The effects of childhood sexual abuse on cortisol trajectories in pregnancy are moderated by current family functioning

Childhood abuse and perinatal outcomes for mother and child: A systematic review of the literature

Childhood abuse can have long-term adverse outcomes in adulthood. These outcomes may pose a particular threat to the health and well-being of perinatal women; however, to date, this body of knowledge has not been systematically collated and synthesized. This systematic review examined the child abuse literature and a broad range of perinatal outcomes using a comprehensive search strategy. The aim of this review was to provide a clearer understanding of the distinct effect of different abuse types and areas where there may be gaps in our knowledge. Following PRISMA guidelines, EBSCO, PsychInfo, Scopus, Medline, CINAHL, PubMed, and Google Scholar databases and gray literature including preprints, dissertations and theses were searched for literature where childhood abuse was associated with any adverse perinatal outcome between 1969 and 2022. Exclusion criteria included adolescent samples, abuse examined as a composite variable, editorials, letters to the editor, qualitative studies, reviews, meta-analyses, or book chapters. Using an assessment tool, two reviewers extracted and assessed the methodological quality and risk of bias of each study. From an initial 12,384 articles, 95 studies were selected, and the outcomes were categorized as pregnancy, childbirth, postnatal for the mother, and perinatal for mother and child. The prevalence of childhood abuse ranged from 5-25% with wide variability (physical 2-78%, sexual 2-47%, and emotional/psychological 2-69%). Despite some consistent findings relating to psychological outcomes (i.e., depression and PTSD), most evidence was inconclusive, effect sizes were small, or the findings based on a limited number of studies. Inconsistencies in findings stem from small sample sizes and differing methodologies, and their diversity meant studies were not suitable for a meta-analysis. Research implication include the need for more rigorous methodology and research in countries where the prevalence of abuse may be high. Policy implications include the need for trauma-informed care with the Multi-level Determinants of Perinatal Wellbeing for Child Abuse Survivors model a useful framework. This review highlights the possible impacts of childhood abuse on perinatal women and their offspring and areas of further investigation. This review was registered with PROSPERO in 2021 and funded by an internal grant from Charles Sturt University.

Social Support Buffers the Effects of Prenatal Depressed Mood: A Mixed-Methods Study

BACKGROUND: Women use various coping strategies to deal with stress and depression. These strategies are shaped by social contexts over the life course and may attenuate and/or exacerbate the physiologic effects of depression. AIMS: The purpose of this study was to determine whether coping strategies (active, disengaged, or social support coping) moderate depression-related diurnal cortisol dysregulation and to explore how social context influences women's use of coping. METHODS: This was a mixed-methods study of pregnant women (N = 65) during mid-pregnancy. Cortisol was measured in saliva collected during the waking hours of the day. Participants completed the Edinburgh Depression Scale and the Brief COPE. A subset of the sample participated in semistructured qualitative interviews (n = 20). RESULTS: Social support coping, but not active or disengaged coping, moderated end-of-day cortisol levels. Among depressed women, higher use of social support was associated with lower and more dynamic (i.e., less flat) diurnal cortisol rhythms. The qualitative findings revealed how complex social dynamics related to financial insecurity, lack of mutuality, and social identity affected women's use of and access to social support. CONCLUSION: These findings support theories of the stress-buffering effects of social support. Future research is needed to examine how social determinants affect access to social support, and how early life social experiences condition women's adaptive formation of social support coping strategies over the life course. Clinically, these findings underscore the value of relationship-centered nursing care for depressed women.

The role of the hypothalamic-pituitary-adrenal axis in depression across the female reproductive lifecycle: current knowledge and future directions

The aim of this narrative review is to consolidate knowledge on the role of the hypothalamic-pituitary-adrenal (HPA) axis in depression pathophysiology at different reproductive stages across the female lifespan. Despite growing evidence about the impact of gonadal hormones on mood disorders, no previous review has examined the interaction between such hormonal changes and the HPA axis within the context of depressive disorders in women. We will focus on HPA axis function in depressive disorders at different reproductive stages including the menstrual cycle (e.g., premenstrual dysphoric disorder [PMDD]), perinatally (e.g., postpartum depression), and in perimenopausal depression. Each of these reproductive stages is characterized by vast physiological changes and presents major neuroendocrine reorganization. The HPA axis is one of the main targets of such functional alterations, and with its key role in stress response, it is an etiological factor in vulnerable windows for depression across the female lifespan. We begin with an overview of the HPA axis and a brief summary of techniques for measuring HPA axis parameters. We then describe the hormonal milieu of each of these key reproductive stages, and integrate information about HPA axis function in depression across these reproductive stages, describing similarities and differences. The role of a history of stress and trauma exposure as a contributor to female depression in the context of HPA axis involvement across the reproductive stages is also presented. This review advances the pursuit of understanding common biological mechanisms across depressive disorders among women. Our overarching goal is to identify unmet needs in characterizing stress-related markers of depression in women in the context of hormonal changes across the lifespan, and to support future research in women's mental health as it pertains to pathophysiology, early diagnosis, and treatment targets.

Recalibration of the stress response system over adult development: Is there a perinatal recalibration period?

