Prenatal Stress and Externalizing Behaviors in Childhood and Adolescence: A Meta-analysis

• In Event: Intergenerational and Developmental Origins of Health: Maternal Prenatal Distress and Implications for Offspring Psychopathology

Abstract

Background: Accumulating evidence suggests that psychological distress during pregnancy is linked to offspring risk for externalizing outcomes (e.g., reactive/aggressive behaviors, hyperactivity and impulsivity). However, effect sizes across studies have varied widely due to differences in study design and methodology, including control for the confounding continuation of stress in the postnatal period. Clarifying these inconsistencies is necessary to guide the precision of prevention efforts and inform public health policies. The goals of this study were to: (1) Systematically review the literature and use meta-analytic procedures to summarize the overall association between prenatal psychological distress and offspring externalizing behaviors in childhood and adolescence; (2) Control for the effects of postnatal distress to test the incremental prediction of prenatal distress on offspring externalizing behavior, independent of postnatal distress; and (3) Examine whether the magnitude of association differed based on type or timing of prenatal distress, stability of distress from prenatal to postnatal periods, type or timing of externalizing behavior, or offspring sex.

Method: A meta-analysis was conducted with 45 well-controlled longitudinal studies to investigate the association between prenatal psychological distress and offspring externalizing behaviors, including aggressive behavior, rule-breaking behavior, attention-deficit/hyperactivity disorder (ADHD), and oppositional defiant disorder (ODD) or conduct disorder (CD). Article screening and data extraction were systematically conducted with DistillerSR software using standardized forms developed for title/abstract screening, full-text review, and data extraction, with high inter-rater reliability. Data were analyzed in R using the metafor package for meta-analysis combined with the robumeta package to accommodate robust standard error measurement with clustering factors. Heterogeneity in effect sizes was estimated using the Cochran Q test and I2 values. To explore potential variables that may explain heterogeneity in effect sizes (i.e., moderators), we conducted multilevel random effects models separately for each moderator.

Results: Results revealed a significant but small effect (r=.162) of prenatal distress on offspring externalizing behaviors. The magnitude of the prenatal distress effect size remained largely unchanged after adjusting for postnatal distress (r=.156), implicating a unique and incremental effect of psychological distress during the prenatal period in the etiology of externalizing behaviors. Moderation tests showed that prenatal effects did not vary based on type and timing of prenatal distress; however, greater instability of distress from prenatal to postnatal periods predicted larger effects. Prenatal effects were comparable across most externalizing outcomes (Figures 1-2), consistent with the common comorbidity and shared etiology of externalizing spectrum disorders. Significant associations persisted across all developmental periods, appearing slightly larger in early childhood compared to adolescence.

Discussion: Findings suggests that stress exposure during the prenatal period may uniquely increase children’s vulnerability to aggressive, disinhibited, and impulsive behaviors. Effects are relatively small but persist across developmental periods from early childhood through adolescence. We discuss these results in the context of developmental and psychobiological theories of externalizing behavior, offer preliminary clinical and public health implications, and highlight directions for future research including the need for a broader range of longitudinal studies with more racially and socioeconomically diverse families.

Author

• Irene Tung, California State University - Dominguez Hills
  Presenting Author