Model of perinatal care but not prenatal stress exposure is associated with birthweight and gestational age at Birth: The Australian birth in the time of COVID (BITTOC) study.

OBJECTIVE: The present study aimed to understand, relative to standard care, whether continuity of care models (private midwifery, continuity of care with a private doctor, continuity of care with a public midwife), and women's experience of maternity care provision, during the perinatal period buffered the association between prenatal maternal stress (PNMS) and infant birth outcomes (gestational age [GA], birth weight [BW] and birth weight for gestational age [BW for GA]). METHODS: 2207 women who were pregnant in Australia while COVID-19 restrictions were in place reported on their COVID-19 related objective hardship and subjective distress during pregnancy and provided information on their model of maternity care. Infant birth outcomes (BW, GA) were reported on at 2-months postpartum. RESULTS: Multiple linear regressions showed no relationship between PNMS and infant BW, GA or BW for GA, and neither experienced continuity of care, nor model of maternity care moderated this relationship. However, compared with all other models of care, women enrolled in private midwifery care reported the highest levels of experienced continuity of care and birthed infants at higher GA. BW and BW for GA were higher in private midwifery care, relative to standard care. CONCLUSION: Enrollment in continuous models of perinatal care may be a better predictor of infant birth outcomes than degree of PNMS exposure. These results highlight the possibility that increased, continuous support to women during pregnancy may play an important role in ensuring positive infant birth outcomes during future pandemics.

Relationships between cortisol levels across early childhood and processing speed at age 4.5 years in children born very preterm.

Children born very low gestational age (VLGA, 29-32 weeks gestational age [GA]) display slower processing speed and altered hypothalamic pituitary adrenal (HPA) axis function, with greater effects in those born extremely low gestational age (ELGA; 24-28 weeks GA). We investigated trajectories of HPA axis activity as indexed by cortisol output and patterns across cognitive assessment at ages 1.5, 3 and 4.5 years, comparing children born ELGA and VLGA and associations with 4.5-year processing speed. In a prospective longitudinal cohort study, infants born very preterm (<33 weeks gestation) returned for developmental assessment at ages 1.5, 3, and 4.5 years. At each age, children completed standardized cognitive testing and saliva samples collected before (Pretest), during (During) and after (End) challenging cognitive tasks were assayed for cortisol. For the total group (n = 188), cortisol area under the curve with respect to ground (AUCg) decreased, while cortisol reactivity to challenge (Pre-test to During) increased from 1.5 to 3 years, remaining stable to 4.5 years. This longitudinal pattern was related to higher Processing Speed (WPPSI-IV) scores at 4.5 years. Children born ELGA displayed higher AUCg than VLGA, particularly at age 3, driven by higher Pre-test cortisol levels. Overall, relative to those born VLGA, children born ELGA displayed greater cortisol responsivity to cognitive challenge. A higher setpoint of cortisol levels at age 3-years in children born ELGA may reflect altered HPA axis regulation more broadly and may contribute to difficulties with information processing in this population, critical for academic and social success.

Cortisol levels are related to neonatal pain exposure in children born very preterm at age 18 months in two independent cohorts.