During early life-sensitive periods (i.e., fetal, infancy), the developing stress response system adaptively calibrates to match environmental conditions, whether harsh or supportive. Recent evidence suggests that puberty is another window when the stress system is open to recalibration if environmental conditions have shifted significantly. Whether additional periods of recalibration exist in adulthood remains to be established. The present paper draws parallels between childhood (re)calibration periods and the perinatal period to hypothesize that this phase may be an additional window of stress recalibration in adult life. Specifically, the perinatal period (defined here to include pregnancy, lactation, and early parenthood) is also a developmental switch point characterized by heightened neural plasticity and marked changes in stress system function. After discussing these similarities, lines of empirical evidence needed to substantiate the perinatal stress recalibration hypothesis are proposed, and existing research support is reviewed. Complexities and challenges related to delineating the boundaries of perinatal stress recalibration and empirically testing this hypothesis are discussed, as well as possibilities for future multidisciplinary research. In the theme of this special issue, perinatal stress recalibration may be a mechanism of multilevel, multisystem risk, and resilience, both intra-individually and intergenerationally, with implications for optimizing interventions.

Experiences of maltreatment in childhood are associated with increasing anxiety and lower body acceptance over pregnancy

OBJECTIVE

Prior studies have established that childhood sexual abuse (CSA) survivors are at increased risk for anxiety during pregnancy. Less is known about the course of anxiety throughout pregnancy for CSA survivors as well as underlying mechanisms linking CSA and perinatal anxiety. We assessed change in anxiety over the course of pregnancy for CSA survivors and examined whether acceptance and awareness of pregnancy-related body changes mediated this change.

METHODS

299 pregnant participants from two larger longitudinal cohort studies were grouped into CSA (n = 67), "other Maltreatment" (OM; n = 111); and "no abuse" (NA; n = 121) based on responses to the Adverse Childhood Events scale. We used a general linear mixed model with repeated measures to examine change in anxiety (Hamilton Anxiety Scale) at two time points (MEGA = 26.2 weeks and 34.9) by abuse/maltreatment group and then examined whether group differences in anxiety were mediated by body awareness/acceptance (from Maternal Fetal Attachment Scale) using structural equation modeling.

RESULTS

The CSA group demonstrated higher anxiety at both gestational time-points and significantly greater increase in anxiety over gestation compared to OM and NA groups (F(1, 280) p = .046). CSA and OM groups reported significantly lower body acceptance than those without abuse/maltreatment (F(2, 287) = 3.486, p = .032). A small proportion of the total effect of CSA on change in anxiety (0.5%) was attributable to body acceptance.

CONCLUSION

Pregnant CSA survivors experienced a greater increase in anxiety over pregnancy compared to other groups. Both abuse/maltreatment groups exhibited lower body acceptance, yet this contributed little to the association between CSA and anxiety.

Adverse Childhood Experiences Predict Diurnal Cortisol Throughout Gestation

OBJECTIVE

Adverse childhood experiences (ACEs) are associated with negative prenatal and perinatal health outcomes and may, via these pathways, have intergenerational effects on child health and development. We examine the impact of ACEs on maternal salivary cortisol, a key measure of prenatal biology previously linked with pregnancy-related health outcomes.

METHODS

Leveraging assessments across three trimesters, we used linear mixed-effects models to analyze the influence of ACEs on maternal prenatal diurnal cortisol patterns in a diverse cohort of pregnant women (analytic sample, n = 207). Covariates included comorbid prenatal depression, psychiatric medications, and sociodemographic factors.

RESULTS

Maternal ACEs were significantly associated with flatter diurnal cortisol slopes (i.e., less steep decline), after adjusting for covariates, with effects consistent across gestation (estimate = 0.15, standard error = 0.06, p = .008).

CONCLUSIONS

ACEs experienced before pregnancy may have a robust and lasting influence on maternal prenatal hypothalamic-pituitary-adrenal activity throughout gestation, a key biological marker associated with perinatal and child health outcomes. The findings suggest one route of intergenerational transmission of early adverse experiences and underscore the potential value of assessing prepregnancy adverse experiences for promoting perinatal and maternal and child health.

Stress before conception and during pregnancy and maternal cortisol during pregnancy: A scoping review

BACKGROUND

Stress before conception and during pregnancy is associated with less favorable maternal and child health. Alterations in prenatal cortisol levels may serve as a central biological pathway linking stress to adverse maternal and child health. Research examining associations between maternal stress from childhood through pregnancy and prenatal cortisol has not been comprehensively reviewed.

METHOD

The current scoping review of 48 papers synthesizes studies reporting on associations between stress before conception and during pregnancy with maternal cortisol in pregnancy. Eligible studies measured childhood, the proximal preconception period, pregnancy, or lifetime stress based on stress exposures or appraisals and measured cortisol in saliva or hair during pregnancy.

RESULTS

Higher maternal childhood stress was associated with higher cortisol awakening responses and alterations in typical pregnancy-specific changes in diurnal cortisol patterns across studies. In contrast, most studies of preconception and prenatal stress reported null associations with cortisol and those reporting significant effects were inconsistent in direction. A few studies found that the associations between stress and cortisol during pregnancy varied as a function of several moderators including social support and environmental pollution.

CONCLUSIONS

Although many studies have evaluated effects of maternal stress on prenatal cortisol, this scoping review is the first to synthesize existing literature on this topic. The association between stress before conception and during pregnancy and prenatal cortisol may depend on the developmental timing of stress and several moderators. Maternal childhood stress was more consistently associated with prenatal cortisol than proximal preconception or pregnancy stress. We discuss methodological and analytic factors that may contribute to mixed findings.

