offspring. It is also crucial to explore the possibility of variable periods of vulnerability throughout gestation. The aim of this commentary is to reexamine the current literature on the ill-effects of maternal stress during pregnancy on the offspring and to explore avenues for future treatment and prevention.

Entwicklungspsychopathologie der ersten Lebensjahre

Externalisierende Verhaltensstörungen entwickeln sich zumeist bereits in der frühen Kindheit. Befunde aus der Säuglingsforschung und Neurobiologie weisen darauf hin, welche Risiken in der Genese früh auftretender Verhaltensprobleme beteiligt sind und über welche Mechanismen sie wirken. Aufgrund der enormen Plastizität des kindlichen Gehirns repräsentiert die pränatale und frühkindliche Entwicklungsperiode eine Phase erhöhter Vulnerabilität gegenüber stressinduzierenden widrigen Erfahrungen, die durch Merkmale der Beziehungsgestaltung zwischen dem Kind und seinen primären Bezugspersonen kompensiert oder verstärkt werden können. Für die klinische Praxis ergibt sich, dass Präventions- und Interventionsmaßnahmen mit dem Einsetzen der Schwangerschaft erfolgen und sich stärker an der aktuellen psychosozialen Lebenssituation und dem psychischen Befinden der Mutter orientieren sollten.

Dyadic Intervention during Pregnancy? Treating Pregnant Women and Possibly Reaching the Future Baby

It is well established that postnatally, maternal psychopathology greatly increases a child's risk for emotional disorders. This article addresses the formative phase that precedes the mother–infant mutually regulating dyad. Biopsychological data presented here suggest that women's affective states during pregnancy—specifically depression, anxiety, and elevated life‐stress—are associated with subtle alterations in the neurobiological substrate of the fetus' emerging affect regulation system. The article moves to a general discussion of the emotional experience of pregnancy, and to the use of psychodynamic psychotherapy when problematic aspects of women's representational world lead to negative or dysregulated affect. Two case vignettes are presented: one described in brief and the other in greater detail. This kind of therapeutic intervention aims to achieve mood improvement, address women's emerging relationship with her baby, and potentially, influence the course of fetal development. Winnicott (1960) said there is no such thing as a baby alone; all the more so during pregnancy.

Depression, anxiety and influencing factors in pregnancy: a study in a Turkish population

OBJECTIVES

to determine the prevalence of depression in pregnancy and the factors that influence the development of depression and anxiety in pregnancy in a Turkish population.

DESIGN

a descriptive, correlational study.

SETTING

a public hospital in Ankara Province Centre, Ankara, Turkey.

PARTICIPANTS

1,039 pregnant women selected using a convenience sampling method.

FINDINGS

27.9% (n=290) of the 1,039 women were found to be experiencing depression at a level requiring treatment. In a stepwise multiple linear regression analysis model developed for depression and anxiety, the following were found to be statistically significant factors influencing the experience of both depression and anxiety: perceived social support; recent experience of marital or emotional problems during and before this pregnancy; recent experience of life stress; having a negative self-perception; experience of physical violence; and experience of physical problems during pregnancy. Statistically significant factors influencing depression were marital dissatisfaction, being a housewife, having an unwanted pregnancy, and having a formal marriage. The correlation between total anxiety and depression scores was at a medium level (Pearson correlation=0.592).

KEY CONCLUSIONS

many factors influenced the development of depression and anxiety in pregnancy, and a positive correlation was found between depression and anxiety. Midwives and nurses can evaluate pregnant women for these risk factors, and arrange for additional follow-up. They can also offer preventive care and, when necessary, assist with early diagnosis and treatment to improve the health of mothers and babies.

The association of major depression, conduct disorder, and maternal overcontrol with a failure to show a cortisol buffered response in 4-month-old infants of teenage mothers

BACKGROUND

Adolescent pregnancy can be associated with major depression (MD) and conduct disorder (CD). Some infants of adolescent mothers are prenatally exposed to these factors, which may result in heightened risk for perturbations of their stress systems. Between 2 and 4 months, a normal shift occurs in the adrenocortical system in which we observe a marked decrease in infant cortisol response when facing mild stressors. This study aimed to explore whether MD (lifetime, during pregnancy, postpartum), CD, and maternal overcontrol are associated with increased cortisol reactivity in 4-month-old infants of teenage mothers.

