Smoking during pregnancy and psychiatric disorders in preschoolers

Prenatal smoking, alcohol and caffeine exposure and offspring externalizing disorders: a systematic review and meta-analysis

BACKGROUND AND AIMS

Several studies have indicated an association between maternal prenatal substance use and offspring externalizing disorders; however, it is uncertain whether this relationship is causal. We conducted a systematic review to determine: (1) if the literature supports a causal role of maternal prenatal substance use on offspring externalizing disorders diagnosis and (2) whether these associations differ across externalizing disorders.

METHODS

We searched Web of Science, Embase, PsycINFO and Medline databases. Risk of bias assessment was conducted using the Newcastle-Ottawa Scale (NOS), and where possible meta-analysis was conducted for studies classed as low risk of bias. We included studies of any design that examined prenatal smoking, alcohol or caffeine use. Studies in non-English language, fetal alcohol syndrome and comorbid autism spectrum disorders were excluded. Participants in the included studies were mothers and their offspring. Measurements included prenatal smoking, alcohol or caffeine use as an exposure, and diagnosis of attention-deficit hyperactivity disorder (ADHD), conduct disorder (CD) and oppositional defiant disorder (ODD) in offspring as an outcome.

RESULTS

We included 63 studies, 46 of which investigated smoking and ADHD. All studies were narratively synthesized, and seven studies on smoking and ADHD were meta-analysed. The largest meta-analysis based on genetically sensitive design included 1 011 546 participants and did not find evidence for an association [odds ratio (OR)_{1-9 cigarettes}  = 0.90, 95% confidence interval (CI) = 0.83-1.11; OR _{> 10 cigarettes}  = 1.04, 95% CI = 0.79-1.36). Studies on alcohol exposure in all the outcomes reported inconsistent findings and no strong conclusions on causality can be made. Studies on caffeine exposure were mainly limited to ADHD and these studies do not support a causal effect.

CONCLUSIONS

There appears to be no clear evidence to support a causal relationship between maternal prenatal smoking and offspring attention-deficit hyperactivity disorder. Findings with alcohol and caffeine exposures and conduct disorder and oppositional-defiant disorder need more research, using more genetically sensitive designs.

Assessment of the Relationship Between Smoking and Depression in Pregnant Women

Smoking during pregnancy has negative effects on both maternal and fetal health. One of these negative maternal effects is the potential for depression. A high rate of cigarette smoking in pregnancy is an important public health issue since it affects not only the pregnant woman but also the newborn and its healthy development. The aim of this study is to investigate the relationship between smoking, influencing factors, and depression prevalence in pregnant Syrian refugees and pregnant citizens of the Republic of Turkey (TR). Pregnant citizens in the TR and pregnant Syrian refugees who were registered at health centers between 15.04.2017 and 15.10.2017 in the border city of Ceylanpınar in the Province of Şanlıurfa in Syria were visited in their living areas in the district center and at a tent village, respectively. A total of 414 pregnant women agreed to participate in the study and were included in the survey. To collect data for the cross-sectional study, a sociodemographic and pregnancy characteristics questionnaire was used, in addition to the Fageström Test for Nicotine Dependence (FTND) and the Beck Depression Inventory (BDI). The rate of smoking in all pregnant women was determined to be 49.3% (n = 204) before pregnancy and 37.9% (n = 157) during pregnancy. A statistically significant difference was found between age groups and educational status in relation to smoking status (p = 0.005, p = 0.001). There was also a statistically significant difference between the smoking status of pregnant women and that of their partners and family members (p = 0.001, p = 0.002). The percentage of pregnant women who were passive smokers was 80.2% (n = 332), and a statistically significant difference was found between passive smoking and smoking status (Fisher; 0.000). The presence of risk for depression was detected in 49.8% (n = 206) of all pregnant women surveyed; the rate of depression risk was 50.5% (n = 104) in pregnant TR citizens and 49.5% (n = 102) in pregnant refugees, with no significant difference between the two groups. There was a statistically significant difference between smoking status in pregnancy and the presence of depression risk (p = 0.001). 32.5% of pregnant women were highly nicotine dependent. A moderate positive correlation was determined between the FTND and BDI scores of pregnant women (r = 0.346; p = 0.001). It was found that one-third of all pregnant women smoked and that one of every two showed a risk for depression. A statistically significant correlation was found between smoking status and risk for depression. No statistically significant difference was determined between the two groups, despite high levels of smoking, nicotine dependence, and depression in both. These data suggest the need to develop new preventive strategies in regard to smoking among pregnant women.