Association between childhood maltreatment and adult cortisol concentrations mediated through subjective health complaints

Background

Lower cortisol concentrations in adulthood were repeatedly associated with more severe childhood maltreatment. Additionally, childhood maltreatment was reported to promote health risk behavior, such as smoking or alcohol consumption, and to increase the risk of mental and somatic diseases during adulthood, such as major depressive disorders or obesity. The present study investigated if health risk behavior and disease symptoms in adults mediate the associations between past childhood maltreatment and present basal serum cortisol concentrations.

Methods

Data from two independent adult cohorts of the general population-based Study of Health in Pomerania (SHIP-TREND-0: N = 3,517; SHIP-START-2: N = 1,640) was used. Childhood maltreatment was assessed via the Childhood Trauma Questionnaire (CTQ). Cortisol concentrations were measured in single-point serum samples. Health risk behavior and mental and physical symptoms were used as mediators. Mediation analyses were calculated separately for both cohorts; results were integrated via meta-analyses.

Results

In mediator-separated analyses, associations between childhood maltreatment and basal serum cortisol concentrations were partly mediated by depressive symptoms (BDI-II: βindirect effect = -.011, pFDR = .017, 21.0% mediated) and subjective somatic health complaints (somatic complaints: βindirect effect = -.010, pFDR = .005, 19.4% mediated). In the second step, both mediators were simultaneously integrated into one mediation model. The model replicated the mediation effects of the subjective somatic health complaints (whole model: βindirect effect = -.014, p = .001, 27.6% mediated; BDI-II: βindirect effect = -.006, p = .163, 11.4% mediated, somatic complaints: βindirect effect = -.020, p = .020, 15.5% mediated).

Conclusion

The results support the hypothesis that the long-lasting effects of childhood maltreatment on the stress response system are partly mediated through self-perceived disease symptoms. However, no mediation was found for health risk behavior or physically measured mediators. Mediation models with multiple simultaneous mediators pointed to a relevant overlap between the potential mediators. This overlap should be focused on in future studies.

Associations between childhood maltreatment, poor sleep, and prenatal distress in pregnant adolescents

Childhood maltreatment (CM) is a known risk factor for adolescent pregnancy. Sleep disturbances and psychological distress, both common negative sequelae of CM, often co-occur during pregnancy, although directionality remains unclear. Furthermore, little is known about how CM affects sleep-distress associations during pregnancy. In pregnant adolescents, we examined: (a) whether there are significant predictive associations from CM to sleep quality and distress and (b) bidirectional influences of distress and sleep quality. Healthy pregnant adolescents (n = 204) were recruited before or during the 2nd trimester. CM was assessed at enrollment; sleep quality and distress were assessed in the 2nd and 3rd trimesters. Hypotheses were tested using path analysis. Findings revealed that CM was associated with worse 2nd trimester sleep quality and distress (β = .19, p < .05 for sleep; β = .30, p < .001 for distress). Higher levels of 2nd trimester distress were associated with lower 3rd trimester sleep quality (β = .19, p < .05). Findings provide novel information about (a) associations from CM to prenatal mood and sleep in pregnant adolescents, and (b) sleep-distress directionality over the course of pregnancy. These results have implications for better understanding the ways in which CM potentially exerts influences later in life, and for targeting interventions to address physical and mental health during pregnancy.

Maternal History of Adverse Experiences and Posttraumatic Stress Disorder Symptoms Impact Toddlers’ Early Socioemotional Wellbeing: The Benefits of Infant Mental Health-Home Visiting

Background

The present study examined the efficacy of the Michigan Model of Infant Mental Health-Home Visiting (IMH-HV) infant mental health treatment to promote the socioemotional wellbeing of infants and young children. Science illuminates the role of parental “co-regulation” of infant emotion as a pathway to young children’s capacity for self-regulation. The synchrony of parent–infant interaction begins to shape the infant’s own nascent regulatory capacities. Parents with a history of childhood adversity, such as maltreatment or witnessing family violence, and who struggle with symptoms of post-traumatic stress may have greater challenges in co-regulating their infant, thus increasing the risk of their children exhibiting social and emotional problems such as anxiety, aggression, and depression. Early intervention that targets the infant–parent relationship may help buffer the effect of parental risk on child outcomes.

Methods

Participants were 58 mother–infant/toddler dyads enrolled in a longitudinal randomized control trial testing the efficacy of the relationship-based IMH-HV treatment model. Families were eligible based on child age (&lt;24 months at enrollment) and endorsement of at least two of four socio-demographic factors commonly endorsed in community mental health settings: elevated depression symptoms, three or more Adverse Childhood Experiences (ACEs) parenting stress, and/or child behavior or development concerns. This study included dyads whose children were born at the time of study enrollment and completed 12-month post-baseline follow-up visits. Parents reported on their own history of ACEs and current posttraumatic stress disorder (PTSD) symptoms, as well as their toddler’s socioemotional development (e.g., empathy, prosocial skills, aggression, anxiety, prolonged tantrums).

Results

Maternal ACEs predicted more toddler emotional problems through their effect on maternal PTSD symptoms. Parents who received IMH-HV treatment reported more positive toddler socioemotional wellbeing at follow-up relative to the control condition. The most positive socioemotional outcomes were for toddlers of mothers with low to moderate PTSD symptoms who received IMH-HV treatment.

Conclusion

Results indicate the efficacy of IMH-HV services in promoting more optimal child socioemotional wellbeing even when mothers reported mild to moderate PTSD symptoms. Results also highlight the need to assess parental trauma when infants and young children present with socioemotional difficulties.