METHODS

Using arm restraint as a stressor, morning salivary cortisol was taken prestressor and poststressor in 212 infants during a laboratory visit. Major depression and CD were measured with the computerized National Institute of Mental Health Diagnostic Interview Schedule (NIMH-DIS), postpartum depressive mood was measured with the Edinburgh Postnatal Depression Scale, and overcontrol was observed with the CARE-Index.

RESULTS

Independent of the predictors, there was a dampened cortisol response. Infants of mothers with lifetime MD and of average to highly overcontrolling mothers showed increased cortisol reactivity. Conduct disorder and cortisol levels were not associated.

CONCLUSIONS

Future studies should detect whether the absence of a dampened cortisol response in infants whose mothers have lifetime MD or display overcontrolling parenting is stable over time.

Are prenatal psychological or physical stressors associated with suboptimal outcomes in neonates born to adolescent mothers?

Examined whether prenatal psychological stress and/or physical stress were associated with suboptimal neonatal outcomes in a pilot study of adolescent mothers (n=20). The results provide preliminary support for associations between prenatal psychological stress and little evidence for the association between prenatal physical stress and suboptimal neonatal outcomes.

Maternal anxiety in the pre- and postnatal period: a literature review

This study intended to present a systematic review to analyze the empirical studies published between 1998 and 2003 about maternal anxiety in the prenatal and postnatal periods, focusing on pre-term and term births. Nineteen studies were found; six of which evaluated maternal anxiety in the prenatal period, 12 studies evaluated anxiety in mothers in the postnatal period and only one study evaluated maternal anxiety in both periods. The results showed that high levels of maternal anxiety in the prenatal phase were associated with obstetric problems, emotional damages to fetal development, behavioral problems in childhood and adolescence. The mothers presented higher anxiety levels when compared with the fathers. The co-occurrence of maternal anxiety and depression was found. The maternal anxiety assessment is relevant to identify both maternal mental health and child development at risk.

Depression and anxiety during pregnancy: a risk factor for obstetric, fetal and neonatal outcome? A critical review of the literature

OBJECTIVE

Research from the past two decades has suggested a link between prenatal maternal psychological distress and adverse obstetric, fetal and neonatal outcome. Comparability of study results, however, is complicated by a diversity of definitions and measurements of prenatal maternal stress and different time points of assessment. Our aim was to critically review studies assessing maternal anxiety and depression during pregnancy and their impact on obstetric, fetal and neonatal outcome.

METHODS

We carried out a computerized literature search of PubMed, PsycLIT and EMBASE (1990-2005) and a manual search of bibliographies of pertinent articles. In total 35 studies were identified that fulfilled the inclusion criteria.

RESULTS

Elevated levels of depression and anxiety were found to be associated with obstetric outcome (obstetric complications, pregnancy symptoms, preterm labor and pain relief under labor), and had implications for fetal and neonatal well-being and behavior. However, prediction of the impact of mood and anxiety disorders during pregnancy is very limited due to methodological problems. Most notably, the majority of the studies included pregnant women with elevated symptoms of depressed mood and anxiety and did diagnose mood and anxiety disorders. Also, potentially confounding and protecting factors as well as biological mechanisms with a possible role in adverse outcome in pregnant women with depression and anxiety disorders have received little attention.

CONCLUSIONS

Enhanced levels of depression and anxiety symptoms during pregnancy contribute independently of other biomedical risk factors to adverse obstetric, fetal and neonatal outcome. However, conclusions for women with mood or anxiety disorders are limited.

Correlates of anxiety symptoms during pregnancy and association with perinatal outcomes: a meta-analysis

OBJECTIVE

The purpose of this study was to identify correlates of anxiety symptoms during pregnancy and determine the strength of the relationship between anxiety symptoms and adverse perinatal outcomes.

STUDY DESIGN

A meta-analytic review was conducted of studies that evaluated the relationship between self-reported anxiety symptoms during pregnancy and potential correlates or perinatal outcomes.

