Prenatal stress and externalizing behaviors in childhood and adolescence: A systematic review and meta-analysis.

Abstract

Accumulating evidence suggests that psychological distress during pregnancy is linked to offspring risk for externalizing outcomes (e.g., reactive/aggressive behaviors, hyperactivity, and impulsivity). Effect sizes across studies have varied widely, however, due to differences in study design and methodology, including control for the confounding continuation of distress in the postnatal period. Clarifying these inconsistencies is necessary to guide the precision of prevention efforts and inform public health policies. A meta-analysis was conducted with 55 longitudinal studies to investigate the association between prenatal psychological distress (anxiety, depression, and perceived stress) and offspring externalizing behaviors. Results revealed a significant but small effect (r = .160) of prenatal distress on externalizing behaviors. The magnitude of the prenatal effect size remained largely unchanged after adjusting for postnatal distress (r = .159), implicating a unique 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 psychological distress during pregnancy. Greater instability of distress from prenatal to postnatal periods predicted larger effects. Prenatal effects were comparable across most externalizing outcomes, consistent with the common comorbidity of externalizing spectrum disorders, although effects appeared smaller for nonaggressive rule-breaking (vs. aggressive) behaviors. Significant associations persisted across all developmental periods, appearing slightly larger in early childhood. 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 longitudinal studies with more racially and socioeconomically diverse families.

Programming the next generation of prenatal programming of stress research: A review and suggestions for the future of the field

“…In contrast, studies in larger samples at older child ages have found no moderation by child sex in the prediction of maternal report of child internalizing at age 4 (N = 1948; Bush et al, 2023); or age 4-13 internalizing (N = 7,944; O' Donnell et al, 2014); or age 8 youth self-report of depression or anxiety (N = 1,389; Noroña-Zhou et al, 2022). The recent metanalysis of maternal distress effects on externalizing (Tung et al, 2023) also found no support for child-sex-specific associations. It is quite possible that biological sex differences may be more important for other child outcomes or for developmental periods, such as adolescence, where pubertal onset and associated hormonal shifts play in important role in the development of mental health (Gunnar et al, 2009).…”

“…That said, researchers do and should continue to attempt to untangle timing. Notably, the meta-analysis of studies predicting children's externalizing problems revealed that prenatal stress effects on child externalizing did not vary based on type and timing of psychological distress during pregnancy (Tung et al, 2023), although effects were larger for earlier outcome timepoints and greater instability of distress between the pre-and postnatal period was associated with larger effects on children's behavior.…”

“…The evidence for intergenerational transmission of stress effects extends to outcomes across development, suggesting persistence of effects into early childhood and adolescence in the form of socioemotional and behavioral problems as well as a full range of more specific indicators of neurodevelopment, cognitive development, negative affectivity, difficult temperament and psychiatric disorders (Van den Bergh et al, 2020). Using externalizing problems as an example, a recent meta-analytic review of 55 studies (Tung et al, 2023) found that psychological distress during pregnancy was uniquely associated with increased risk for child externalizing problems (age 2-18 years), including aggressive, disinhibited, and impulsive behaviors. Notably, these effects were largely similar across the range of externalizing outcomes examined, although the size of effects was larger for aggressive behaviors than nonaggressive rule-breaking behaviors.…”

Resilience to stress during pregnancy: Biopsychosocial mechanisms and implications for offspring emotional and behavioral outcomes in toddlerhood.

“…Exposure to high levels of stress during pregnancy is a known risk factor for a wide range of offspring outcomes, including early differences in emotionality and behavioral regulation (MacKinnon et al, 2018; Tung et al, 2023; Van den Bergh et al, 2020). Drawing from the Developmental Origins of Health and Disease theory, growing evidence suggests that frequent exposure to life stressors during pregnancy may be a key pathway through which stress-related health disparities are maintained across generations (Entringer et al, 2015; Lefmann & Combs-Orme, 2014; Lu & Halfon, 2003).…”