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

The CARING study: Examining biological, behavioral, and genetic mechanisms in the intergenerational transmission of toxic stress

When children experience extreme or persistent stressors (e.g., maltreatment, housing insecurity, intimate partner violence), prolonged elevation of the stress-response system can lead to disrupted development of multiple physiological systems. This response, known as toxic stress, is associated with poor physical and mental health across the life course. Emerging evidence suggests that the effects of toxic stress may be transmitted through generations, but the biological and behavioral mechanisms that link caregivers' childhood history with the health of the children they care for remain poorly understood. The purpose of this report is to describe the research protocol for The CARING (Childhood Adversity and Resilience In the Next Generation) Study, a cross-sectional study of caregivers with children aged 3-5 years designed to (1) examine the intergenerational transmission of toxic stress and protective factors; (2) explore three hypothesized pathways of transmission: parenting, daily routines, stressors, and supports; and (3) explore the extent to which genotypic variation in candidate genes related to caregiving and stress contribute to caregivers' and children's susceptibility to the effects of early childhood experiences (i.e., gene × environment interactions). We expect that findings from this study will provide critical data needed to identify targets for precision health interventions, reduce health disparities related to toxic stress, and prevent cycles of adversity among families at risk.

Childhood Adversities and the ATTACHTM Program's Influence on Immune Cell Gene Expression

OBJECTIVE

To determine whether maternal Adverse Childhood Experiences (ACEs) are (a) associated with increased inflammatory gene expression in mother-child dyads and (b) whether a parenting intervention (ATTACH™) moderates the association between maternal ACEs and mother and/or child inflammatory gene expression.

METHODS

Twenty mother-child dyads, recruited from a domestic violence shelter in Calgary, AB, Canada, were randomized into an ATTACH™ parenting intervention group (n = 9) or a wait-list control group (n = 11). Maternal ACEs were assessed. The mothers and children each provided one non-fasting blood sample after the intervention group completed the ATTACH™ program, which was assayed to quantify the Conserved Transcriptional Response to Adversity (CTRA) score, indicating inflammatory gene expression profile. Mixed-effect linear models were used, separately in mothers and children, to examine the associations between CTRA score, maternal ACEs, and the ACEs-by-intervention group interaction term. The covariates were age, sex, ethnicity, and maternal medication use.

RESULTS

Higher maternal ACEs were associated with higher child CTRA scores (b = 0.123 ± SE 0.044, p = 0.005), indicating an increased pro-inflammatory gene expression profile. The ATTACH™ parenting intervention moderated this association between maternal ACEs and child CTRA scores (b = 0.328 ± SE 0.133, p = 0.014). In mothers, the ACEs-by-intervention interaction terms were insignificant (p = 0.305).

CONCLUSIONS

Maternal ACEs could exert an intergenerational impact on child inflammatory activity, and this association could be moderated by participating in the ATTACH™ parenting intervention.

Looking for the good in times of adversity: Examining the interplay of temperament and social schemas in shaping resilience in youth

AIM

Resilience is a broad and dynamic concept that can be seen as being constituted by the combination of internal factors, for example, temperament profiles, and external factors, for example, social support. This paper aimed to identify temperament profiles in help-seeking youth exposed to adverse childhood experiences, and to investigate whether temperament (putative internal protective factor) interacts with social schemas (as proxy for the putative external protective factor social support) such that their combination is associated with (a) reduced mental health problems and (b) attenuated decrease in positive affect following daily life stressors.

METHODS

Self-report questionnaires were used to measure temperament, social schemas and mental health problems. The experience sampling method was used to assess stress and positive affect (i.e., stress-sensitivity as a potential daily life resilience mechanism). Temperament profiles were identified by latent profile analysis and regression analyses were used to examine (interaction) effects.

RESULTS

In 138 subjects, three temperament profiles were identified, that is, a moderate, volatile and persevering profile, of which the latter was negatively associated with mental health problems. Neither mental health problems nor stress sensitivity were found to be affected by the interaction between temperament and social schemas. However, positive social schemas were found to be independently associated with reduced mental health problems (b = -4.41; p = <.001) and reduced stress sensitivity (b = .10, p = .044).

CONCLUSIONS

Findings are relevant for both practice and research, and contribute to improving our understanding of putative protective factor in the development of mental ill-health, thereby further unravelling the construct of resilience.

The effects of IPV and mental health symptoms on HPA axis functioning during early pregnancy

Maternal HPA axis dysregulation during early pregnancy can negatively affect maternal functioning. However, findings are mixed regarding how intimate partner violence (IPV), a common traumatic stressor, impacts HPA axis regulation during pregnancy. Interactions between IPV and mental health symptoms as they influence cortisol production are rarely examined, especially among pregnant women. Therefore, this study examined the impact of IPV, mental health symptoms, and their interactions on the maternal HPA axis during early pregnancy; 255 pregnant women, oversampled for experiences of IPV, completed a laboratory stressor and measures of depressive and post-traumatic stress symptoms (PTSS) at 15-18 weeks of pregnancy. Participants provided saliva samples following the Trier Social Stress Test that were assayed for cortisol; the area under the curve with respect to ground (AUCg) was computed as a measure of cortisol reactivity. The interactive effects of IPV, depressive symptoms, and PTSS on AUCg were significant, but the main effects were not. At low levels of depressive symptoms, the association between IPV and AUCg was negative; at moderate levels of depressive symptoms, it was not significant, and at high levels, it was positive. At low and moderate levels of PTSS, the effects of IPV on cortisol AUCg were not significant, but at high levels, the association was positive. IPV during early pregnancy was associated with both hyperactive and blunted stress reactivity, depending on the type and severity of mental health symptoms. These patterns of dysregulation of the HPA axis may have differential effects both for women's functioning throughout pregnancy as well as for the offspring.

Impact of the COVID-19 pandemic on new parents enrolled in the 'BABY1000' birth cohort study in Sydney, Australia: A mixed-methods study

OBJECTIVE

The COVID-19 pandemic was, and continues to be, uniquely experienced by women in the perinatal period and their families. Whilst long-term impacts of the pandemic are unknown, exposures in pregnancy and early life have impacts across the life-course and future generations. The objective of this manuscript was to explore how the pregnancy, postpartum and parenting experiences of a subset of participants from the 'BABY1000' cohort in Sydney, Australia, were affected by the COVID-19 pandemic, and explore associations between these experiences and state anxiety.

METHODS

Mixed methods were used. Participants were requested to complete an online survey including the State-Trait Anxiety Inventory short form (STAI-6), followed by an invitation to participate in focus group discussions (FGDs).

RESULTS

From September to November 2021, 88 parents completed the survey (mean age 33.5 years, 60% born in Australia, 58% primiparous). Twenty-two parents participated in FGDs. Six themes were identified regarding the experience of parents: (1) Maternal support, (2) Family relationships, (3) Stress and mental health, (4) Healthcare, (5) Family lifestyle and routine, and (6) Long-term impacts. The mean STAI-6 score was 40 (SD 12.3), representing high anxiety. High anxiety was significantly associated with concern regarding COVID-19 and feeling overburdened and lonely.

CONCLUSIONS

The COVID-19 pandemic and associated public health orders significantly impacted participants' pregnancy, postpartum and parenting experiences. Whilst these experiences included some unexpected positives, for many, these were outweighed by negative impacts on mental health, social support, health behaviours, and family relationships.

IMPLICATIONS FOR PUBLIC HEALTH

Ongoing longitudinal research is imperative to identify potential long-term effects of the pandemic across the life-course, better support families in the short and long-term, and plan for public health crises in the future.

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.