RESULTS

Fifty studies of 48 samples of women met inclusion criteria. Anxiety symptoms during pregnancy were associated with a number of psychosocial variables including depressive symptoms (r = 0.66), stress (r = 0.40), and self-esteem/self-worth (r = -0.47). There were no significant associations of anxiety symptoms with perinatal outcomes (all rs < 0.19).

CONCLUSION

Anxiety symptoms during pregnancy appear to be associated with similar psychosocial variables as anxiety at other times. There is no evidence of an association of anxiety symptoms with adverse perinatal outcomes among those studied thus far. However, significant gaps still exist in the literature in this area.

Assessing mid-trimester salivary cortisol levels across three consecutive days in pregnant women using an at-home collection protocol

The Pregnancy Outcomes and Community Health (POUCH) Study enrolled women in their 15th to 27th week of pregnancy from 52 prenatal clinics located in five communities. After the study began, an at-home protocol to measure maternal stress was added, which included collection of urine and saliva twice a day (waking = AM, bedtime = PM) for three consecutive days, and completion of a daily diary. The at-home protocol was in place for 2852 POUCH participants at enrollment, and 81.3% (n = 2318) consented and returned samples and diary. For these analyses, salivary cortisol was analysed in a subset of 846 women who delivered at term. Day-to-day correlation coefficients for AM cortisol (0.45-0.55) exceeded those for PM cortisol (0.31-0.43). Study diaries indicated that there was variation in the time interval between waking and sample collection. Analyses of discrete intervals showed the same awakening response pattern in cortisol levels that has been reported in studies with serial AM sampling. The adjusted mean AM cortisol (microg/dL) was 0.506 at 0-15 min post-waking, 0.544 at 16-30 min (P < 0.05), 0.582 at 31-60 min (P < 0.01), and 0.515 at >60 min post-waking. In addition, adjusted mean AM cortisol in samples collected at or before 9 a.m. was higher than that in samples collected after 9 a.m. (0.564 vs. 0.510 microg/dL, P < 0.01). Among working women, adjusted mean AM cortisol was higher on work days than non-work days (0.564 vs. 0.489 microg/dL, P < 0.01), and in multiparae compared with primiparae (0.551 vs. 0.502 microg/dL, P = 0.07). The parity effect was not evident in non-working women. The adjusted mean PM cortisol significantly increased as week of pregnancy at sampling increased, but was not significantly related to time of collection, work day and parity. Factors influencing AM and PM cortisol levels in pregnancy appear to differ. In studies of AM cortisol levels, it is important to gather data on time of sample collection, interval from waking to sample collection, parity and work.

The Postpartum Support Questionnaire: Psychometric Properties in Adolescents

PROBLEM

Receiving adequate social support has been associated with positive outcomes for the postpartum adolescent and her baby. Therefore, social support is an important variable to include in research studies of postpartum adolescents. However, instruments developed for use in adults cannot be assumed to reliably and validly measure health-related concepts such as social support in adolescents (Rogler, 1999; Yarcheski, Mahon, & Yarcheski, 1992) without psychometric evaluation.

PURPOSE

Therefore, the purpose of this study was to describe the reliability and validity of the Postpartum Support Questionnaire (PSQ) (Logsdon, 2002; Logsdon, Usui, Birkimer, McBride, 1996) with adolescents.

METHOD

The PSQ was revised for use with adolescents, based upon focus groups with adolescents and professionals. Then, the PSQ was administered to a convenience sample of postpartum adolescents (N = 109) recruited from the Teenage Parent Program.

FINDINGS

High internal consistency reliability was demonstrated for the total instrument and subscales. Factor analysis supported four factors, in line with the PSQ data with adults, with some indication for an additional adolescent factor. However, in adolescents material support and emotional support tend to load on the same factor.

CONCLUSIONS

Social support may be defined differently in postpartum adolescents, but further research with a larger sample is needed to substantiate this finding. Instruments with psychometric data specific to adolescents should be chosen by researchers who study this group.