Co-occurrence of preconception maternal childhood adversity and opioid use during pregnancy: Implications for offspring brain development

Understanding of the effects of in utero opioid exposure on neurodevelopment is a priority given the recent dramatic increase in opioid use among pregnant individuals. However, opioid abuse does not occur in isolation-pregnant individuals abusing opioids often have a significant history of adverse experiences in childhood, among other co-occurring factors. Understanding the specific pathways in which these frequently co-occurring factors may interact and cumulatively influence offspring brain development in utero represents a priority for future research in this area. We highlight maternal history of childhood adversity (CA) as one such co-occurring factor that is more prevalent among individuals using opioids during pregnancy and which is increasingly shown to affect offspring neurodevelopment through mechanisms beginning in utero. Despite the high incidence of CA history in pregnant individuals using opioids, we understand very little about the effects of comorbid prenatal opioid exposure and maternal CA history on fetal brain development. Here, we first provide an overview of current knowledge regarding effects of opioid exposure and maternal CA on offspring neurodevelopment that may occur during gestation. We then outline potential mechanistic pathways through which these factors might have interactive and cumulative influences on offspring neurodevelopment as a foundation for future research in this area.

The Impact of Early-Life Exposures on Women's Reproductive Health in Adulthood

Purpose of Review

To review the effects of early-life, preconception, and prior-generation exposures on reproductive health in women.

Recent Findings

Women’s early-life factors can affect reproductive health by contributing to health status or exposure level on entering pregnancy. Alternately, they can have permanent effects, regardless of later-life experience. Nutrition, social class, parental smoking, other adverse childhood experiences, environmental pollutants, infectious agents, and racism and discrimination all affect reproductive health, even if experienced in childhood or in utero. Possible transgenerational effects are now being investigated through three- or more-generation studies. These effects occur with mechanisms that may include direct exposure, behavioral, endocrine, inflammatory, and epigenetic pathways.

Summary

Pregnancy is increasingly understood in a life course perspective, but rigorously testing hypotheses on early-life effects is still difficult. In order to improve the health outcomes of all women, we need to expand our toolkit of methods and theory.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40471-021-00279-0.

Integrative Review of Early Life Adversity and Cortisol Regulation in Pregnancy

OBJECTIVE

To synthesize published findings on the relationship between early life adversity and hypothalamic-pituitary-adrenal axis cortisol parameters in pregnant women.

DATA SOURCES

We searched PubMed, CINAHL, and PsycINFO databases using variants and combinations of the keywords early life adversity, pregnancy, hypothalamic-pituitary-adrenal axis, and cortisol.

STUDY SELECTION

We selected articles that included pregnant participants, included measures of cortisol and early life adversity, were published in English in a peer-reviewed journal, and were of sufficient methodologic quality. Date of publication was unrestricted through May 2020.

DATA EXTRACTION

Twenty-five articles met the inclusion criteria and were evaluated for quality and risk of bias. Sources of cortisol included saliva, hair, plasma, and amniotic fluid.

DATA SYNTHESIS

We categorized findings according to four physiologically distinct cortisol output parameters: diurnal (daily pattern), phasic (in response to an acute stressor), tonic (baseline level), and pregnancy-related change. Preliminary evidence suggests that early adversity may be associated with elevated cortisol awakening response (diurnal) and blunted response to acute stressors (phasic), irrespective of other psychosocial symptoms or current stress. For women with high levels of current stress or psychological symptoms, early adversity was associated with higher baseline (tonic) cortisol levels.

CONCLUSION

Early life adversity in women is linked with alterations in cortisol regulation that are apparent during pregnancy. Researchers should examine how variations in each cortisol parameter differentially predict pregnancy health risk behaviors, maternal mental health, and neonatal health outcomes.

Trauma services for youth victims of sexual abuse- does one size fit all? A qualitative study among service providers in Ontario, Canada

BACKGROUND

Despite a range of interventions available to treat mental health symptoms experienced by youth with a history of child sexual abuse (CSA), limited empirical work has examined practitioner delivery of these interventions in real-world practice.

OBJECTIVE

This paper aimed to qualitatively explore the delivery of trauma-based interventions in community settings in Ontario, Canada.

PARTICIPANTS AND SETTINGS

Using qualitative description, a purposeful sample of service providers (N = 51; 92 % female) were recruited from nine community-based organizations located in Southern Ontario, Canada providing psychotherapeutic trauma-based interventions to youth with a history of child sexual abuse.

METHODS

Semi-structured one-on-one (n = 17), joint (n = 3) and focus group (n = 5) interviews elicited provider descriptions of their strategies and approaches for addressing trauma-related symptoms in this population. Data were interpreted using conventional content analyses.

RESULTS

Eclectic delivery of interventions and multifactorial decision-making processes were identified as core elements of treatment planning and intervention delivery among providers. Eclectic treatment was described to involve the consideration of four core elements (provider judgement; youth voice; youth characteristics; and clinical team discussion) of intervention and three key principles (meeting youth needs; providing client-centered care; addressing safety and stability).

CONCLUSIONS

Research capable of characterizing the efficacy of client-centered, eclectic approaches to treat symptoms experienced by youth with a history of CSA is needed.

Child Sexual Abuse and Pregnancy: A Systematic Review of the Literature

BACKGROUND

Child sexual abuse is related to many negative outcomes but less known is the effect on pregnancy and childbirth.

OBJECTIVE

This review critically examined the literature on the occurrence of child sexual abuse and outcomes associated with this abuse during pregnancy and childbirth.