Maternal and Paternal Adverse Childhood Experiences (ACEs) and Offspring Health and Wellbeing: A Scoping Review

BACKGROUND

Adverse childhood experiences (ACEs) are common, often co-occur, and are associated with poor health outcomes across the life course. Emerging research has emphasized the lasting consequences of ACEs across generations, suggesting parental ACEs are associated with poor physical and mental health outcomes in children. However, the individual effects of fathers' ACEs and pathways of transmission remain unclear. A scoping review was conducted to summarize the current knowledgebase of the intergenerational consequences of parental ACEs on offspring health, clarify pathways of transmission, understand how ACEs are operationalized in the intergenerational literature, and identify gaps in knowledge.

METHODS

Six electronic databases were searched for articles published in English from 1995 to 2022 relating to the long-term consequences of parental ACEs on offspring physical and mental health. Articles underwent title, abstract, and full-text review by two investigators. Content analysis was performed to integrate findings across the included studies.

RESULTS

The search yielded 14,542 unique articles; 49 met the inclusion criteria. Thirty-six articles focused exclusively on mothers, one solely on fathers, and 12 included both mothers and fathers in their analyses. Six studies used an expanded definition of ACEs. Both direct and indirect associations between parental ACEs and poor offspring outcomes were identified, primarily through biological and psychosocial pathways.

CONCLUSIONS

Findings underscore the importance and oversight of fathers and the need to solidify a unified definition and measure of ACEs. This review identified modifiable protective factors (social support, father involvement) and pathways of transmission (parental mental health, parenting); both having important implications for intervention development.

Maternal Early Life Adversity and Infant Stress Regulation: Intergenerational Associations and Mediation by Maternal Prenatal Mental Health

Early life adversity is a potent risk factor for poor mental health outcomes across the lifespan, including offspring vulnerability to psychopathology. Developmentally, the prenatal period is a sensitive window in which maternal early life experiences may influence offspring outcomes and demarcates a time when expectant mothers and offspring are more susceptible to stressful and salutary influences. This prenatal plasticity constituted the focus of the current study where we tested the association of maternal early life adversity with infant stress regulation through maternal prenatal internalizing symptoms and moderation by prenatal social support. Mother-infant dyads (n = 162) were followed prospectively and mothers completed assessments of social support and depressive and anxiety symptoms across pregnancy. Infants completed standardized stress paradigms at one month and six months. There were several key findings. First, maternal prenatal depressive symptoms significantly mediated predictions of infant cortisol reactivity to the heel stick at one month from maternal early life adversity: specifically, maternal early life adversity positively predicted depressive symptoms in pregnancy, which in turn predicted dampened infant cortisol reactivity. Second, prenatal social support did not significantly moderate predictions of depressive or anxiety symptoms in pregnancy from maternal early life adversity nor did it alter the associations of maternal depressive or anxiety symptoms with infant stress regulation. These results suggest that maternal prenatal mental health is a key mechanism by which maternal early life adverse experiences affect offspring risk for psychopathology. We discuss potential clinical and health implications of dysregulated infant cortisol reactivity with respect to lifespan development.

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.

Intergenerational Transmission of Parental Adverse Childhood Experiences and Children's Outcomes: A Scoping Review

Adverse childhood experiences (ACEs) are among the leading environmental causes of morbidity and mortality. Extending research on within-generation effects, more recent scholarship has explored between-generation consequences of ACEs. Despite growing interest in the intergenerational effects of parents' ACEs on children's outcomes, this line of scholarship has yet to be coalesced into a comprehensive review. The current study is a scoping review on the intergenerational transmission of parental ACEs and children's outcomes. Ten databases such as PubMed, APA PsycArticles, and Social Work Abstracts were searched. To be included, empirical studies must have been published in English and analyzed associations between a cumulative measure of at least four parental ACEs and children's outcomes. Sixty-eight studies qualified for the review and, among these, 60 were published in the most recent 5 years (2018-2022). Fifty-one studies had sample sizes smaller than 500, and 55 focused on the effect of maternal ACEs. Nearly all studies demonstrated that parental ACEs could affect children's outcomes directly or indirectly via mechanisms like maternal mental health problems or parenting-related factors. By scoping the extant literature, this review advances the knowledge base regarding the intergenerational impacts of parental childhood trauma and children's outcomes. It also reveals methodological limitations that should be addressed in future research to strengthen causal inferences along with practical implications for interventions that aim to interrupt the intergenerational transmission of trauma.

Maternal adverse childhood experiences on child growth and development in rural Pakistan: An observational cohort study

Maternal adverse childhood experiences (ACEs) have significant impacts on the next generation with links to negative birth outcomes, impaired cognitive development, and increased socioemotional problems in children. However, not all types or levels of adversity are similarly deleterious and research from diverse contexts is needed to better understand why and how intergenerational transmission of adversity occurs. We examined the role of maternal ACEs on children's growth, cognitive, and socioemotional development at 36 months postpartum in rural Pakistan. We used data from 877 mother-child dyads in the Bachpan Cohort, a birth cohort study. Maternal ACEs were captured using an adapted version of the ACE-International Questionnaire. Outcomes at 36 months of age included child growth using the WHO growth z-scores, fine motor and receptive language development assessed with the Bayley Scales of Infant and Toddler Development, and socioemotional and behavioral development measured with the Ages and Stages Questionnaire: Socioemotional and Strengths and Difficulties Questionnaire. To estimate the associations between maternal ACEs and child outcomes, we used multivariable generalized linear models with inverse probability weights to account for sampling and loss to follow-up. Over half of mothers in our sample (58%) experienced at least one ACE. Emotional abuse, physical abuse, and emotional neglect were the most commonly reported ACEs. We found null relationships between the number of maternal ACEs and child growth. Maternal ACEs were associated with higher fine motor and receptive language development and worse socioemotional and behavioral outcomes. Maternal ACE domains had similarly varying relationships with child outcomes. Our findings highlight the complexity of intergenerational associations between maternal ACEs and children's growth and development. Further work is necessary to examine these relationships across cultural contexts and identify moderating factors to mitigate potential negative intergenerational effects.

Indigenous Cultural Identity Protects Against Intergenerational Transmission of ACEs Among Indigenous Caregivers and Their Children

A large body of empirical research has demonstrated that caregiver adverse childhood experiences (ACEs) predict ACEs in one's child, a phenomenon known as the intergenerational transmission of ACEs. Little of this empirical research, however, has focused specifically on Indigenous peoples despite a growing body of theoretical literature and the wisdom of Elders and Traditional Knowledge Keepers that speaks to the presence of this phenomenon within Indigenous communities as well as the protective role of Indigenous cultural identity in preventing the intergenerational transmission of ACEs. The purpose of the current study was to conduct an empirical evaluation of this hypothesis, specifically that Indigenous cultural identity and social support protects against the intergenerational transmission of ACEs among Indigenous peoples and their children in the USA. Participants were 106 Indigenous women caregivers of children ages 10 to 14 in South Dakota who completed surveys. Results showed that Indigenous cultural identity moderated the association between caregiver ACEs and child ACEs. At high levels of cultural identity, there was no association between caregiver ACEs and child ACEs. At low levels of Indigenous cultural identity, however, there was a strong and positive relationship between caregiver ACEs and child ACEs. Social support did not moderate the association between caregiver ACEs and child ACEs. These findings underscore the need for initiatives that enhance Indigenous cultural identity and social support among Indigenous caregivers to prevent the intergenerational transmission of ACEs.

Thinking about the next generation: The case for a mentalization-informed approach to perinatal and intergenerational mental health

BACKGROUND

There has been substantial progress made across multiple disciplines to emphasize the importance of perinatal mental health both for parents and offspring. This focuses on what has been termed the 'First 1000 Days' from conception to the child's second birthday. We argue that our understanding of this issue can go further to create an intergenerational approach to mental health. Despite the existence of theoretical frameworks and practical approaches to implementation, there are gaps in the understanding of perinatal and intergenerational mental health including which psychological mechanisms are implicated in the transmission of risk and resilience within the perinatal period; and how to leverage these into treatment approaches.