Exposure to pain-related stress from frequent invasive procedures in the neonatal intensive care unit (NICU) has been associated with altered physiological stress regulation, neurodevelopment, and behavior in children born very preterm (≤32 weeks gestation). Previously, in a cohort born 2003-2006 (Cohort 1), we found that, at 18 months corrected age (CA), children born extremely low gestational age (ELGA; 24-28 weeks) and very low gestational age (VLGA; 29-32 weeks), had higher pre-test cortisol levels and a different pattern of cortisol output across a developmental assessment involving cognitive challenge compared to children born full-term (FT; 39-41 weeks). Also, greater neonatal pain-related stress exposure among the preterm children was related to higher pre-test cortisol levels. Given the adverse long-term effects of neonatal pain in preterm infants and the ensuing rise in clinical concerns to appropriately manage pain in the NICU in recent years, we aimed to examine whether our findings from Cohort 1 would still be evident in an independent cohort (Cohort 2) born 2006-2011 and recruited from the same tertiary NICU in Vancouver, Canada. We also compared the cortisol patterns, clinical and socio-demographic factors, and their interrelationships between the two cohorts. In Cohort 2, our findings using multi-level modeling support and extend our earlier findings in Cohort 1, demonstrating that children born ELGA display higher pre-test cortisol levels than FT. As well, greater cortisol output across assessment was related to more anxiety/depressive behaviors in children born VLGA. Importantly, children born ELGA were exposed to less neonatal pain/stress, mechanical ventilation, and morphine in Cohort 2 than Cohort 1. In both cohorts, however, cortisol levels and patterns were related to neonatal pain/stress and clinical factors (days on mechanical ventilation, overall morphine exposure). Despite less exposure to pain/stress and adverse clinical factors in Cohort 2 compared to Cohort 1, cortisol levels and patterns across cognitive challenge in preterm children at 18-month CA were consistent across the two independent cohorts. These findings highlight that, despite improvements to neonatal care, children born extremely preterm continue to display altered HPA axis activity, which is associated with their poorer neurodevelopmental and behavioral outcomes.

Prenatal maternal stress was not associated with birthweight or gestational age at birth during COVID-19 restrictions in Australia: The BITTOC longitudinal cohort study.

BACKGROUND: Various forms of prenatal maternal stress (PNMS) have been reported to increase risk for preterm birth and low birthweight. However, the associations between specific components of stress - namely objective hardship and subjective distress - and birth outcomes are not well understood. AIMS: Here, we aimed to determine the relationship between birthweight and gestational age at birth and specific prenatal factors (infant gender and COVID-19 pandemic-related objective hardship, subjective distress, change in diet), and to determine whether effects of hardship are moderated by maternal subjective distress, change in diet, or infant gender. MATERIALS AND METHODS: As part of the Birth in the Time of COVID (BITTOC study), women (N = 2285) who delivered in Australia during the pandemic were recruited online between August 2020 and February 2021. We assessed objective hardship and subjective distress related to the COVID pandemic and restrictions, and birth outcomes through questionnaires that were completed at recruitment and two months post-partum. Analyses included hierarchical multiple regressions. RESULTS: No associations between maternal objective hardship or subjective distress and gestational age at birth or birthweight were identified. Lower birthweight was significantly associated with female gender (adjusted ß = 0.083, P < 0.001) and with self-reported improvement in maternal diet (adjusted ß = 0.059, P = 0.015). CONCLUSIONS: In a socioeconomically advantaged sample, neither objective hardship nor subjective distress related to COVID-19 were associated with birth outcomes. Further research is warranted to understand how other individual factors influence susceptibility to PNMS and how these findings are applicable to women with lower socioeconomic status.

Early-life exposure to analgesia and 18-month neurodevelopmental outcomes in very preterm infants.

BACKGROUND: We assessed variability of analgesic use across three tertiary neonatal intensive care units (NICUs) accounting for early-life pain, quantified as number of invasive procedures. We also determined whether analgesia exposure modifies associations between early-life pain and neurodevelopment. METHODS: Multicenter prospective study of 276 very preterm infants (born <24-32 weeks' gestational age [GA]). Detailed data of number of invasive procedures and duration of analgesia exposure were collected in initial weeks after birth. Eighteen-month neurodevelopmental assessments were completed in 215 children with Bayley Scales for Infant Development-Third edition. RESULTS: Multivariable linear regressions revealed significant differences in morphine use across sites, for a given exposure to early-life pain (interaction p < 0.001). Associations between early-life pain and motor scores differed by duration of morphine exposure (interaction p = 0.01); greater early-life pain was associated with poorer motor scores in infants with no or long (>7 days) exposure, but not short exposure (≤7 days). CONCLUSIONS: Striking cross-site differences in morphine exposure in very preterm infants are observed even when accounting for early-life pain. Negative associations between greater early-life pain and adverse motor outcomes were attenuated in infants with short morphine exposure. These findings emphasize the need for further studies of optimal analgesic approaches in preterm infants. IMPACT: In very preterm neonates, both early-life exposure to pain and analgesia are associated with adverse neurodevelopment and altered brain maturation, with no clear guidelines for neonatal pain management in this population. We found significant cross-site variability in morphine use across three tertiary neonatal intensive care units in Canada. Morphine use modified associations between early-life pain and motor outcomes. In infants with no or long durations of morphine exposure, greater early-life pain was associated with lower motor scores, this relationship was attenuated in those with short morphine exposure. Further trials of optimal treatment approaches with morphine in preterm infants are warranted.