METHODS

Five databases were searched over 50 years using an iterative approach and the terms pregnancy, sexual abuse/assault, childbirth/labour, identifying 49 studies.

RESULTS

The prevalence of child sexual abuse in pregnant women ranged from 2.63% to 37.25 with certain characteristics more common with a higher (e.g., specific questions, low income) or lower (broad questions, higher education) prevalence. Compared to women with no history of abuse, child sexual abuse survivors may have more concerns with their care, greater health complaints, fear childbirth and have difficulties with delivery. They also had a higher likelihood of PTSD symptomology and anxiety, consumed more harmful substances (e.g., alcohol, cigarettes, and drugs) and had greater concerns with their appearance, poorer health, sleep and may also have a higher risk of re-victimisation.

CONCLUSIONS

The balance of evidence suggests that compared to non-abused women, women with a child abuse history have more adverse experiences with pregnancy, childbirth, and care, with their abuse history, likely contributes to harmful behaviours and psychopathology. However, variability in operationalisation and measurement of abuse may contribute to these findings so tentative conclusions are drawn. Future research should examine the generalisability of the findings (relating to scale limitations) and recommendations for screening (e.g., sensitive items, scoring). Clinical implications of the findings point to the need for early identification of women with a child abuse history as such women require trauma-sensitive care and consideration. A useful tool is the Pregnancy-related Anxiety Scale which provides insights into specific areas of concern.

The role of HPA-axis function during pregnancy in the intergenerational transmission of maternal adverse childhood experiences to child behavior problems

The current study aimed to understand the mediating and/or moderating role of prenatal hypothalamic-pituitary-adrenal (HPA) axis function in the association between maternal adverse childhood experiences (ACEs) and child internalizing and externalizing behavior problems at age 4. The influence of timing and child sex were also explored. Participants were 248 mother-child dyads enrolled in a prospective longitudinal cohort study (the Alberta Pregnancy Outcomes and Nutrition Study). Maternal ACEs were retrospectively assessed while maternal self-reported depression and diurnal salivary cortisol were assessed prospectively at 6-26 weeks gestation (T1) and 27-37 weeks gestation (T2). Maternal report of child internalizing and externalizing problems was assessed at 4 years (T3). Results revealed that there was a negative indirect association between maternal ACEs and child internalizing behavior via a higher maternal cortisol awakening response (CAR). Maternal diurnal cortisol slope moderated the association between maternal ACEs and child behavior problems. Some of these effects were dependent on child sex, such that higher ACEs and a flatter diurnal slope at T1 was associated with more internalizing behavior in female children and more externalizing behavior in male children. There were timing effects such that the mediating and moderating effects were strongest at T1.

Maternal Adverse Childhood Experiences, Family Strengths, and Chronic Stress in Children

BACKGROUND

Researchers have demonstrated that maternal adverse childhood experiences (ACEs), such as abuse and neglect, are associated with prenatal risk factors and poor infant development. However, associations with child physiologic and health outcomes, including biomarkers of chronic or "toxic" stress, have not yet been explored.

OBJECTIVES

The purpose of this study was to examine the associations among past maternal experiences, current maternal posttraumatic stress disorder (PTSD) symptoms, and children's indicators of exposure to chronic stress in a multiethnic sample of mothers and children at early school age (4 to 9 years).

METHODS

This cross-sectional study included maternal-child dyads (N = 54) recruited from urban community health centers in New Haven, Connecticut. Mothers reported history of ACEs, family strengths, and current PTSD symptoms. Child measures included biomarkers and health and developmental outcomes associated with chronic stress. Correlational and regression analyses were conducted.

RESULTS

Childhood trauma in mothers was associated with higher systolic blood pressure percentile (ρ = .29, p = .03) and behavioral problems (ρ = .47, p = .001) in children, while maternal history of family strengths was associated with lower salivary interleukin (IL)-1β (ρ = -.27, p = .055), salivary IL-6 (ρ = -.27, p = .054), and body mass index z-scores (ρ = -.29, p = .03) in children. Maternal PTSD symptoms were associated with more child behavioral problems (ρ = .57, p < .001) and higher odds of asthma history (ρ = .30, p = .03).

DISCUSSION

Results indicate that past maternal experiences may have important influences on a child's health and affect his or her risk for experiencing toxic stress.

Adverse childhood experiences and associated health outcomes: A systematic review and meta-analysis

BACKGROUND

The Center for Disease Control (CDC) and Kaiser Permanente developed the Adverse Childhood Experiences (ACE) scale to identify negative experiences in childhood. The goal of this study is to systematically review outcomes associated with the ACEs in the CDC-Kaiser ACE scale to understand the diversity of outcomes associated with this scale.

METHODS

The authors conducted a search of English language articles published through September 30, 2016 using OVID Medline®; Ovid Medline® Daily; Epub Ahead of Print, In-Process & Other Non-indexed citations; ERIC®; HAPI®; and SCOPUS®. Articles were selected by trained reviewers based on a priori inclusion criteria including: research, healthy sample, used the CDC-Kaiser ACE scale, and assessed some health outcome. Two reviewers used an abstraction form to independently collect data from each study. Unadjusted and adjusted odds ratio associated with ACE scale scores were aggregated and compared.

RESULTS

From 3167 unique titles, we identified 96 articles that assessed health outcomes associated with the ACEs in the CDC-Kaiser ACE scale. There were more studies focusing on psychosocial/behavioral outcomes than medical outcomes. The majority of the included studies were retrospective, observational, and relied on the same data set. Psychosocial/behavioral outcomes had higher odds ratio than medical outcomes with increasing ACE scale scores.