AIMS AND METHODS

In this paper, we explore the potential for mentalization as a candidate psychological approach to intergenerational mental health.

RESULTS

We contextualize this issue in terms of the points of contact between mentalization and broader theoretical models such as the social determinants of health and the Developmental Origins of Health and Disease (DoHaD) model. Further, we provide an overview of the existing evidence base for the relevance of mentalization to perinatal mental health.

DISCUSSION

Finally, we sketch out an outline model for integrating mentalization into perinatal and intergenerational mental health, highlighting several areas of opportunity to develop research and practice from diverse geographies and demographics. Here, we suggest that integration of mentalization with other conceptual frameworks such as DoHaD can mutually enrich the understanding of each model, pointing the way towards more effective early and preventative interventions.

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.

A Review of Factors that Serve to Protect Pregnant and Post-partum Women from Negative Outcomes Associated with Adverse Childhood Experiences

PURPOSE

The objective of this review is to examine factors, during the perinatal period, that serve to protect women and infants from poor mental or physical outcomes most commonly associated with maternal adverse childhood experiences (ACEs).

METHODS

The electronic databases of PubMed, Ovid MEDLINE, CINAHL and Web of Science were searched. The searches were conducted using the following mesh terms and keywords: ('adverse childhood experiences' or 'ACEs') and ('protective factor' or 'social support' or 'buffer' or 'resilience') and ('pregnan*' or 'prenatal' or 'postpartum' or 'maternal' or 'antenatal'). Studies that examined the association of maternal ACEs and protective factors during the perinatal period were included. A total of 317d articles were screened and 19 are included in this review. The quality of the articles was evaluated with the Newcastle-Ottawa-Scale (NOS).

RESULTS AND CONCLUSION

This review indicates a positive association between maternal ACEs and protective perinatal factors including social support, resiliency and positive childhood experiences.

Cumulative effects of pre-pandemic vulnerabilities and pandemic-related hardship on psychological distress among pregnant individuals

OBJECTIVE

Our primary objective was to determine whether pre-existing vulnerabilities and resilience factors combined with objective hardship resulted in cumulative (i.e., additive) effects on psychological distress in pregnant individuals during the COVID-19 pandemic. A secondary objective was to determine whether any of the effects of pandemic-related hardship were compounded (i.e., multiplicative) by pre-existing vulnerabilities.

METHOD

Data are from a prospective pregnancy cohort study, the Pregnancy During the COVID-19 Pandemic study (PdP). This cross-sectional report is based upon the initial survey collected at recruitment between April 5, 2020 and April 30, 2021. Logistic regressions were used to evaluate our objectives.

RESULTS

Pandemic-related hardship substantially increased the odds of scoring above the clinical cut-off on measures of anxiety and depression symptoms. Pre-existing vulnerabilities had cumulative (i.e., additive) effects on the odds of scoring above the clinical cut-off on measures of anxiety and depression symptoms. There was no evidence of compounding (i.e., multiplicative) effects. Social support had a protective effect on anxiety and depression symptoms, but government financial aid did not.

CONCLUSION

Pre-pandemic vulnerability and pandemic-related hardship had cumulative effects on psychological distress during the COVID-19 pandemic. Adequate and equitable responses to pandemics and disasters may require more intensive supports for those with multiple vulnerabilities.

A Review of the Impact of Maternal Prenatal Stress on Offspring Microbiota and Metabolites

Maternal prenatal stress exposure affects the development of offspring. We searched for articles in the PubMed database and reviewed the evidence for how prenatal stress alters the composition of the microbiome, the production of microbial-derived metabolites, and regulates microbiome-induced behavioral changes in the offspring. The gut-brain signaling axis has gained considerable attention in recent years and provides insights into the microbial dysfunction in several metabolic disorders. Here, we reviewed evidence from human studies and animal models to discuss how maternal stress can modulate the offspring microbiome. We will discuss how probiotic supplementation has a profound effect on the stress response, the production of short chain fatty acids (SCFAs), and how psychobiotics are emerging as novel therapeutic targets. Finally, we highlight the potential molecular mechanisms by which the effects of stress are transmitted to the offspring and discuss how the mitigation of early-life stress as a risk factor can improve the birth outcomes.

Study protocol: development and randomized controlled trial of a preventive blended care parenting intervention for parents with PTSD

BACKGROUND

Children of parents with post-traumatic stress disorder (PTSD) are at increased risk of adverse psychological outcomes. An important risk mechanism is impaired parental functioning, including negative parenting behavior, perceived incompetence, and lack of social support. Several parenting interventions for trauma-exposed parents and parents with psychiatric disorders exist, but none have specifically targeted parents with PTSD. Our objective is to evaluate the effectiveness of a blended care preventive parenting intervention for parents with PTSD.

METHODS

The intervention was adapted from an existing online intervention, KopOpOuders Self-Help. In co-creation with parents with PTSD and partners, the intervention was adapted into KopOpOuders-PTSD, by adding PTSD-specific content and three in-person-sessions with a mental health prevention professional. Effectiveness will be tested in a randomized controlled trial among N = 142 parents being treated for PTSD at Arkin Mental Health Care (control condition: treatment as usual, n = 71; intervention condition: treatment as usual + intervention, n = 71). Online questionnaires at pretest, posttest, and three-month follow-up and ecological momentary assessment at pretest and posttest will be used. Intervention effects on primary (parenting behavior) and secondary outcomes (perceived parenting competence, parental social support, parenting stress, child overall psychological problems and PTSD symptoms) will be analyzed using generalized linear mixed modeling. We will also analyze possible moderation effects of parental PTSD symptoms at pretest on primary and secondary outcomes.

DISCUSSION

This study protocol describes the randomized controlled trial of KopOpOuders-PTSD, a blended care preventive parenting intervention for parents with PTSD. Findings can contribute to understanding of the effectiveness of parenting support in clinical practice for PTSD.

TRIAL REGISTRATION

This protocol (Version 1) was registered on 11-02-2022 at ClinicalTrials.gov under identification number NCT05237999.

Prenatal Stress and the Developing Brain: Postnatal Environments Promoting Resilience

Heightened maternal stress during pregnancy is associated with atypical brain development and an elevated risk for psychopathology in offspring. Supportive environments during early postnatal life may promote brain development and reverse atypical developmental trajectories induced by prenatal stress. We reviewed studies focused on the role of key early environmental factors in moderating associations between prenatal stress exposure and infant brain and neurocognitive outcomes. Specifically, we focused on the associations between parental caregiving quality, environmental enrichment, social support, and socioeconomic status with infant brain and neurocognitive outcomes. We examined the evidence that these factors may moderate the effects of prenatal stress on the developing brain. Complementing findings from translational models, human research suggests that high-quality early postnatal environments are associated with indices of infant neurodevelopment that have also been associated with prenatal stress, such as hippocampal volume and frontolimbic connectivity. Human studies also suggest that maternal sensitivity and higher socioeconomic status may attenuate the effects of prenatal stress on established neurocognitive and neuroendocrine mediators of risk for psychopathology, such as hypothalamic-pituitary-adrenal axis functioning. Biological pathways that may underlie the effects of positive early environments on the infant brain, including the epigenome, oxytocin, and inflammation, are also discussed. Future research in humans should examine resilience-promoting processes in relation to infant brain development using large sample sizes and longitudinal designs. The findings from this review could be incorporated into clinical models of risk and resilience during the perinatal period and used to design more effective early programs that reduce risk for psychopathology.