Association of Neonatal Pain-Related Stress and Parent Interaction With Internalizing Behaviors Across 1.5, 3.0, 4.5, and 8.0 Years in Children Born Very Preterm.

Importance: Internalizing (anxiety and/or depressive) behaviors are prevalent in children born very preterm (24-32 weeks' gestation). Procedural pain-related stress in the neonatal intensive care unit (NICU) is associated with long-term internalizing problems in this population; however, whether positive parenting during toddlerhood attenuates development of internalizing behaviors across childhood is unknown. Objective: To investigate whether neonatal pain-related stress is associated with trajectories of internalizing behaviors across 1.5, 3.0, 4.5, and 8.0 years, and whether supportive parenting behaviors and lower parenting stress at 1.5 and 3.0 years attenuate this association. Design, Setting, and Participants: In this prospective longitudinal cohort study, preterm neonates (born at 24-32 weeks' gestation) were recruited from August 16, 2006, to September 9, 2013, with follow-up visits at ages 1.5, 3.0, 4.5, and 8.0 years. The study was conducted at BC Women's Hospital, Vancouver, Canada, with recruitment from a level III neonatal intensive care unit and sequential developmental assessments performed in a Neonatal Follow-up Program. Data analysis was performed from August to December 2021. Main Outcomes and Measures: Parental report of child internalizing behaviors on the Child Behavior Checklist at 1.5, 3.0, 4.5, and 8.0 years. Results: A total of 234 neonates were recruited, and 186 children (101 boys [54%]) were included in the current study across ages 1.5 (159 children), 3.0 (169 children), 4.5 (162 children), and 8.0 (153 children) years. After accounting for clinical factors associated with prematurity, greater neonatal pain-related stress was associated with more internalizing behaviors across ages (B = 4.95; 95% CI, 0.76 to 9.14). Higher parenting stress at age 1.5 years (B = 0.17; 95% CI, 0.11 to 0.23) and a less supportive parent environment (less sensitivity, structure, nonintrusiveness, nonhostility, and higher parenting stress; B = -5.47; 95% CI, -9.44 to -1.51) at 3.0 years were associated with greater internalizing problems across development to age 8.0 years. Conclusions and Relevance: In this cohort study of children born very preterm, exposure to repetitive neonatal pain-related stress was associated with persistent internalizing behavior problems across toddlerhood to age 8.0 years. Supportive parenting behaviors during early childhood were associated with better long-term behavioral outcomes, whereas elevated parenting stress was associated with more child anxiety and/or depressive behaviors in this population. These findings reinforce the need to prevent pain in preterm neonates and inform future development of targeted parent-led behavioral interventions.

Neonatal pain, thalamic development and sensory processing behaviour in children born very preterm.