CONCLUSIONS

Exposure to multiple ACEs is associated with a wide variety of outcomes. This data suggests a benefit of screening for ACEs using this scale and highlights the need to find interventions to ameliorate their effects.

Translating basic research knowledge on the biological embedding of early-life stress into novel approaches for the developmental programming of lifelong health

This review integrates scientific knowledge obtained over the past few decades on the biological mechanisms that contribute to the profound association between exposure to early adversity, including childhood trauma and prenatal stress, and the lifelong elevated risk to develop a broad range of diseases. We further discuss insights into gene-environment interactions moderating the association between early adversity and disease manifestation and we discuss the role of epigenetic and other molecular processes in the biological embedding of early adversity. Based on these findings, we propose potential mechanisms that may contribute to the intergenerational transmission of risk related to early adversity from the mother to the fetus. Finally, we argue that basic research knowledge on the biological embedding of early adversity must now be translated into novel intervention strategies that are mechanism-driven and sensitive to developmental timing. Indeed, to date, there are no diagnostic biomarkers of risk or mechanism-informed interventions that we can offer to victims of early adversity in order to efficiently prevent or reverse adverse health outcomes. Such translational efforts can be expected to have significant impact on both clinical practice and the public health system, and will promote precision medicine in pediatrics and across the lifespan.

Perinatal promotive and protective factors for women with histories of childhood abuse and neglect

BACKGROUND

Integrative research summarizing promotive and protective factors that reduce the effects of childhood abuse and neglect on pregnant women and their babies' healthy functioning is needed.

OBJECTIVE

This narrative systematic review synthesized the quantitative literature on protective and promotive factors that support maternal mental health and maternal-infant bonding among women exposed to childhood adversity, including childhood abuse and neglect.

METHODS

Using a comprehensive list of key terms related to the perinatal period, childhood adversity, and protective/promotive factors, 8423 non-duplicated articles were identified through database searches in PsychInfo and Web of Science, and references in retrieved articles. Thirty-seven full text articles were inspected; of those 18 were included.

RESULTS

Protective and promotive factors fell into three categories: a) women's internal capacities (e.g., self-esteem, coping ability), b) external early resources (e.g., positive childhood experiences) and c) external contemporaneous resources (e.g., social support). Although all three categories were associated with more resilient outcomes, external contemporaneous factors, and specifically, social support, were the most commonly-studied protective and/or promotive factor. Social support from family and romantic partners during the perinatal period was particularly protective for women with histories of childhood abuse and neglect and was examined across several dimensions of support and contexts.

CONCLUSIONS

The presence of women's internal capacities, and external early and contemporaneous resources help to foster more positive outcomes during the perinatal period for women with histories of childhood adversity. Future research should study co-occurring multilevel promotive and protective factors to inform how they integratively deter the intergenerational transmission of risk.

Childhood adversity impact on gut microbiota and inflammatory response to stress during pregnancy

BACKGROUND

Adverse childhood experiences (ACEs), such as abuse or chronic stress, program an exaggerated adult inflammatory response to stress. Emerging rodent research suggests that the gut microbiome may be a key mediator in the association between early life stress and dysregulated glucocorticoid-immune response. However, ACE impact on inflammatory response to stress, or on the gut microbiome, have not been studied in human pregnancy, when inflammation increases risk of poor outcomes. The aim of this study was to assess the relationships among ACE, the gut microbiome, and cytokine response to stress in pregnant women.

METHODS

Physically and psychiatrically healthy adult pregnant women completed the Adverse Childhood Experiences Questionnaire (ACE-Q) and gave a single stool sample between 20 and 26 weeks gestation. Stool DNA was isolated and 16S sequencing was performed. Three 24-hour food recalls were administered to assess dietary nutrient intake. A subset of women completed the Trier Social Stress Test (TSST) at 22-34 weeks gestation; plasma interleukin-6 (IL-6), interleukin-1β (IL-1β), high sensitivity C-reactive protein (hsCRP), tumor necrosis factor α (TNF-α), and cortisol were measured at four timepoints pre and post stressor, and area under the curve (AUC) was calculated.

RESULTS

Forty-eight women completed the ACE-Q and provided stool; 19 women completed the TSST. Women reporting 2 or more ACEs (high ACE) had greater differential abundance of gut Prevotella than low ACE participants (q = 5.7 × 10^-13). Abundance of several gut taxa were significantly associated with cortisol, IL-6, TNF-α and CRP AUCs regardless of ACE status. IL-6 response to stress was buffered among high ACE women with high intake of docosahexaenoic acid (DHA) (p = 0.03) and eicosapentaenoic acid (EPA) (p = 0.05).

DISCUSSION

Our findings suggest that multiple childhood adversities are associated with changes in gut microbiota composition during pregnancy, and such changes may contribute to altered inflammatory and glucocorticoid response to stress. While preliminary, this is the first study to demonstrate an association between gut microbiota and acute glucocorticoid-immune response to stress in a clinical sample. Finally, exploratory analyses suggested that high ACE women with high dietary intake of ω-3 polyunsaturated fatty acids (PUFAs) had a dampened inflammatory response to acute stress, suggesting potentially protective effects of ω-3s in this high-risk population. Given the adverse effects of inflammation on pregnancy and the developing fetus, mechanisms by which childhood adversity influence the gut-brain axis and potential protective factors such as diet should be further explored.