The Impact of COVID-19 on Maternal Mental Health during Pregnancy: A Comparison between Canada and China within the CONCEPTION Cohort

The effect of the COVID-19 pandemic on maternal mental health has been described in Canada and China but no study has compared the two countries using the same standardized and validated instruments. In this study, we aimed to evaluate and compare the impact of COVID-19 public health policies on maternal mental health between Canada and China, as we hypothesize that geographical factors and different COVID-19 policies are likely to influence maternal mental health. Pregnant persons >18 years old were recruited in Canada and China using a web-based strategy. All participants recruited between 26 June 2020 and 16 February 2021 were analyzed. Self-reported data included sociodemographic variables, COVID-19 experience and maternal mental health assessments (Edinburgh Perinatal Depression Scale (EPDS), Generalized Anxiety Disorders (GAD-7) scale, stress and satisfaction with life). Analyses were stratified by recruitment cohort, namely: Canada 1 (26 June 2020-10 October 2020), Canada 2 and China (11 October 2020-16 February 2021). Overall, 2423 participants were recruited, with 1804 participants within Canada 1, 135 within Canada 2 and 484 in China. The mean EDPS scores were 8.1 (SD, 5.1) in Canada 1, 8.1 (SD, 5.2) in Canada 2 and 7.7 (SD, 4.9) in China (p-value Canada 2/China: p = 0.005). The mean GAD-7 scores were 2.6 (SD, 2.9) in China, 4.3 (SD, 3.8) in Canada 1 (p < 0.001) and 5.8 (SD, 5.2) in Canada 2 (p < 0.001). When adjusting for stress and anxiety, being part of the Chinese cohort significantly increased the chances of having maternal depression by over threefold (adjusted OR 3.20, 95%CI 1.77-5.78). Canadian and Chinese participants reported depressive scores nearly double those of other crises and non-pandemic periods. Lockdowns and reopening periods have an important impact on levels of depression and anxiety among pregnant persons.

Prenatal maternal stress and offspring aggressive behavior: Intergenerational and transgenerational inheritance

Even though studies have shown that prenatal maternal stress is associated with increased reactivity of the HPA axis, the association between prenatal maternal stress and fetal glucocorticoid exposure is complex and most likely dependent on unidentified and poorly understood variables including nature and timing of prenatal insults. The precise mechanisms in which prenatal maternal stress influence neuroendocrine signaling between the maternal-placental-fetal interface are still unclear. The aim of this review article is to bring comprehensive basic concepts about prenatal maternal stress and mechanisms of transmission of maternal stress to the fetus. This review covers recent studies showing associations between maternal stress and alterations in offspring aggressive behavior, as well as the possible pathways for the “transmission” of maternal stress to the fetus: (1) maternal-fetal HPA axis dysregulation; (2) intrauterine environment disruption due to variations in uterine artery flow; (3) epigenetic modifications of genes implicated in aggressive behavior. Here, we present evidence for the phenomenon of intergenerational and transgenerational transmission, to better understands the mechanism(s) of transmission from parent to offspring. We discuss studies showing associations between maternal stress and alterations in offspring taking note of neuroendocrine, brain architecture and epigenetic changes that may suggest risk for aggressive behavior. We highlight animal and human studies that focus on intergenerational transmission following exposure to stress from a biological mechanistic point of view, and maternal stress-induced epigenetic modifications that have potential to impact on aggressive behavior in later generations.

Anxiety, attitudes-behaviors, coping styles, and social support among high-risk pregnant women in the late period of the coronavirus disease 2019 pandemic

OBJECTIVE

The purpose of this study was to investigate the prevalence of anxiety among high-risk pregnant women in the late period of the coronavirus disease 2019 pandemic and to evaluate the relationship between anxiety levels, attitudes-behaviors, coping styles, and other psychometric parameters.

METHODS

Pregnant women who were followed up in our gynecology outpatient clinic were evaluated during their admissions between November 15, 2020 and February 15, 2021. This cross-sectional study analyzes prospectively collected data from a university hospital. Inclusion criteria were those being at risk of pregnancy and between the age of 18 and 45 years, while exclusion criteria were mental retardation and the presence of serious psychiatric illness. The study included 140 participants. Sociodemographic and pregnant attitudes-behaviors data form, State-Trait Anxiety Inventory, Coping Styles Scale Brief Form (Brief-COPE), and Multidimensional Scale of Perceived Social Support were used to collect data.

RESULTS

Participants had high anxiety levels (State-STAI: 40.32±9.88; Trait-STAI: 42.71±7.32) and high prevalence of probable clinical anxiety [State-STAI: 84 (60.0%); Trait-STAI: 92 (65.7%)]. The fact concerning the transmission of the coronavirus disease 2019 to the baby during pregnancy/birth, extent to which coronavirus disease 2019 pandemic prevents regular pregnancy checkups, and family subgroup-Multidimensional Scale of Perceived Social Support predicted state probable clinical anxiety. Use of disinfectants predicted trait probable clinical anxiety. Employment status predicted state/trait probable clinical anxiety. The existence of trait probable clinical anxiety was significantly associated with behavioral disengagement and substance use which are considered ineffective coping styles. Participants without trait probable clinical anxiety had significantly more adopted positive reinterpretation, one of emotion-focused coping styles.

CONCLUSION

Based on our results, the concern of the transmission of the coronavirus disease 2019 to the babies during pregnancy/birth may be the main factor influencing anxiety among high-risk pregnant women.

Infant DNA methylation: an early indicator of intergenerational trauma?

Exposure to adverse childhood experiences (ACEs) increases risk for mental and physical health problems. Intergenerationally, mothers' ACEs predict children's health problems including neurodevelopmental and behavioural problems and poorer physical health. Theories of intergenerational trauma suggest that ACEs experienced in one generation negatively affect the health and well-being of future generations, with DNA methylation (DNAm) being one of several potential biological explanations. To begin exploring this hypothesis, we tested whether infant DNA methylation associated with intergenerational trauma. Secondary analysis employed data from the Alberta Pregnancy Outcomes and Nutrition (APrON) study. Subsample data were collected from mothers during pregnancy and postpartum on measures of distress, stress and ACEs and from infants at 3 months of age on DNAm from blood (n = 92) and buccal epithelial cells (BECs; n = 124; primarily nonoverlapping individuals between tissues). Blood and BECs were examined in separate analyses. Preliminary associations identified in blood and BECs suggest that infant DNAm patterns may relate to maternal ACEs. For the majority of ACE-related DNAm sites, neither maternal perinatal distress, nor maternal cortisol awakening response (CAR; a measure of hypothalamic-pituitary-adrenocortical axis function), substantially reduced associations between maternal ACEs and infant DNAm. However, accounting for maternal perinatal distress and cortisol substantially changed the effect of ACEs in a greater proportion of blood DNAm sites than BEC DNAm sites in the top ACEs-associated correlated methylated regions (CMRs), as well as across all CMRs and all remaining CpGs (that did not fall into CMRs). Possible DNAm patterns in infants, thus, might capture a signature of maternal intergenerational trauma, and this effect appears to be more dependent on maternal perinatal distress and CAR in blood relative to BECs.