Maternal smoking during pregnancy and risks to depression and anxiety in offspring: An observational study and genome-wide gene-environment interaction analysis in UK biobank cohort

BACKGROUND

Maternal smoking during pregnancy (MSDP) has been reported to be associated with increased anxiety and depression behaviors in offspring. However, there is still scant evidence to support the link between MSDP and anxiety/depression.

METHODS

Using the subjects from the UK Biobank cohort (n = 371,903-432,881). Logistic regression analyses were first conducted to test the correlation between MSDP and anxiety/depression in offspring. Second, genome-wide gene-environment interaction study (GWGEIS) analyses were conducted by PLINK, using MSDP as environmental factor. Genetic correlation analysis of anxiety/depression and smoking was conducted by the LDSC software using the published genome-wide association study (GWAS) summary data of four smoking traits (n = 337,334-1,232,091), anxiety (n = 31,880) and depression (n = 490,359). Finally, pathway enrichment analysis was carried out to detect the pathway involved in the development of offspring anxiety caused by the interaction of MSDP × SNPs.

RESULTS

Observational analyses showed that anxiety and depression status in offspring were significantly associated with MSDP (all p < 0.0001). Further GWEGI analyses observed significant MSDP-gene interaction effects at UNC80 gene for anxiety (p = 9.09 × 10^-9). LDSC did not detect significant genetic correlation between anxiety and smoking traits. Pathway analysis identified 19 significant pathways for anxiety, such as MANALO_HYPOXIA_UP (FDR = 5.50 × 10^-4), REACTOME_ADHERENS_JUNCTIONS_INTERACTIONS (FDR = 0.0304) and ONDER_CDH1_TARGETS_2_UP (FDR = 0.0371).

CONCLUSION

Our study results suggested the important impact of MDSP on the risk of anxiety in offspring, partly attributing to environment-gene interactions effects.

Disruptive Behavior in Siblings Discordant for Exposure to Maternal Smoking During Pregnancy: A Multi-rater Approach

INTRODUCTION

Maternal smoking during pregnancy (SDP) is associated with disruptive behavior. However, there is debate whether the SDP-disruptive behavior association is a potentially causal pathway or rather a spurious effect confounded by shared genetic and environmental factors.

AIMS AND METHODS

The Missouri Mothers and Their Children Study is a sibling comparison study that includes families (n = 173) selected for sibling pairs (aged 7-16 years) discordant for SDP. Critically, the sibling comparison design is used to disentangle the effects of SDP from familial confounds on disruptive behavior. An SDP severity score was created for each child using a combination of SDP indicators (timing, duration, and amount of SDP). Multiple informants (parents and teachers) reported on disruptive behavior (i.e., DSM-IV semi-structured interview, the Child Behavior Checklist, and Teacher Report Form).

RESULTS

The variability in disruptive behavior was primarily a function of within-family differences (66%-100%). Consistent with prior genetically informed approaches, the SDP-disruptive behavior association was primarily explained by familial confounds (genetic and environmental). However, when using a multi-rater approach (parents and teachers), results suggest a potentially causal effect of SDP on disruptive behavior (b = 0.09, SE = 0.04, p = 0.03). The potentially causal effect of SDP remained significant in sensitivity analyses.

DISCUSSION

These findings suggest that familial confounding likely plays a complex role in the SDP-disruptive behavior association when examining both parent and teacher reports of behavior. Importantly, the current study highlights the importance of multiple raters, reflecting a more comprehensive measure of complex behaviors (e.g., disruptive behavior) to examine the teratogenic effects of SDP.

IMPLICATIONS

Our study provides additional evidence that controlling for genetic and family factors is essential when examining the effect of SDP on later behavioral problems, as it explains a portion of the association between SDP and later behavioral problems. However, we found a significant association between SDP and disruptive behavior when using a multi-rater approach that capitalizes on both parent and teacher report, suggesting that parent and teacher ratings capture a unique perspective that is important to consider when examining SDP-behavior associations.