Maternal psychological distress during pregnancy in relation to child development at age two

Concern exists that a constellation of negative maternal emotions during pregnancy generates persistent negative consequences for child development. Maternal reports of anxiety, pregnancy-specific and nonspecific stress, and depressive symptoms were collected during mid-pregnancy and at 6 weeks and 24 months after birth in a sample of healthy women with low risk pregnancies. Developmental assessment and cardiac vagal tone monitoring were administered to 94 children at age 2. Higher levels of prenatal anxiety, nonspecific stress, and depressive symptoms were associated with more advanced motor development in children after postnatal control for each psychological measure; anxiety and depression were also significantly and positively associated with mental development. Mild to moderate levels of psychological distress may enhance fetal maturation in healthy populations.

Psychobiology of persistent antisocial behavior: Stress, early vulnerabilities and the attenuation hypothesis

Stress experienced during the sensitive prenatal, postnatal and early childhood periods of brain development can have damaging consequences for developing biological systems. Stressors imposed by early physical vulnerabilities and an adverse care giving environment is proposed to set in motion early precursors of later persistent antisocial behavior. The purpose of this report is to present an integrated theoretical perspective of potential mechanisms involved in the development of persistent antisocial behavior with an emphasis on early stressors and the neuroendocrinology of stress. The attenuation of endocrine physiology of the stress system is considered a key mechanism involved in persistent antisocial behavior. The amygdala is considered a structure/process linking subjective experiences, emotional learning, brain development and stress physiology. Attenuated cortisol level subsequent to early vulnerabilities is considered a risk marker for persistent antisocial behavior.

Effects of psychologic stress on fetal development and pregnancy outcome

Data from animal studies show that maternal stress is associated with disturbances in pregnancy outcomes and offspring development and behavior, possibly as a result of permanent structural and functional changes termed "early-life programming." There is growing interest in whether similar relationships are present in humans. Here we review recent significant findings from the literature on the impact of prenatal psychologic stressors on pregnancy outcome and offspring development, with a particular focus on the developing brain. Relevant papers were searched using PubMed, and reference lists from obtained articles were checked. In humans, prenatal stress is associated with pregnancy complications, developmental, cognitive, and behavioral disorders, and possible onset of psychopathology in later life. In contrast to the available research done in animals, virtually nothing is known about the effects of prenatal stress on morphologic fetal brain development, and the mechanisms underlying subsequent associated behavioral changes.

Antenatal maternal anxiety and stress and the neurobehavioural development of the fetus and child: links and possible mechanisms. A review

A direct link between antenatal maternal mood and fetal behaviour, as observed by ultrasound from 27 to 28 weeks of gestation onwards, is well established. Moreover, 14 independent prospective studies have shown a link between antenatal maternal anxiety/stress and cognitive, behavioural, and emotional problems in the child. This link generally persisted after controlling for post-natal maternal mood and other relevant confounders in the pre- and post-natal periods. Although some inconsistencies remain, the results in general support a fetal programming hypothesis. Several gestational ages have been reported to be vulnerable to the long-term effects of antenatal anxiety/stress and different mechanisms are likely to operate at different stages. Possible underlying mechanisms are just starting to be explored. Cortisol appears to cross the placenta and thus may affect the fetus and disturb ongoing developmental processes. The development of the HPA-axis, limbic system, and the prefrontal cortex are likely to be affected by antenatal maternal stress and anxiety. The magnitude of the long-term effects of antenatal maternal anxiety/stress on the child is substantial. Programs to reduce maternal stress in pregnancy are therefore warranted.

Pain reactivity in 2-month-old infants after prenatal and postnatal serotonin reuptake inhibitor medication exposure

OBJECTIVE

In this prospective study, we examined biobehavioral responses to acute procedural pain at 2 months of age in infants with prenatal and postnatal selective serotonin reuptake inhibitor (SSRI) medication exposure. Based on previous findings showing reduced pain responses in newborns after prenatal exposure, we hypothesized that altered pain reactivity would also be found at 2 months of age.