Effects of social and emotional context on neural activation and synchrony during movie viewing

Sharing emotional experiences impacts how we perceive and interact with the world, but the neural mechanisms that support this sharing are not well characterized. In this study, participants (N = 52) watched videos in an MRI scanner in the presence of an unfamiliar peer. Videos varied in valence and social context (i.e., participants believed their partner was viewing the same (joint condition) or a different (solo condition) video). Reported togetherness increased during positive videos regardless of social condition, indicating that positive contexts may lessen the experience of being alone. Two analysis approaches were used to examine both sustained neural activity averaged over time and dynamic synchrony throughout the videos. Both approaches revealed clusters in the medial prefrontal cortex that were more responsive to the joint condition. We observed a time‐averaged social‐emotion interaction in the ventromedial prefrontal cortex, although this region did not demonstrate synchrony effects. Alternatively, social‐emotion interactions in the amygdala and superior temporal sulcus showed greater neural synchrony in the joint compared to solo conditions during positive videos, but the opposite pattern for negative videos. These findings suggest that positive stimuli may be more salient when experienced together, suggesting a mechanism for forming social bonds.

Examining Parent Adverse Childhood Experiences as a Distal Risk Factor in Pediatric Chronic Pain

OBJECTIVES

Adverse childhood experiences (ACEs; ie, exposure to abuse, neglect, household dysfunction in childhood) are associated with poor mental and physical health outcomes across the lifespan. Emerging research suggests parent ACEs also confer risk for poor child outcomes. The relation between parent ACEs and child pain in youth with chronic pain has not yet been examined. The aim of the current longitudinal study was to examine the associations among parent ACEs, parent health, and child pain, in a clinical sample of youth with chronic pain.

METHODS

In total, 192 youth (75.5% female, 10 to 18 y old) and one of their parents (92.2% female) were recruited from tertiary pediatric chronic pain clinics in Canada. At baseline, parents completed self-report measures of ACEs, chronic pain status, anxiety and depressive symptoms, and posttraumatic stress disorder symptoms. At a 3-month follow-up, youth completed self-report measures of pain intensity and pain interference.

RESULTS

Regression and mediation analyses revealed that parent ACEs significantly predicted parent chronic pain status and depressive symptoms, but not parent anxiety or posttraumatic stress disorder symptoms. Moreover, parent ACEs were not significantly related to youth pain, either directly or indirectly through parent health variables.

DISCUSSION

Findings suggest that an intergenerational cascade from parent ACEs to parent health to child pain was not present in the current sample. Further research that examines the role of parent ACEs in the development of child chronic pain, as well as other risk and resiliency factors that may mediate or moderate the association between parent ACEs and child chronic pain, is needed.

Prenatal mother-father cortisol linkage predicts infant executive functions at 24 months

The present study investigated associations between prenatal mother-father cortisol linkage and infant executive functions. Data come from an international sample (N = 358) of predominantly white and middle- to upper-class first-time parents. During late pregnancy, parents collected diurnal salivary cortisol samples and reported on levels of psychological stress. At 24 months, children completed a battery of executive function tasks. Parent cortisol linkage was operationalized as the time-dependent, within-dyad association between maternal and paternal diurnal cortisol. Results indicated that prenatal linkage was positively related to infant executive functions, suggesting that stronger mother-father cortisol linkage was associated with higher executive function scores. Additionally, this relation was moderated by paternal average cortisol levels such that executive function scores were lower when fathers had higher average cortisol levels and linkage was weak. This association suggests that elevated paternal cortisol amplifies the negative relation between lower cortisol linkage and lower infant executive function scores. Importantly, these findings were observed while controlling for observational measures of caregiving and self-report measures of psychosocial functioning and infant social-emotional behavior. These results suggest that prenatal linkage of mother's and father's stress physiology plays a potentially important part in programming and regulating infant neurocognitive development.

Charting a Course towards Resilience Following Adverse Childhood Experiences: Addressing Intergenerational Trauma via Strengths-Based Intervention

Early research on adverse childhood experiences (ACEs) provided staggering evidence of the significant ramifications of ACEs on physical health and functioning. It brought to the forefront the importance of addressing trauma and family dysfunction to enhance public health. Over the past several decades, the study of childhood adversity has blossomed, with expanded conceptualizations and assessments of ACEs. This review brings together various biological, psychological, and sociological principles that inform our understanding of ACEs and our approach to treatment. Specifically, we document the evolution of ACEs research, focusing on the intergenerational impact of ACEs, the importance of incorporating a resilience framework when examining ACEs, and implementing interventions that address adversity across generations and at multiple levels of the social ecology. Evidence is provided to support the evolving perspective that ACEs have long-lasting effects beyond the ACE(s)-exposed individual, with significant attention to the impact of parental ACEs on child development. An intergenerational and multilevel approach to understanding and addressing ACEs offers specific areas to target in interventions and in public policy.

Perinatal Behavioral Health, the COVID-19 Pandemic, and a Social Determinants of Health Framework

The United States has greater prevalence of mental illness and substance use disorders than other developed countries, and pregnant women are disproportionately affected. The current global COVID-19 pandemic, through the exacerbation of psychological distress, unevenly affects the vulnerable population of pregnant women. Social distancing measures and widespread closures of businesses secondary to COVID-19 are likely to continue for the foreseeable future and to further magnify psychosocial risk factors. We propose the use of a social determinants of health framework to integrate behavioral health considerations into prenatal care and to guide the implementation of universal and comprehensive psychosocial assessment in pregnancy. As the most numerous and well-trusted health care professionals, nurses are ideally positioned to influence program and policy decisions at the community and regional levels and to advocate for the full integration of psychosocial screening and behavioral health into prenatal and postpartum care as core components.

Maternal Adverse Childhood Experiences and Child Behavior Problems: A Systematic Review

CONTEXT

A growing body of research has examined the role of maternal adverse childhood experiences (ACEs) on child behavior problems.

OBJECTIVE

To summarize the literature examining the association between maternal ACEs and child behavior problems via a systematic review.

DATA SOURCES

Electronic searches were conducted in Medline, PsycINFO, and Embase (1998-June 2020). Reference lists were reviewed. In total, 3048 records were screened.

STUDY SELECTION

Studies were included if an association between maternal ACEs and child externalizing (eg, aggression) and/or internalizing (eg, anxiety) problems was reported. In total, 139 full-text articles were reviewed for inclusion.

DATA EXTRACTION

Data from 16 studies met full inclusion criteria. Studies were synthesized by child externalizing and internalizing outcomes.

RESULTS

Maternal ACEs were significantly associated with child externalizing problems across all studies (number of studies synthesized per outcome [k] = 11). Significant associations were also found for inattention, hyperactivity, and impulsivity (k = 4), and aggression (k = 2). For internalizing problems (k = 11), significant associations were identified across 8 studies and nonsignificant associations were reported for 3 studies. Maternal ACEs were consistently associated with child anxiety and depression (k = 5). However, inconsistent findings were reported for somatization (k = 2).

LIMITATIONS

Results are limited to mother-child dyads and questionnaire measures of behavior problems in primarily North American countries.

CONCLUSIONS

Mothers' ACEs demonstrated largely consistent associations with children's behavior problems. Future research is needed to determine if specific types of maternal ACEs (eg, household dysfunction) are more strongly associated with child behavior problems.

Parental history of childhood maltreatment and child average RSA shape parent-child RSA synchrony

We examined whether dynamic parent-child RSA synchrony varied by individual differences in child average RSA and parental history of childhood maltreatment (CM), which has been linked to parental behavioral and physiological dysregulation. We also examined whether RSA synchrony was curvilinear, reflecting homeostatic regulation. Synchrony was defined as the dynamic association between parent and child RSA reactivity (change relative to their own mean) within epoch across a challenging task. Eighty-three mother-preschooler and 61 father-preschooler dyads participated. State-trait modeling showed that RSA synchrony was curvilinear such that significant relations were only found at lower and higher child reactivity. Children's higher task average RSA predicted maternal RSA augmentation and lower task average RSA predicted maternal RSA withdrawal, regardless of whether child reactivity in the moment was low or high, suggesting individual differences in child regulatory capacity were associated with dynamic maternal reactivity. When maternal CM history and child average RSA were both higher, mothers showed RSA augmentation. Father-child synchrony was not moderated by child average RSA but greater paternal CM history predicted fathers' greater RSA withdrawal regardless of whether child RSA reactivity was low or high. Findings offer novel insights into the nature and meaning of RSA synchrony with parents at risk.