Social buffering of the maternal and infant HPA axes: Mediation and moderation in the intergenerational transmission of adverse childhood experiences

Supportive social relationships can reduce both psychological and physiological responses to stressful experiences. Recently, studies have also assessed the potential for social relationships to buffer the intergenerational transmission of stress. The majority of these studies, however, have focussed on social learning as a mechanism responsible for the intergenerational transmission of stress. Evidence of biological mechanisms is lacking. The objective of the current study was, therefore, to determine whether the association between maternal adverse childhood experiences (ACEs) and infant hypothalamic-pituitary-adrenal (HPA) axis function is mediated by maternal HPA axis function during pregnancy and moderated by social support. Data were from 243 mother-infant dyads enrolled in a prospective longitudinal cohort (the Alberta Pregnancy Outcomes and Nutrition Study). Maternal history of ACEs was retrospectively assessed while maternal perceived social support and salivary cortisol were assessed prospectively at 6-22 weeks gestation (Time 1) and 27-37 weeks gestation (Time 2), and infant cortisol reactivity to a laboratory stressor and maternal perceived social support were assessed at 5-10 months postnatal (Time 3). Results revealed that maternal HPA axis function during pregnancy mediated the effects of maternal ACEs on infant HPA axis reactivity, suggesting that the maternal HPA axis is a mechanism by which maternal early life stress is transmitted to offspring. Furthermore, social support in the prenatal and postnatal periods moderated the cascade from maternal ACEs to infant HPA axis reactivity. Specifically, prenatal social support moderated the association between ACEs and maternal HPA axis function during pregnancy, and postnatal social support moderated the association between maternal HPA axis function and infant cortisol reactivity. These findings highlight the social sensitivity of the HPA axis and suggest the utility of social relationships as an intervention target to reduce the effects of maternal early life stress on infant outcomes.

Exposure to traumatic events in childhood predicts cortisol production among high risk pregnant women

Childhood exposure to traumatic events has a profound and disruptive impact on mental and physical health, including stress physiology. In the current study, we evaluate 90 pregnant women at risk for preterm delivery and assess the association between history of exposure to traumatic events and hair cortisol concentrations, an integrated measure of cortisol production. Exposure to more traumatic events in childhood and in adulthood independently predicted elevated hair cortisol concentrations in pregnancy. Notably, the impact of childhood exposure to traumatic events remained after accounting for more proximal traumatic events in adulthood. Further, there was a significant interaction between childhood and adult exposures. Traumatic experiences in adulthood were more strongly associated with hair cortisol concentrations among mothers with a history of greater childhood trauma. Findings suggest that not only do proximal adult exposures impact HPA-axis functioning during pregnancy, but that childhood traumatic experiences have persisting consequences for HPA-axis functioning during pregnancy. Maternal HPA-axis dysregulation in pregnancy has consequences for both maternal health and for fetal development. Therefore, we consider prenatal maternal HPA-axis functioning as a potential biological pathway underlying intergenerational consequences of childhood trauma.

Childhood maltreatment and inflammation among pregnant women with gestational diabetes mellitus: A pilot study

BACKGROUND

Women with childhood maltreatment histories are at increased risk for adverse birth outcomes. Mechanisms explaining this link are poorly understood. Past research is limited by sampling pregnant women at low risk for adverse maternal and neonatal outcomes.

METHODS

This pilot study was a secondary data analysis of 24 women with gestational diabetes mellitus; 17% of the sample also reported a maltreatment history. Women provided a blood sample to measure inflammatory cytokines and insulin resistance, and saliva samples to measure diurnal cortisol. Birth outcomes for past and current pregnancies were recorded.

RESULTS

Histories of maltreatment were associated with elevated interleukin-15 and a marginally greater incidence of preterm delivery in current and past pregnancies.

CONCLUSIONS

This pilot study was the first to demonstrate an association between childhood maltreatment history and inflammatory cytokine levels in pregnant women diagnosed with gestational diabetes mellitus.

Intergenerational Transmission of Maternal Childhood Maltreatment Exposure: Implications for Fetal Brain Development

OBJECTIVE

Growing evidence suggests the deleterious consequences of exposure to childhood maltreatment (CM) not only might endure over the exposed individual's lifespan but also might be transmitted across generations. The time windows, mechanisms, and targets of such intergenerational transmission are poorly understood. The prevailing paradigm posits that mother-to-child transmission of the effects of maternal CM likely occurs after her child's birth. The authors seek to extend this paradigm and advance a transdisciplinary framework that integrates the concepts of biological embedding of life experiences and fetal origins of health and disease risk.

METHOD

The authors posit that the period of embryonic and fetal life represents a particularly sensitive time for intergenerational transmission; that the developing brain represents a target of particular interest; and that stress-sensitive maternal-placental-fetal biological (endocrine, immune) pathways represent leading candidate mechanisms of interest.

RESULTS

The plausibility of this model is supported by theoretical considerations and empirical findings in humans and animals. The authors synthesize several research areas and identify important knowledge gaps that might warrant further study.

CONCLUSION

The scientific and public health relevance of this effort relates to achieving a better understanding of the "when," "what," and "how" of intergenerational transmission of CM, with implications for early identification of risk, prevention, and intervention.

Using item response theory to optimize measurement of chronic stress in pregnancy

OBJECTIVE

Utilize Rasch analysis to develop an optimized self-reported measure of stress in pregnancy and examine the association with patient demographics and biologic measures of stress.