METHODS

Facial action (Neonatal Facial Coding System) and cardiac autonomic reactivity derived from the respiratory activity and heart rate variability (HRV) responses to a painful event (heel-lance) were compared between 3 groups of infants: (1) infants with prenatal SSRI exposure alone (n = 11; fluoxetine, n = 2; paroxetine, n = 9); (2) infants with prenatal and postnatal SSRI (via breast milk) exposure (total n = 30; fluoxetine, n = 6; paroxetine, n = 20; sertraline, n = 4); and (3) control infants (n = 22; nonexposed) during baseline, lance, and recovery periods. Measures of maternal mood and drug levels were also obtained, and Bayley Scales of Infant Development-II were administered at ages 2 and 8 months.

RESULTS

Facial action increased in all groups immediately after the lance but was significantly lower in the pSE group during the lance period. HR among infants in the pSE and ppSE groups was significantly lower during recovery. Using measures of HRV and the transfer relationship between heart rate and respiration, exposed infants had a greater return of parasympathetic cardiac modulation in the recovery period, whereas a sustained sympathetic response continued in control infants. Although postnatal exposure via breast milk was extremely low when infant drug levels could be detected in ppSE infants, changes in HR and HRV from lance to recovery were greater compared among infants with levels too low to be quantified. Neither maternal mood nor the presence of clonazepam influenced pain responses.

CONCLUSIONS

Blunted facial-action responses were observed among infants with prenatal SSRI exposure alone, whereas both prenatal and postnatal exposure was associated with reduced parasympathetic withdrawal and increased parasympathetic cardiac modulation during recovery after an acute noxious event. These findings are consistent with patterns of pain reactivity observed in the newborn period in the same cohort. Given that postnatal exposure via breast milk was extremely low and altered biobehavioral pain reactivity was not associated with levels of maternal reports of depression, these data suggest possible sustained neurobehavioral outcomes beyond the newborn period. This is the first study of pain reactivity in infants with prenatal and postnatal SSRI exposure, and our findings were limited by the lack of a depressed nonmedicated control group, small sample size, and understanding of infant behaviors associated with pain reactivity that could have also have been influenced by prenatal SSRI exposure. The developmental and clinical implications of our findings remain unclear, and the mechanisms that may have altered 5-hydroxytryptamine-mediated pain modulation in infants after SSRI exposure remain to be studied. Treating maternal depression with antidepressants during and after pregnancy and promoting breastfeeding in this setting should remain a key goal for all clinicians. Additional study is needed to understand the long-term effects of prenatal and early postnatal SSRI exposure.

Impact of stress reduction instructions on stress and cortisol levels during pregnancy

This pilot study examined whether giving stress reduction (SR) instructions to pregnant women would be effective in regulating stress, mood, and cortisol levels during pregnancy. Forty-one predominantly low-income Latina women, receiving prenatal services at a public county hospital, completed measures of stress and mood (depressive symptoms, positive and negative affect) and provided morning and evening saliva samples to measure cortisol prior to and after receiving SR instructions. We hypothesized that adherence to these SR instructions would result in lower levels of stress, negative mood states, and cortisol levels when compared to baseline values. Repeated measures ANOVA analyses demonstrated significantly lower levels of stress (P < 0.001), lower symptoms of depression and negative affect (P < 0.001), and lower levels of morning cortisol (P = 0.01) under the SR condition, compared to baseline. Health behaviors that were engaged in during the SR condition and implications for prenatal health interventions are discussed.

Prevalence, course, and predictors of emotional distress in pregnant and parenting adolescents

This study examines trajectories and correlates of emotional distress symptoms in pregnant adolescents (n = 203) and nulliparous adolescents (n = 188) from economically disadvantaged communities over an 18-month period. For both groups, the prevalence of significant emotional distress exceeded expectation based on adolescent norms; however, the severity of symptoms did not differ between the 2 groups. Results from growth curve modeling revealed a significant decline in symptoms during the study period for both groups, but pregnant adolescents experienced a different pattern of decline. Also, certain interpersonal factors (e.g., history of physical maltreatment, partner support) appeared to play a more important role in the emotional well-being of pregnant and parenting adolescents relative to nulliparous adolescents. Implications for early identification and intervention are discussed.