Impact of COVID-19 pandemic on postpartum depression among mothers of extreme and early preterm infants

Objective

To examine the impact of the coronavirus disease 2019 (COVID‐19) pandemic and the resulting isolation measures on the risk of postpartum depression (PPD) after preterm birth.

Methods

This is a cross‐sectional study of mothers of extreme and early preterm infants who completed the Edinburgh Postnatal Depression Scale (EPDS) at the standardized 3–6 months follow‐up consultation for preterm infants. Mothers assessed during the COVID‐19 pandemic (n = 34; from April 1, 2020 to March 31, 2021) were compared with an antecedent control group (n = 108; from January 1, 2017 to December 31, 2019). A multivariable logistic regression model was used to examine the relationship between the pandemic and the risk of PPD (EPDS score ≥13).

Results

The prevalence of depressive symptoms was significantly higher in the COVID‐19 study group (26% versus 12%, P = 0.043). The multivariable logistic regression model showed a significant association between the COVID‐19 pandemic and the risk of PPD (adjusted odds ratio 3.60, 95% confidence interval 1.06–12.59, P = 0.040).

Conclusion

Among mothers of extreme and early preterm infants, the COVID‐19 pandemic was independently associated with a higher risk of PPD. This confirms the need for a close and long‐term follow up of maternal psychological health after preterm birth.

The COVID‐19 pandemic was independently associated with a higher risk of postpartum depression among mothers of extreme and early preterm infants.

The role of maternal nutrition during pregnancy in the intergenerational transmission of childhood adversity

Adverse childhood experiences (ACEs) of a woman can lead to dysregulated hypothalamus-pituitary-adrenal (HPA) axis during pregnancy, which can in turn adversely affect her offspring HPA axis function. Choline and docosahexaenoic acid (DHA) are dietary factors with the potential to favorably modify the stress response system. The current study aimed to investigate whether maternal choline intake and DHA status moderate the effects of maternal ACEs exposure on maternal and infant HPA axes function. Participants were a sub-sample of the prospective longitudinal Alberta Pregnancy Outcomes and Nutrition (APrON) study consisting of 340 mothers and 238 infants. We collected data on maternal ACEs, maternal choline intake (24-hour dietary recall) and serum phospholipid DHA concentrations (at each trimester). Women self-collected saliva samples on two consecutive days (at waking, +30 min, 1100 h, and 2100 h) in each trimester to calculate the cortisol awakening response (CAR) and total daytime cortisol. Infants' salivary cortisol was measured before and after (20, and 40 min) exposure to a blood draw stressor 3 months postpartum. During pregnancy, choline intake moderated (reduced) the association between maternal ACEs and CAR (β = -0.003; 95% CI -0.006, -0.003), but not total daytime cortisol. DHA status did not moderate the association between ACEs and CAR or total daytime cortisol. Choline intake also moderated (reduced) the association between maternal CAR and infant cortisol during a stress task (β = -0.0001; 95% CI -0.0002, -0.00003). Maternal DHA status revealed no modifying effects on these associations. Our findings suggest that maternal choline intake, but not DHA status, can buffer the associations between ACEs and maternal HPA axis, as well as maternal and infant HPA axes function.

Mental health effect of COVID-19 pandemic among women who are pregnant and/or lactating: A systematic review and meta-analysis

OBJECTIVES

The purpose of this study is to examine the effects of coronavirus disease 2019 pandemic on the prevalence of anxiety, depression, stress, insomnia, and social dysfunction among pregnant and/or lactating women and to measure the global pooled prevalence of mental health effects among these populations in the era of coronavirus disease 2019 pandemic.

METHODS

Comprehensive literature searching was conducted and studies published from 1 January 2020 to 30 September 2020 reporting the prevalence of anxiety, depression; stress, insomnia, and social dysfunctions were included. The pooled prevalence of anxiety, depression, stress, insomnia, and social dysfunctions was estimated using a random-effect model. In this study, all statistical analyses were performed using STATA (version 15) software.

RESULTS

There were a total of 19 studies included in the meta-analysis, of which 16, 14, 4, 2, and 2 studies were included in computing the pooled prevalence of anxiety, depression, stress, insomnia, and social dysfunction, respectively. The pooled prevalence of anxiety was 33% (95% confidence interval: 50%-61%), with significant heterogeneity between studies (I2 = 99.68%, p = 0.001). The pooled prevalence of depression was 27% (95% confidence interval: 9%-45%), with remarkable heterogeneity between studies (I2 = 99.29%, p = 0.001). Likewise, the pooled prevalence of stress was 56% (95% confidence interval: 30.07%-82.22%), with significant heterogeneity between studies (I2 = 98.8%, p = 0.0001). The pooled prevalence of social dysfunction was 24.3% (95% confidence interval: 13.41%-62.03%), with significant heterogeneity between studies (I2 = 97.5%, p = 0.0001) and finally, the pooled prevalence of insomnia was 33.53% (95% confidence interval: 3.05%-64.0%), with significant heterogeneity between studies (I2 = 99.6%, p = 0.0001).

CONCLUSIONS

In this study, the mental health effects of the COVID-19 pandemic among pregnant and lactating women were found to be significant. Stress was the most common mental health problem in these population groups. Therefore, policymakers and health planners should give great emphasis to addressing maternal mental well-being during and after this global health crisis. Maternal mental health must be one of the international and national public health priority agendas to enhance the well-being of pregnant and lactating women. Besides, giving psychological support to pregnant and lactating women may reduce the long-term negative effects of this pandemic.

Protocol for the Pregnancy During the COVID-19 Pandemic (PdP) Study: A Longitudinal Cohort Study of Mental Health Among Pregnant Canadians During the COVID-19 Pandemic and Developmental Outcomes in Their Children

BACKGROUND

The COVID-19 pandemic and countermeasures implemented by governments around the world have led to dramatically increased symptoms of depression and anxiety. Pregnant individuals may be particularly vulnerable to the negative psychological effects of COVID-19 public health measures because they represent a demographic that is most affected by disasters and because pregnancy itself entails significant life changes that require major psychosocial and emotional adjustments.

OBJECTIVE

The PdP study was designed to investigate the associations among exposure to objective hardship caused by the pandemic, perceived stress and psychological distress in pregnant individuals, and developmental outcomes in their offspring.

METHODS

The PdP study comprises a prospective longitudinal cohort of individuals who were pregnant at enrollment, with repeated follow-ups during pregnancy and the postpartum period. Participants were eligible if they were pregnant, ≥17 years old, at ≤35 weeks of gestation at study enrollment, living in Canada, and able to read and write in English or French. At enrollment, participants completed an initial survey that assessed demographic and socioeconomic characteristics, previous pregnancies and births, prepregnancy health, health conditions during pregnancy, medications, psychological distress, social support, and hardships experienced because of the COVID-19 pandemic (eg, lost employment or a loved one dying). For the first three months following the initial survey, participants received a monthly email link to complete a follow-up survey that asked about their experiences since the previous survey. After three months, follow-up surveys were sent every other month to reduce participant burden. For each of these surveys, participants were first asked if they were still pregnant and then routed either to the next prenatal survey or to the delivery survey. In the postpartum period, surveys were sent at 3, 6, and 12 months of infant age to assess maternal stress, psychological distress, and infant development.