Prenatal and Postnatal PCB-153 and p,p'-DDE Exposures and Behavior Scores at 5–9 Years of Age among Children in Greenland and Ukraine

BACKGROUND

Studies have reported some evidence of adverse effects of organochlorine exposures on child development, but the results have been inconsistent, and few studies have evaluated associations with child behavior.

OBJECTIVE

We investigated the association between prenatal and early-life exposures to 2,2',4,4',5,5'-hexachlorobiphenyl (PCB-153) and 1,1-dichloro-2,2-bis(p-chlorophenyl)-ethylene (p,p'-DDE) and behaviors in children between 5 and 9 y of age.

METHODS

In the Biopersistent organochlorines in diet and human fertility: Epidemiologic studies of time to pregnancy and semen quality in Inuit and European populations (INUENDO) cohort, consisting of mother-child pairs from Greenland and Ukraine (n=1,018), maternal serum PCB-153 and p,p'-DDE concentrations were measured during pregnancy, and cumulative postnatal exposures during the first 12 months after delivery were estimated using a pharmacokinetic model. Parents completed the Strengths and Difficulties Questionnaire (SDQ), and children's behaviors were dichotomized as abnormal (high) versus normal/borderline for five SDQ subscales and the total difficulties score.

RESULTS

The total difficulties score, an overall measure of abnormal behavior, was not clearly associated with pre- or postnatal exposures to PCB-153 or to p,p'-DDE. However, pooled adjusted odds ratios (ORs) for high conduct problem scores with a doubling of exposure were 1.19 (95% CI: 0.99, 1.42) and 1.16 (95% CI: 0.96, 1.41) for pre- and postnatal PCB-153, respectively, and 1.25 (95% CI: 1.04, 1.51) and 1.24 (95% CI: 1.01, 1.51) for pre- and postnatal p,p'-DDE, respectively. Corresponding ORs for high hyperactivity scores were 1.24 (95% CI: 0.94, 1.62) and 1.08 (95% CI: 0.81, 1.45) for pre- and postnatal PCB-153, respectively, and 1.43 (95% CI: 1.06, 1.92) and 1.27 (95% CI: 0.93, 1.73) for pre- and postnatal p,p'-DDE, respectively.

CONCLUSION

Prenatal and early postnatal exposures to p,p'-DDE and PCB-153 were associated with a higher prevalence of abnormal scores for conduct and hyperactivity at 5–9 y of age in our study population. These findings provide further support for the importance of minimizing organochlorine exposures to young children and to women of childbearing age. https://doi.org/10.1289/EHP553.

Disruptive Behavior Disorders in Children 0 to 6 Years Old

Disruptive behavior disorders (DBDs), specifically oppositional defiant disorder and conduct disorder, are common, serious, and treatable conditions among preschoolers. DBDs are marked by frequent aggression, deceitfulness, and defiance, and often persist through the lifespan. Exposure to harsh or inconsistent parenting, as frequently seen with parental depression and stress, increases DBD risk. Candidate genes that may increase DBD risk in the presence of childhood adversity have also been identified, but more research is needed. Neurophysiologic and structural correlates with DBD also exist. Parent management training programs, focusing on increasing parenting competence and confidence, are the gold standard treatment of preschool DBDs.

Prenatal smoking exposure and neuropsychiatric comorbidity of ADHD: a finnish nationwide population-based cohort study

BACKGROUND

Prenatal smoking exposure has been associated with attention-deficit/hyperactivity disorder (ADHD). ADHD is commonly associated with a wide spectrum of psychiatric comorbidity. The association between smoking and neuropsychiatric comorbidity of ADHD has remained understudied. The aim of this study is to examine the association between prenatal exposure to maternal smoking and offspring ADHD, and test whether the smoking-ADHD associations are stronger when ADHD is accompanied by other lifetime neuropsychiatric comorbidities.

METHODS

The study is based on a nested case-control design and includes all Finnish singletons born between 1991 and 2005 and diagnosed with ADHD by 2011 (n = 10,132), matched with four controls (n = 38,811) on date of birth, sex and residence in Finland.