BACKGROUND: Altered sensory processing is commonly reported in children born very preterm (≤32 weeks' gestational age [GA]). The immature nervous system, particularly the development of connections from the thalamus to the cortex, may show enhanced vulnerability to excessive sensory stimulation, and may contribute to altered sensory processing. Our objective was to determine whether sensory processing assessed at preschool-aged in children born very preterm was predicted by neonatal procedural pain and thalamic development. METHODS: In a prospective longitudinal cohort study, N = 140 very preterm infants (median GA at birth 28 weeks) underwent MRI early-in-life and again at term-equivalent age. Children returned for assessment at 4.5 years. Parents reported on child sensory processing behaviors on the Short Sensory Profile. General linear models were used to assess factors associated with sensory processing behaviors, adjusting for clinical and demographic factors. RESULTS: Among extremely preterm neonates (born 24-28 weeks' GA), but not very-preterm neonates (29-32 weeks' GA), more invasive procedures were associated with poorer sensory processing (B = -0.09, 95%CI [-0.17, -0.01] p = 0.03). In the overall cohort, fewer sensory processing problems were associated with greater thalamic growth between birth and term-equivalent age (B = 0.3, 95%CI [0.11, 0.42], p < 0.001). Extremely preterm neonates exposed to a high number of skin-breaking procedures who exhibited slower neonatal thalamic growth displayed the highest sensory processing problems (B = -26.2, 95%CI [-45.96, -6.38], p = 0.01). CONCLUSION: Early exposure to pain and related alterations in the developing thalamus may be a key factor underlying later sensory problems in children born extremely preterm.

Prenatal stress from the COVID-19 pandemic predicts maternal postpartum anxiety as moderated by psychological factors: The Australian BITTOC Study.

BACKGROUND: While there have been reports of increased perinatal anxiety during the COVID-19 pandemic (Stepowicz et al., 2020), there has been a lack of research on the relative importance of objective hardship and subjective distress. In this study, we explored the extent to which resilience, tolerance of uncertainty, and cognitive appraisal of the pandemic's consequences moderate the effect of prenatal objective hardship and subjective distress due to the pandemic on 2-month postpartum anxiety. METHODS: Data were collected as part of the Birth in the Time of COVID (BITTOC) study. We measured objective hardship and subjective distress, mental health, and potential psychological moderators in 419 pregnant women residing in Australia, and at two months postpartum. Hierarchical multiple regressions were used. RESULTS: Objective hardship and subjective distress independently predicted postpartum anxiety. All three psychological factors moderated the effect of objective hardship on anxiety. For women with low/neutral resilience, or low/moderate tolerance of uncertainty, or a negative cognitive appraisal, greater objective hardship predicted higher postpartum anxiety. Conversely, for women with high resilience, or high tolerance of uncertainty, or neutral/positive cognitive appraisal, there was no association. Only a neutral/positive cognitive appraisal significantly buffered the effect of subjective distress on anxiety. LIMITATIONS: Participants self-selected themselves into the study. The generalizability of our results could be restricted to women of higher socio-economic status. CONCLUSIONS: These findings help us better understand options for intervention and assessment of vulnerable women during times of stress, along with the mechanisms by which COVID-related stress during pregnancy contributes to postpartum anxiety.

Perinatal Depression in Australian Women during the COVID-19 Pandemic: The Birth in the Time of COVID-19 (BITTOC) Study.

The COVID-19 pandemic has impacted perinatal mental health globally. We determined the maternal factors and pandemic-related experiences associated with clinically significant perinatal (pregnant and post-partum) depressive symptoms in Australian women. Participants (n = 2638; pregnant n = 1219, postnatal n = 1419) completed an online survey (August 2020 through February 2021) and self-reported on depression, social support, and COVID-19 related experiences. We found elevated depressive symptoms amongst 26.5% (pregnant) and 19% (postnatal) women. Multiple logistic regression analyses showed higher likelihood of elevated depression associated with residence in Victoria, lower education, past/current mental health problems, greater non-pandemic prenatal stress, age ≥ 35 years (pregnant women) and existing physical health issues or disability in self or others (postnatal women). Greater family stress/discord and lower social support (friends) was associated with higher odds of elevated perinatal depression, while lower social support (family) was significantly associated with elevated depressive symptoms in pregnant women. Greater depression was associated with social distancing, pandemic-related news exposure and changes to prenatal care (pregnant women). Single postnatal women showed lower odds of elevated depression than partnered women. Our findings underscore the importance of universal screening for depression and targeted support during a pandemic for perinatal women displaying vulnerability factors.