RESULTS

Participant recruitment via social media (Facebook and Instagram) began on April 5, 2020, and is ongoing. As of April 2021, more than 11,000 individuals have started the initial survey. Follow-up data collection is ongoing.

CONCLUSIONS

This longitudinal investigation seeks to elucidate the associations among hardships, maternal psychological distress, child development during the COVID-19 pandemic, and risk and resilience factors that amplify or ameliorate these associations. The findings of this study are intended to generate knowledge about the psychological consequences of pandemics on pregnant individuals and point toward prevention and intervention targets.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/25407.

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.

A systematic review of caregiver-child physiological synchrony across systems: Associations with behavior and child functioning

Extensive research has established a positive association between caregiver-child behavioral synchrony and child developmental functioning. Burgeoning research examining physiological synchrony has yet to elucidate its impact for children's developing self-regulation. The objectives of this systematic review were to: 1) determine whether there is evidence that caregiver-child physiological synchrony promotes positive child development, 2) examine developmental differences in physiological synchrony and its correlates, and 3) explore whether context, risk, and/or stress influence patterns of synchrony. Sixty-nine studies met the following criteria on PubMed and PsycINFO: 1) peer-reviewed empirical articles in English that 2) examine autonomic, hypothalamic-pituitary-adrenocortical, and/or central nervous system activity 3) for caregivers and children 4) in response to a task and 5) directly examine the association between caregiver and child physiology. Findings varied based on developmental period and current behavioral context. Functional differences may exist across physiological systems and contexts. Synchrony may have different developmental consequences for dyads with and without certain risk factors. Few studies examine physiological synchrony across multiple systems or contexts, nor do they measure child characteristics associated with synchrony. Statistical and methodological challenges impede interpretation. Findings generally support the idea that physiological synchrony may support children's developing self-regulation. Longitudinal research is needed to examine child developmental outcomes over time.

Elevated depression and anxiety symptoms among pregnant individuals during the COVID-19 pandemic

BACKGROUND

Anxiety and depression symptoms in pregnancy typically affect between 10 and 25% of pregnant individuals. Elevated symptoms of depression and anxiety are associated with increased risk of preterm birth, postpartum depression, and behavioural difficulties in children. The current COVID-19 pandemic is a unique stressor with potentially wide-ranging consequences for pregnancy and beyond.

METHODS

We assessed symptoms of anxiety and depression among pregnant individuals during the current COVID-19 pandemic and determined factors that were associated with psychological distress. 1987 pregnant participants in Canada were surveyed in April 2020. The assessment included questions about COVID-19-related stress and standardized measures of depression, anxiety, pregnancy-related anxiety, and social support.

RESULTS

We found substantially elevated anxiety and depression symptoms compared to similar pre-pandemic pregnancy cohorts, with 37% reporting clinically relevant symptoms of depression and 57% reporting clinically relevant symptoms of anxiety. Higher symptoms of depression and anxiety were associated with more concern about threats of COVID-19 to the life of the mother and baby, as well as concerns about not getting the necessary prenatal care, relationship strain, and social isolation due to the COVID-19 pandemic. Higher levels of perceived social support and support effectiveness, as well as more physical activity, were associated with lower psychological symptoms.

CONCLUSION

This study shows concerningly elevated symptoms of anxiety and depression among pregnant individuals during the COVID-19 pandemic, that may have long-term impacts on their children. Potential protective factors include increased social support and exercise, as these were associated with lower symptoms and thus may help mitigate long-term negative outcomes.

Phenotyping stress exposures related to perinatal health disparities

Black American women living in low-resource environments are exposed to multiple stressors and are at high risk for perinatal complications. Stress exposure likely impacts pregnancy and birth complications via alterations in health systems that are engaged in regulating the stress response. Stressors may vary in terms of magnitude and pattern of effect on such health systems. In the present study, we test associations between three types of stress exposure: perceived stress, negative life events, and discrimination stress on neuroendocrine and cardiac response to a controlled laboratory stressor during the first trimester of pregnancy. In all, 100 pregnant Black women with Medicaid insurance completed a laboratory assessment during which salivary cortisol and heart rate variability (HRV) were used to measure stress response to the Trier Social Stress Test (TSST). Results revealed that only discrimination stress was significantly associated with cortisol and HRV in response to the TSST. High levels of discrimination stress were associated with lower levels of cortisol reactivity and higher levels of HRV across the visit. These results highlight the differential impact of domains of stress exposure on stress regulation during pregnancy and provide further evidence of the impact of discrimination stress on Black American women's health.

Adverse childhood experiences in parents of youth with chronic pain: prevalence and comparison with a community-based sample

Supplemental Digital Content is Available in the Text.

Parents of youth with chronic pain reported high rates of adverse childhood experiences, including significantly higher rates of physical neglect than a community-based sample.

Introduction:

Adverse childhood experiences (ACEs) are common occurrences that are related to poor health outcomes, including chronic pain, in youth and adults. Research suggests that children of parents exposed to ACEs are also at risk of poor outcomes. However, little is known about the risk that ACEs confer for chronic pain across generations. Parent ACEs may play an important role in pediatric chronic pain, given their association with key parent factors (eg, mental and physical health).

Objectives:

This study evaluated the prevalence of ACEs in parents of youth with chronic pain and compared these rates to a community-based sample.

Methods:

One hundred seventy parents of youth (aged 10–18 years) with chronic pain, recruited from a tertiary-level chronic pain program at a pediatric hospital in Canada, completed a self-report measure of ACEs. A comparison sample (n = 3914) was drawn from a local, community-based study that examined ACEs among adults in primary care.

Results:

Among parents of youth with chronic pain, 67.6% reported ≥1 ACE and 23.5% reported ≥4 ACEs. Controlling for sociodemographic factors, ACEs were similar across samples, except parents of youth with chronic pain reported significantly higher rates of physical neglect (odds ratio = 2.14; 95% confidence interval = 1.35–3.40) than the community-based sample.

Conclusion:

Adverse childhood experiences are prevalent among parents of youth with chronic pain, with physical neglect reported more frequently than the community-based sample. Further research that examines the association between parent ACEs and child chronic pain, as well as neurobiological and psychosocial factors that may mediate this potential relation, is needed.

Chronic Depression Alters Mothers' DHEA and DEHA-to-Cortisol Ratio: Implications for Maternal Behavior and Child Outcomes

Maternal depression is a major public health problem that typically occurs in the period surrounding childbirth. The neurobiological mechanisms underlying maternal depression have been the focus of increasing research and studies pointed to the crucial role of the HPA axis in this disorder. However, most studies focused on cortisol expression and regulation while recent attention has shifted to include the sulfate steroids DHEA and DHEA-S. A community cohort of 1,983 women with no comorbid risk was recruited at birth and depression was assessed periodically across the first postpartum year. At 6 years, 156 families were re-visited: 46 mothers were defined as chronically-depressed and 103 controls reported no depression from birth to six years. Mothers and children were diagnosed by structured psychiatric interviews and mother-child interactions were observed. Maternal diurnal cortisol (CT) and dehydroepiandrosterone (DHEA) were assessed. Depressed mothers had lower levels of DHEA (AUCg), flattened DHEA diurnal variability (AUCi), and smaller DHEA-to-CT Ratio. Regression analysis demonstrated that maternal sensitivity during mother-child interaction was independently predicted by maternal depression, DHEA levels, child CT, and child social withdrawal. Results underscore the need for multi-level understanding of the dynamic interplay between maternal psychopathology, mother-child relationship, and pituitary-adrenal-cortex-to-medulla balance in studying the cross generational transfer of psychiatric vulnerability from depressed mothers to their children.