RESULTS

The risk for ADHD with or without comorbidity was significantly increased among offspring exposed to maternal smoking on adjusting for potential confounders (OR = 1.75, CI 95 % = 1.65-1.86). Compared to the only ADHD cases, subjects with comorbid conduct disorder or oppositional defiant disorder had a significantly stronger association with smoking exposure (OR = 1.80, CI 95 % = 1.55-2.11).

CONCLUSIONS

Prenatal smoking represents an important risk factor for the ADHD comorbid with CD/ODD. Further research on the association between prenatal smoking exposure and neuropsychiatric comorbidity of ADHD is needed considering the increased risk among these subjects of an overall poor health outcome as compared to only ADHD. In particular, studies utilizing biomarkers or including subjects with neuropsychiatric conditions with and without comorbid ADHD are needed.

Effects of tobacco exposure on perinatal suicidal ideation, depression, and anxiety

Background

Previous studies have stressed the importance of tobacco exposure for the mood disorders of depression and anxiety. Although a few studies have focused on perinatal women, none have specifically considered the effects of smoking and secondhand smoke exposure on perinatal suicidal ideation. Thus, this study aimed to investigate the relationships of smoking/secondhand smoke exposure status with suicidal ideation, depression, and anxiety from the first trimester to the first month post partum.

Methods

This cross-sectional study based on self-reported data was conducted at five hospitals in Taipei, Taiwan from July 2011 to June 2014. The questionnaire inquired about women’s pregnancy history, sociodemographic information, and pre-pregnancy smoking and secondhand smoke exposure status, and assessed their suicidal ideation, depression, and anxiety symptoms. Logistic regression models were used for analysis.

Results

In the 3867 women in the study, secondhand smoke exposure was positively associated with perinatal depression and suicidal ideation. Compared with women without perinatal secondhand smoke exposure, women exposed to secondhand smoke independently exhibited higher risks for suicidal ideation during the second trimester (odds ratio (OR) = 7.63; 95 % confidence interval (CI) = 3.25–17.93) and third trimester (OR = 4.03; 95 % CI = 1.76–9.23). Women exposed to secondhand smoke had an increased risk of depression, especially those aged 26–35 years (OR = 1.71; 95 % CI = 1.27–2.29).

Conclusions

Secondhand smoke exposure also considerably contributes to adverse mental health for women in perinatal periods, especially for the severe outcome of suicidal ideation. Our results strongly support the importance of propagating smoke-free environments to protect the health of perinatal women.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3254-z) contains supplementary material, which is available to authorized users.

Prenatal tobacco exposure and self-regulation in early childhood: Implications for developmental psychopathology

Prenatal tobacco exposure (PTE) has a well-documented association with disruptive behavior in childhood, but the neurocognitive effects of exposure that underlie this link are not sufficiently understood. The present study was designed to address this gap, through longitudinal follow-up in early childhood of a prospectively enrolled cohort with well-characterized prenatal exposure. Three-year-old children (n = 151) were assessed using a developmentally sensitive battery capturing both cognitive and motivational aspects of self-regulation. PTE was related to motivational self-regulation, where children had to delay approach to attractive rewards, but not cognitive self-regulation, where children had to hold information in mind and inhibit prepotent motor responses. Furthermore, PTE predicted motivational self-regulation more strongly in boys than in girls, and when propensity scores were covaried to control for confounding risk factors, the effect of PTE on motivational self-regulation was significant only in boys. These findings suggest that PTE's impact on neurodevelopment may be greater in boys than in girls, perhaps reflecting vulnerability in neural circuits that subserve reward sensitivity and emotion regulation, and may also help to explain why PTE is more consistently related to disruptive behavior disorders than attention problems.

Tobacco smoking during pregnancy and risk of adverse behaviour in offspring: A follow-up study

OBJECTIVES

This study examines associations between prenatal exposure to tobacco smoking and adverse behaviour in the offspring.

METHODS

We included 1016 pregnant women from Greenland and Ukraine (526 from Greenland and 490 from Ukraine). Serum cotinine measurements were used to identify smoking pregnant women. When the children were from five to nine years of age, the parents assessed the child's behaviour using the Strength and Difficulties Questionnaire (SDQ).