Lower Maternal Chronic Physiological Stress and Better Child Behavior at 18 Months: Follow-Up of a Cluster Randomized Trial of Neonatal Intensive Care Unit Family Integrated Care.

OBJECTIVE: To assess whether Family Integrated Care (FICare) in the neonatal intensive care unit improves maternal chronic physiological stress and child behavior at 18 months of corrected age for infants born preterm. STUDY DESIGN: Follow-up of a multicenter, prospective cluster-randomized controlled trial comparing FICare and standard care of children born at <33 weeks of gestation and parents, stratified by tertiary neonatal intensive care units, across Canada. Primary outcomes at 18 months of corrected age were maternal stress hormones (cortisol, ie, hair cumulative cortisol [HCC], dehydroepiandrosterone [DHEA]) assayed from hair samples. Secondary outcomes included maternal reports of parenting stress, child behaviors (Internalizing, Externalizing, Dysregulation), and observer-rated caregiving behaviors. Outcomes were analyzed using multilevel modeling. RESULTS: We included 126 mother-child dyads from 12 sites (6 FICare sites, n = 83; 6 standard care sites, n = 43). FICare intervention significantly lowered maternal physiological stress as indicated by HCC (B = -0.22 [-0.41, -0.04]) and cortisol/DHEA ratio (B = -0.25 [-0.48, -0.02]), but not DHEA (B = 0.01 [-0.11, 0.14]). Enrollment in FICare led to lower child Internalizing (B = -0.93 [-2.33, 0.02]) and Externalizing behavior T scores (B = -0.91 [-2.25, -0.01]) via improvements to maternal HCC (mediation). FICare buffered the negative effects of high maternal HCC on child Dysregulation T scores (B = -11.40 [-23.01, 0.21]; moderation). For mothers reporting high parenting stress at 18 months, FICare was related to lower Dysregulation T scores via maternal HCC; moderated mediation = -0.17 (-0.41, -0.01). CONCLUSIONS: FICare has long-term beneficial effects for mother and child, attenuating maternal chronic physiological stress, and improving child behavior in toddlerhood. CLINICAL TRIAL REGISTRATION: NCT01852695.

Childhood Anxiety: Prenatal Maternal Stress and Parenting in the QF2011 Cohort.

In this study we examine whether specific 'anxiety-maintaining' parenting behaviors (i.e., overinvolvement and/or negativity) exacerbate the effects of disaster-related prenatal maternal stress (PNMS) on school-age anxiety symptoms. Women (N = 230), pregnant at the time of the 2011 Queensland Floods, reported on their experience of flood-related PNMS (objective hardship, cognitive appraisal, subjective distress). At 4-years, mother-child dyads were coded for maternal overinvolvement and negativity during a challenging task; at 6-years mothers reported on their children's anxiety symptoms and their own mood, N = 83. Results showed no associations between PNMS and 6-year anxiety, nor did parenting moderate these effects. Poorer maternal concurrent mood was associated with greater anxiety symptoms at 6 years (ß = 0.52). Findings suggest maternal concurrent mood, but not exposure to disaster-related PNMS nor 'anxiety-maintaining' parenting behaviors at preschool age, is related to school-age anxiety symptoms.

Sensory processing and cortisol at age 4 years: Procedural pain-related stress in children born very preterm.

Children born preterm display altered sensory processing, which may manifest as hyper- and/or hypo-sensitivity to sensory information. In this vulnerable population, exposure to neonatal pain-related stress is associated with altered stress regulation, as indexed by alterations in cortisol levels. It is unknown whether sensory processing behaviors are also affected by early life adversity, and whether dysregulated cortisol is related to sensory processing problems in preterm children. We examined relationships between neonatal pain-related stress, sensory processing profiles and cortisol levels at age 4 years, and whether pathways were sex-specific. In a longitudinal prospective cohort study, N = 146 infants born 24-32 weeks gestational age were recruited from BC Women's Hospital, Vancouver, BC, Canada; neonatal factors were collected from daily chart review. At age 4 years, saliva to assay cortisol was collected three times across cognitive assessment (pre-test, during, end) and parents completed the Short Sensory Profile questionnaire. Using generalized linear modeling, independent of other neonatal factors, higher number of invasive procedures (pain/stress) was associated with more sensory processing problems (total, hypo- and hyper-sensitivity) for girls only. After accounting for neonatal factors, greater cortisol output across the assessment was associated with more total sensory processing problems in girls only, and hypersensitivity to sensory input in both boys and girls. Findings suggest that in children born very preterm, how a child responds to sensory input and cortisol reactivity to stress are related but may have different precursors. Girls may be somewhat more susceptible to neonatal pain-related stress exposure in relation to sensory processing at preschool age.