STUDY DESIGN

Measured self-reported stress in pregnant women using 12 existing scales. Collected blood for biologic measures of stress (Epstein Barr Virus [EBV], C-Reactive Protein [CRP], Corticotropin Reactive Hormone [pCRH], and Adenocorticotropin Hormone [ACTH]). Used multidimensional scaling and Rasch analysis to produce an item reduced self-report measure.

RESULTS

Enrolled 112 women. Survey items reduced to two factors: perceived stressors and buffers of stress. Women with a domestic partner had lower perceived stress (p = 0.003). Caucasian women reported higher buffers of stress (p = 0.045), as did women with private insurance (p < 0.001), a planned pregnancy (p < 0.01), and a domestic partner (p < 0.001). Women with higher buffers of stress had lower levels of pCRH (adjusted p = 0.01).

CONCLUSION

Item reduced, optimized measures of stress were associated with significant differences in patient demographics and biologic measures of stress.

Impact of Maternal Lifetime Interpersonal Trauma on Children's Asthma: Mediation Through Maternal Active Asthma During Pregnancy

OBJECTIVE

Traumatic stressors, including child abuse and/or interpersonal violence over a woman's lifecourse, can affect the health of her children. This study examines the associations between maternal lifetime interpersonal trauma (IPT) and children's asthma by age 6 years (n = 857).

METHODS

Pregnant women completed the Revised Conflict Tactics Scale; IPT exposure was categorized as unexposed (55%), early (childhood and/or teen years only, 25%), late (adulthood and/or index pregnancy, 7%), and chronic (early and late, 13%). Clinician-diagnosed asthma in children was reported by mothers at each follow-up visit until the child reached age 6 years. We examined the effects of maternal IPT categories and child's asthma using logistic regression. Using structural equation models, we also examined indirect relationships between maternal chronic IPT and child asthma operating through active asthma in pregnancy, prepregnancy BMI, prenatal smoking, and/or increased exposure to other adverse life events or environmental toxins prenatally. Effect modification by the child's sex was examined.

RESULTS

Mothers were primarily Hispanic (55%) or black (30%) with less than high school education (62%). In logistic regression models, chronic maternal IPT (compared with unexposed) was associated with asthma in boys (odds ratio = 2.87, 95% confidence interval = 1.48-5.57) but not girls (odds ratio = 0.69, 95% confidence interval = 0.23-2.12; pinteraction = .042). In structural equation models, chronic IPT was associated with maternal active asthma in pregnancy (β = 0.59, p < .001), maternal active asthma was associated with children's asthma (β = 0.20, p = .009), and the total indirect effect for this path was significant (β = 0.12, p = .031). Associations were most evident among boys.

CONCLUSIONS

Mothers' history of chronic IPT was associated with asthma in boys. This association was mediated through active maternal asthma in pregnancy.

Effects of the Social Environment and Stress on Glucocorticoid Receptor Gene Methylation: A Systematic Review

The early-life social environment can induce stable changes that influence neurodevelopment and mental health. Research focused on early-life adversity revealed that early-life experiences have a persistent impact on gene expression and behavior through epigenetic mechanisms. The hypothalamus-pituitary-adrenal axis is sensitive to changes in the early-life environment that associate with DNA methylation of a neuron-specific exon 17 promoter of the glucocorticoid receptor (GR) (Nr3c1). Since initial findings were published in 2004, numerous reports have investigated GR gene methylation in relationship to early-life experience, parental stress, and psychopathology. We conducted a systematic review of this growing literature, which identified 40 articles (13 animal and 27 human studies) published since 2004. The majority of these examined the GR exon variant 1F in humans or the GR17 in rats, and 89% of human studies and 70% of animal studies of early-life adversity reported increased methylation at this exon variant. All the studies investigating exon 1F/17 methylation in conditions of parental stress (one animal study and seven human studies) also reported increased methylation. Studies examining psychosocial stress and psychopathology had less consistent results, with 67% of animal studies reporting increased exon 17 methylation and 17% of human studies reporting increased exon 1F methylation. We found great consistency among studies investigating early-life adversity and the effect of parental stress, even if the precise phenotype and measures of social environment adversity varied among studies. These results are encouraging and warrant further investigation to better understand correlates and characteristics of these associations.

Childhood trauma and neighborhood-level crime interact in predicting adult posttraumatic stress and major depression symptoms

Previous research has identified several individual-level factors that modify the risk of childhood trauma on adult psychiatric symptoms, including symptoms of major depression (MD) and posttraumatic stress (PTS). Neighborhood-level factors also influence the impact of individual-level exposures on adult psychopathology. However, no prior studies to our knowledge have explored cross-level interactions between childhood trauma and neighborhood-level factors on MD and PTS symptoms. The purpose of this study was therefore to explore cross-level interactions between a neighborhood-level factor - neighborhood-level crime - and childhood trauma on MD and PTS symptoms. Participants in this study (N=3192) were recruited from a large public hospital, and completed self-report inventories of childhood trauma and MD and PTS symptoms. Participant addresses were mapped onto 2010 census tracts, and data on crime within each tract were collected. Multilevel models found a significant cross-level interaction between childhood trauma and neighborhood crime on MD symptoms, such that the influence of high levels of childhood trauma on MD symptoms was enhanced for participants living in high-crime neighborhoods. Supplementary analyses found variation in the strength of cross-level interaction terms by types of childhood trauma and crime, with the strongest associations including emotional neglect paired with personal and property crime. The results provide preliminary support for interventions that help childhood trauma survivors find housing in less vulnerable neighborhoods and build skills to cope with neighborhood crime.