RESULTS

Overall, smoking in pregnancy was not associated with a higher probability of adverse behaviour assessed by the total SDQ score. However, in the crude analysis smoking was associated with a higher mean difference of SDQ-total score. In Greenland the SDQ-total mean difference (MD) was (MD (95% CI)=1.31 points (0.42; 2.19)) and in Ukraine (MD (95% CI)=0.18 points (-1.2; 0.91)), whereas the adjusted mean differences were statistically non-significant.

CONCLUSIONS

In utero exposure to tobacco smoking was not associated with a significant higher risk of adverse behaviour in the offspring, but elevated risk of adverse behaviour among children prenatally exposed to smoking cannot be excluded.

Maternal smoking and offspring inattention and hyperactivity: results from a cross-national European survey

In utero exposure to tobacco smoke is associated with adverse neonatal outcomes; the association with later childhood mental health outcomes remains controversial. We used a strategy involving comparison of maternal and paternal smoking reports in a sample pooling data from six diverse European countries. Data were drawn from mother (N = 4,517) and teacher (N = 4,611) reported attention deficit and hyperactivity disorder (ADHD) symptoms in school children aged 6-11 in Turkey, Romania, Bulgaria, Lithuania, Germany, and the Netherlands, surveyed in 2010. Mothers report on self and husband's smoking patterns during the pregnancy period. Logistic regression used with control covariates including demographics, maternal distress, live births, region, and post-pregnancy smoking. In unadjusted models, maternal prenatal smoking was associated with probable ADHD based on mother [Odds Ratio (OR) = 1.82, 95 % Confidence Interval (CI) 1.45-2.29], teacher (OR = 1.69, 95 % CI 1.33-2.14) and mother plus teacher (OR = 1.49, 95 % CI 1.03-2.17) report. Paternal prenatal smoking was similarly associated with probable ADHD in unadjusted models. When controlled for relevant confounders, maternal prenatal smoking remained a risk factor for offspring probable ADHD based on mother report (OR = 1.44, 95 % CI 1.06-1.96), whereas the effect of paternal prenatal smoking diminished (e.g., mother report: OR = 1.17, 95 % CI 0.92-1.49). Drawing on data from a diverse set of countries across Europe, we document that the association between maternal smoking and offspring ADHD is stronger than that of paternal smoking during the pregnancy period and offspring ADHD. To the extent that confounding is shared between parents, these results reflect a potential intrauterine influence of smoking on ADHD in children.

Determining the impact of prenatal tobacco exposure on self-regulation at 6 months

Our goal in the present study was to examine the effects of maternal smoking during pregnancy on infant self-regulation, exploring birth weight as a mediator and sex as a moderator of risk. A prospective sample of 218 infants was assessed at 6 months of age. Infants completed a battery of tasks assessing working memory/inhibition, attention, and emotional reactivity and regulation. Propensity scores were used to statistically control for confounding risk factors associated with maternal smoking during pregnancy. After prenatal and postnatal confounds were controlled, prenatal tobacco exposure was related to reactivity to frustration and control of attention during stimulus encoding. Birth weight did not mediate the effect of prenatal exposure but was independently related to reactivity and working memory/inhibition. The effect of tobacco exposure was not moderated by sex.

Lifestyle management of unipolar depression

OBJECTIVE

To be used in conjunction with 'Pharmacological management of unipolar depression' [Malhi et al. Acta Psychiatr Scand 2013;127(Suppl. 443):6-23] and 'Psychological management of unipolar depression' [Lampe et al. Acta Psychiatr Scand 2013;127(Suppl. 443):24-37]. To provide clinically relevant recommendations for lifestyle modifications in depression, derived from a literature review.

METHOD

A search of pertinent literature was conducted up to August 2012 in the area of lifestyle factors and depression. A narrative review was then conducted.

RESULTS

There is evidence that level of physical activity plays a role in the risk of depression, and there is a large and validated evidence base for exercise as a therapeutic modality. Smoking and alcohol and substance misuse appear to be independent risk factors for depression, while the new epidemiological evidence supports the contention that diet is a risk factor for depression; good quality diets appear protective and poor diets increase risk.

CONCLUSION

Lifestyle modification, with a focus on exercise, diet, smoking and alcohol, may be of substantial value in reducing the burden of depression in individuals and the community.