The late positive potential (LPP): A neural marker of internalizing problems in early childhood.

BACKGROUND: One potentially relevant neurophysiological marker of internalizing problems (anxiety/depressive symptoms) is the late positive potential (LPP), as it is related to processing of emotional stimuli. For the first time, to our knowledge, we investigated the value of the LPP as a neurophysiological marker for internalizing problems and specific anxiety and depressive symptoms, at preschool age. METHOD: At age 4 years, children (N = 84) passively viewed a series of neutral, pleasant, and unpleasant pictures selected from the International Affective Pictures System. Affective picture processing was measured via the LPP (EEG recorded) and mothers reported on child behavior via the Child Behavior Checklist 1 ½ - 5 (internalizing, DSM-anxiety, DSM-affective/depression subscales). Difference scores between the neutral and affective pictures (i.e., neutral-pleasant and neutral-unpleasant) were computed for posterior, central and anterior brain locations for early (300-700 ms), middle (700-1200 ms) and late (1200-2000 ms) time windows. RESULTS: Greater LPP difference scores for pleasant images in the anterior recording site, in the middle time window, were associated with greater internalizing behaviors. Greater DSM-anxiety symptoms were associated with greater LPP difference scores for unpleasant and pleasant images. After correcting for multiple testing, only the association between greater DSM-affective/depression symptoms and greater LPP difference scores for unpleasant images in the anterior recording site (early time window) remained significant. DISCUSSION: Our study has identified a potential neural marker of preschool internalizing problems. Children with larger LPPs to unpleasant images may be at greater risk of internalizing problems, potentially due to an increased emotional reactivity.

Disaster-related prenatal maternal stress, and childhood HPA-axis regulation and anxiety: The QF2011 Queensland Flood Study.

BACKGROUND: The fetal programming hypothesis suggests that prenatal maternal stress (PNMS) influences aspects of fetal development, such as the Hypothalamic Pituitary Adrenal (HPA) axis, enhancing susceptibility to emotional problems. No study (to our knowledge) has investigated this pathway considering development of preschool anxiety symptoms. Using data from the Queensland Flood study (QF2011), our objective was to determine whether toddler HPA-axis functioning mediated the association between aspects of flood-related PNMS and child anxiety symptoms at 4-years, and whether relationships were moderated by the timing of the stressor in utero or by the child's sex. METHODS: Women, pregnant during the 2011 Queensland floods (N = 230), were recruited soon afterwards and completed questionnaires regarding their objective hardship (e.g., loss of personal property), subjective distress (post-traumatic-like symptoms) and cognitive appraisal of the disaster. At 16 months, indexes of the child's diurnal cortisol rhythm (awakening response, total daily output, diurnal slope [N = 80]), and stress reactivity (N = 111), were obtained. At 4-years, N = 117 mothers reported on their own mood and their children's anxiety symptoms; of these, N = 80 also had valid child cortisol reactivity data, and N = 64 had diurnal cortisol rhythm data. RESULTS: A greater cortisol awakening response at 16 months mediated the relationship between subjective PNMS and anxiety symptoms at 4-years. Greater toddler daily cortisol secretion predicted more anxiety symptoms, independent of PNMS. The laboratory stressor did not elicit a cortisol response. PNMS effects were not dependent upon child sex nor on gestational timing of flood exposure. CONCLUSIONS: Indexes of diurnal cortisol in toddlerhood may represent vulnerability for anxiety symptoms in preschoolers, both independent of, and following, exposure to disaster-related prenatal maternal subjective distress.