The impacts of maternal childhood adversity, stress, and mental health on child development at 6 months in Taiwan: A follow-up study

Exposure to adverse childhood experiences (ACEs) is not only associated with one's adverse health outcomes in adulthood but also increases the risk of child developmental problems in offspring. However, the mechanisms involved in the transmission of the effects of maternal ACEs to the offspring largely remain unexplored. This study sought to identify possible psychosocial pathways of intergenerational effects of maternal ACEs on child development at 6 months. Data from a longitudinal study on maternal childhood adversity and maternal psychosocial risk during pregnancy as well as maternal mental health problems and child development at 6 months postnatal were used. Structural equation modeling with bootstrapping was used to estimate the indirect effects of maternal ACEs on child development at 6 months. The model showed that maternal ACEs indirectly influenced offspring's development via maternal stressful events during pregnancy and pre- and postnatal mental health problems. This finding highlights the possible interventions at the prenatal and postnatal periods. Early identification of women who have ACEs or who are at psychosocial risk during pre- and postnatal periods is critical to provide interventions to buffer those negative effects on offspring's development. Future studies are needed to longitudinally assess the effects of maternal ACEs on child development over time.

Can Children Catch up from the Consequences of Undernourishment? Evidence from Child Linear Growth, Developmental Epigenetics, and Brain and Neurocognitive Development

Recovery from nutritionally induced height deficits continues to garner attention. The current literature on catch-up growth, however, has 2 important limitations: wide-ranging definitions of catch-up growth are used, and it remains unclear whether children can recover from the broader consequences of undernutrition. We addressed these shortcomings by reviewing the literature on the criteria for catch-up in linear growth and on the potential to recover from undernutrition early in life in 3 domains: linear growth, developmental epigenetics, and child brain and neurocognitive development. Four criteria must be met to demonstrate catch-up growth in height: after a period in which a growth-inhibiting condition (criterion 1) causes a reduction in linear growth velocity (criterion 2), alleviation of the inhibiting condition (criterion 3) leads to higher-than-normal velocity (criterion 4). Accordingly, studies that are observational, do not use absolute height, or have no alleviation of an inhibiting condition cannot be used to establish catch-up growth. Adoption and foster care, which provide dramatic improvements in children's living conditions not typically attained in nutrition interventions, led to some (but incomplete) recovery in linear growth and brain and neurocognitive development. Maternal nutrition around the time of conception was shown to have long-term (potentially permanent) effects on DNA methylation in the offspring. Undernourishment early in life may thus have profound irreversible effects. Scientific, program, and policy efforts should focus on preventing maternal and child undernutrition rather than on correcting its consequences or attempting to prove they can be corrected.

Early life adversity and depressive symptoms predict cortisol in pregnancy

Evidence suggests that exposure to early life adversity (ELA) programs the hypothalamic-pituitary-adrenal (HPA) axis to influence responses to later adversity and predisposes women to depression. However, few studies have examined whether ELA moderates the HPA cortisol response to adulthood adversity and depressive symptoms in pregnant women. The aims of this study were to determine (a) whether ELA, adulthood adversity, and depressive symptoms differentially predict patterns of cortisol and (b) whether ELA moderates the relationship of adulthood adversity or depressive symptoms to cortisol. This was a descriptive, cross-sectional study of pregnant women (N = 58, mean = 26.5 weeks gestation). Participants completed the Stress and Adversity Inventory and Edinburgh Depression Scale and collected salivary cortisol five times per day for 3 days to assess cortisol awakening response (CAR), diurnal cortisol slope, and cortisol area under the curve (AUC). ELA predicted a larger CAR, while depressive symptoms predicted a blunted CAR and higher cortisol AUC. Adulthood adversity predicted a blunted CAR and steeper diurnal slope, but only in women with high ELA. ELA also moderated the effect of depressive symptoms on diurnal slope. Early adversity and depressive symptoms appear to have significant effects on the HPA axis during pregnancy, with early adversity also moderating effects of depressive symptoms and adulthood adversity on cortisol regulation. Early adversity may be an important factor in identifying unique HPA phenotypes and risk for HPA axis dysregulation in pregnancy.

Disentangling levels of mother-infant neuroendocrine attunement and longitudinal relations with maternal risk and protective factors

Scientific understanding of mother-infant HPA axis attunement has been limited by discrepant methods for assessing attunement that often conflate different levels of association. We sought to refine the conceptualization of attunement by investigating whether mother-infant cortisol attunement exists as coupling of response trajectories within an acute stress episode, separate from shared developmental patterns and/or overall dyadic similarity in cortisol levels, and whether the degree of attunement depends on within- or between-dyad differences in maternal risk and protective factors. We examined these questions using a longitudinal study with mother/infant salivary cortisol during dyadic stressors at 6, 12, and 18 months postnatal. A three-level hierarchical linear model showed that sample-wide associations between mother and infant cortisol were not significant at any level, suggesting normative lack of attunement; however, there was significant variability in degree of attunement across dyads. Concurrent levels of family resources and social support satisfaction predicted lower mother-infant cortisol attunement within the session, and overall (mean) parenting stress predicted the opposite. Follow-up analyses showed this was typically due to an increase in infants' (but not their mothers') within-session cortisol response slopes with increasing support and decreasing stress. Implications for the role of mother-infant cortisol attunement in intergenerational stress transmission are discussed.

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.

Impact of maternal childhood trauma on child behavioral problems: The role of child frontal alpha asymmetry

Childhood trauma is associated with many long-term negative outcomes, and is not limited to the individual experiencing the trauma, but extends to subsequent generations. However, mechanisms underlying the association between maternal childhood trauma and child psychopathology are not well understood. Here, we targeted frontal alpha asymmetry (FAA) as a potential underlying factor of the relationship between maternal childhood trauma and child behavioral problems. Electroencephalography (EEG) was recorded from (N = 45) children (Mean age = 57.9 months, SD = 3.13) during an eyes-closed paradigm in order to evaluate FAA. Mothers reported on their childhood trauma experiences using the Childhood Trauma Questionnaire (CTQ), and on their child's behavior using the child behavior checklist (CBCL). We found that maternal childhood trauma significantly predicted child total, internalizing, and externalizing behavior at age 5 years. We also observed a role for FAA such that it acted as a moderator, but not mediator, for behavioral problems. We found that children with relative more right/less left frontal activity were more at risk to develop behavioral problems when their mother had been exposed to trauma in her childhood. These results indicate that child frontal asymmetry may serve as a susceptibility marker for child behavioral problems.

Improved Child Mental Health Following Brief Relationship Enhancement and Co-Parenting Interventions During the Transition to Parenthood

The transition to parenthood has been identified as a significant relationship stressor. Many couples report declines in relationship satisfaction and difficulty with individual stress and co-parenting-problems that have been associated with both child temperament as well as emotional and behavioral problems. Several parenting and relationship interventions have been developed to buffer against these difficulties. In the current study, we report secondary analyses of a randomized controlled trial of brief (6-hr) interventions that focused on improving either relationship satisfaction or co-parenting, delivered during pregnancy and the early postpartum period. In this trial, 90 opposite-sex couples (180 participants), who were pregnant with their first child, and were assessed as being at high risk for declines in relationship satisfaction, were randomized to receive either (1) a relationship intervention, (2) a co-parenting intervention, or (3) an information control. At 12 months postpartum, couples who received either the relationship or co-parenting intervention rated their infants as having lower negative emotionality and as having fewer externalizing symptoms compared to the information-only control. Lower externalizing symptoms at 12 months were, in turn, associated with reduced externalizing symptoms at 24 months postpartum. Whereas, lower ratings of child negative emotionality at 12 months were associated with reduced internalizing symptoms at 24 months postpartum. These results indicate that brief relationship or co-parenting interventions delivered during the transition to parenthood have secondary benefits for child mental health.