Toddler Temperament Mediates the Effect of Prenatal Maternal Stress on Childhood Anxiety Symptomatology: The QF2011 Queensland Flood Study.

It is not known whether alterations to temperamental characteristics associated with prenatal maternal stress (PNMS) exposure account for the development of childhood anxiety symptomatology (internalizing behaviors and anxiety symptoms). The QF2011 Queensland flood study examined whether (1) toddler temperamental characteristics explained the association between PNMS exposure and childhood anxiety symptomatology; and (2) whether effects were dependent upon child sex or the timing of gestational exposure to PNMS. We investigated the effects of various aspects of flood-related stress in pregnancy (objective hardship, cognitive appraisal, subjective distress) on maternal report of 16-month toddler temperament (attentional control, shy-inhibition, negative reactivity), 4-year maternal-reported childhood anxiety symptomatology (internalizing and anxiety symptoms; N = 104), and teacher reports of internalizing behaviors (N = 77). Severity of maternal objective hardship during pregnancy and shy-inhibited behaviors were uniquely associated with 4-year child anxiety symptoms. Mediation analyses found that higher levels of 16-month negative reactivity accounted, in part, for the relationship between increased maternal objective flood-related hardship and greater internalizing behaviors (maternal but not teacher report). Neither child sex nor gestational timing of exposure moderated the hypothesized mediations. Our findings highlight several pathways through which varying aspects of disaster-related PNMS may influence early childhood anxiety symptomatology.

The role of prenatal maternal stress in the development of childhood anxiety symptomatology: The QF2011 Queensland Flood Study.

It is possible that findings suggesting a link between prenatal maternal stress (PNMS) and anxiety symptoms in offspring are confounded by postnatal and/or shared mother-child heritability effects. Following exposure to a natural disaster, the Queensland Flood Study investigated the unique and additive effects of various types of disaster-related PNMS (objective hardship, cognitive appraisal, and subjective distress) on childhood anxiety symptomatology (internalizing and/or anxiety symptom measures). Timing of flood exposure during pregnancy and child sex were examined as potential moderators. After controlling for maternal psychosocial factors, greater objective hardship as a result of the floods was significantly associated with greater anxiety symptoms (N = 114) and marginally associated with greater internalizing behaviors (N = 115). Earlier timing of the flood in pregnancy was associated with greater anxiety symptoms. No such associations were found between any PNMS measure and teacher-rated child internalizing behaviors (N = 90). Sex and timing did not moderate associations. Our findings suggest that, in isolation, increased maternal hardship due to exposure to an independent stressor, during pregnancy, may have a programming effect on childhood anxiety symptoms.

Prenatal Maternal Distress: A Risk Factor for Child Anxiety?

The deleterious association between various types of prenatal maternal psychological distress (PNMS, anxiety, depression, psychological distress, stress) and childhood anxiety symptomatology (internalizing behaviors, anxiety symptoms) has been established using both retrospective and prospective longitudinal studies across varied demographic cohorts and throughout development. Yet, the existing literature cannot claim maternal distress during pregnancy to be a specific risk factor for anxiety symptomatology, as studies utilizing such observational designs are unable to adequately account for confounding of potential genetic factors and the postnatal environment. In this review, we examine studies that attempt to minimize such confounding and thus disentangle the unique intrauterine exposure effect of varying types of PNMS on childhood anxiety symptomatology. Such methodologies include paternal versus maternal comparison studies, sibling comparisons, prenatal cross-fostering designs and timing of exposure studies (including disaster studies). Of the identified studies, findings indicate that prenatal maternal distress is likely to constitute a risk factor for anxiety symptomatology, although more studies are needed to replicate current findings in order to determine whether there are clear differences in effects across specific types of PNMS and for specific subpopulations. We review the methodological limitations and strengths of the literature prior to exploring avenues of future research and implications for theory and clinical practice.