Menopause status and climacteric symptoms in a birth cohort of mid-life New Zealand women.

BACKGROUND: There is little current research on the transition to natural menopause among contemporary groups of mid-life women at age 40 years. OBJECTIVE: This study reports on female members of the Christchurch Health and Development Study cohort. This research aimed to: document the menopause status, reproductive outcomes and climacteric symptoms of the women at age 40 years; examine the associations between menopause status and concurrent measures of psychosocial and economic well-being; and document the associations between menopause status and potential predictors of menopause reflecting childhood, family and individual factors prior to age 40 years. METHODS: The Christchurch Health and Development Study is a longitudinal, representative, prospective cohort of 1265 babies (630 females) born in New Zealand in 1977. At age 40 years, 470 women (who had not experienced surgical menopause) were interviewed on their menopause status, climacteric symptoms and associated factors. RESULTS: The majority of women were premenopausal, around 20% were perimenopausal and 2% were postmenopausal. Statistically significant associations were found reflecting higher rates of diagnosed reproductive disorder, climacteric symptoms, low occupational status, non-heterosexual sexuality and exposure to childhood sexual abuse amongst both perimenopausal and postmenopausal women at age 40 years. CONCLUSION: These data will inform directions for future data collection and analyses.

Sexual orientation and mental health over the life course in a birth cohort.

BACKGROUND: Sexual minority individuals consistently report higher rates of mental disorder than heterosexuals. However, much of the research has methodological limitations related to the classification of sexuality, the use of cross-sectional data and problematic sampling procedures such as using convenience samples. METHODS: We used longitudinal data from a birth cohort enrolled in the Christchurch Health and Development Study (n = 1040). Latent class analysis was used to classify participants sexuality based on self-report data of sexual behaviour, attraction, identity and fantasy, gathered over five assessments between the ages of 18 and 35 years. Mental health and substance use outcome data were gathered at four assessments between the ages of 21 and 35 years. Potential covariate variables were collected during childhood. RESULTS: The latent class analysis identified four groups interpreted as: 'heterosexual' 82%, 'mostly heterosexual' 12.6%, 'bisexual' 3.5% and 'gay/lesbian' 1.9%. In the sexual minority groups, women outnumbered men by at least 2:1. Pooled rates for mental health disorders of depression, anxiety disorders, suicidal ideation, cannabis abuse and total disorders, after adjustment for childhood covariate variables, were significantly higher in the sexual minority groups (p < 0.01). The strength of association between sexuality group and mental health outcomes did not differ according to sex. Fluidity in sexuality reports appeared unrelated to risk of mental health outcomes. CONCLUSIONS: Over the life course, membership of a sexual minority group is clearly associated with mental health problems of depression, anxiety and suicidal ideation regardless of the age when same-sex attraction, behaviour, identity or fantasy is expressed.

Cognitive Development Trajectories of Very Preterm and Typically Developing Children.

Cognitive impairment is common among children born very preterm (VPT), yet little is known about how this risk changes over time. To examine this issue, a regional cohort of 110 VPT (≤ 32 weeks gestation) and 113 full-term (FT) born children was prospectively assessed at ages 4, 6, 9, and 12 years using the Wechsler Preschool and Primary Scale of Intelligence-Revised and then Wechsler Intelligence Scale for Children, 4th ed. At all ages, VPT children obtained lower scores than their FT born peers (p < .001). Growth curve modeling revealed stable cognitive trajectories across both groups. Neonatal white matter abnormalities and family socioeconomic adversity additively predicted cognitive risk. Despite some intraindividual variability, cognitive functioning of typically developing and high-risk VPT children was stable and influenced by early neurological development and family rearing context.

Adolescent depression, adult mental health and psychosocial outcomes at 30 and 35 years.

BACKGROUND: There is limited information on long-term outcomes of adolescent depression. This study examines the associations between severity of depression in adolescence and a broad array of adult functional outcomes. METHOD: Data were gathered as part of the Christchurch Health and Development Study, a 35-year longitudinal study of a birth cohort of 1265 children born in Christchurch, New Zealand in 1977. Severity of depression at age 14-16 years was classified into three levels according to DSM symptom criteria for major depression (no depression/sub-threshold symptoms/major depression). This classification was related to adult functional outcomes assessed at ages 30 and 35 years using a generalized estimating equation modeling approach. Outcome measures spanned domains of mental disorder, education/economic circumstances, family circumstances and partner relationships. RESULTS: There were modest but statistically significant bivariate associations between adolescent depression severity and most outcomes. After covariate adjustment there remained weak but significant (p < 0.05) associations with rates of major depression, anxiety disorder, illicit substance abuse/dependence, any mental health problem and intimate partner violence (IPV) victimization. Estimates of attributable risk for these outcomes ranged from 3.8% to 7.8%. For two outcomes there were significant (p < 0.006) gender interactions such that depression severity was significantly related to increased rates of unplanned pregnancy and IPV victimization for females but not for males. CONCLUSIONS: The findings reinforce the importance of the individual/family context in which adolescent depression occurs. When contextual factors and probable maturational effects are taken into account the direct effects of adolescent depression on functioning in mature adulthood appear to be very modest.

Bullying victimization in adolescence and psychotic symptomatology in adulthood: evidence from a 35-year study.

BACKGROUND: There has been considerable recent interest in possible causal linkages between exposure to bullying victimization and later psychotic symptomatology. Prior research in this area has had several limitations which make it difficult to ascertain causality, and to determine the extent to which these effects extend beyond adolescence. METHOD: Data were obtained from the Christchurch Health and Development Study, a 35-year study of a longitudinal birth cohort. This investigation used generalized estimating equation modelling to estimate the associations between bullying victimization (ages 13-16 years) and psychotic symptoms (ages 18-35 years), before and after controlling for possible confounding factors, including: gender; childhood socio-economic status; child intelligence quotient; exposure to sexual abuse in childhood; anxious/withdrawn behaviour and attention problems (ages 7-9 years); and adolescent psychotic symptoms and paranoid ideation (ages 15-16 years). RESULTS: There was a significant (p < 0.0001) bivariate association between bullying victimization in adolescence and psychotic symptomatology in adulthood. Successive models controlling for covariation reduced this association to statistical non-significance. After controlling for covariates, those with the highest level of bullying victimization had rates of psychotic symptoms that were 1.21 (95% confidence interval 0.73-1.99) times higher than those who were not victimized. CONCLUSIONS: The association between bullying victimization in adolescence and psychotic symptomatology in adulthood could be largely explained by childhood behavioural problems, and exposure to sexual abuse in childhood. The results suggest that bullying victimization was unlikely to have been a cause of adult psychotic symptoms, but bullying victimization remained a risk marker for these symptoms.

Life-stress and reactivity by gender in a longitudinal birth cohort at 30 and 35 years.

PURPOSE: Previous literature has shown gender differences in reactivity to stressful life events. However, it is unclear whether gender differences in stress reactivity are consistent across a series of life event domains among longitudinal adult sample populations. METHODS: Data were gathered from the Christchurch Health and Development Study (CHDS). The CHDS is a longitudinal birth cohort of 1265 children born in 1977 in Christchurch, New Zealand. Cohort members were questioned on their experience of, and distress from, a series of life event domains (interpersonal problems; victimization; illness/death; pregnancy/parenthood; employment/finance problems) spanning two age-periods 25-30 years (data collected in 2007) and 30-35 years (data collected in 2012). The data were pooled across observations and analyzed using population-averaged repeated-measures regression methods. RESULTS: Overall, men and women reported experiencing similar numbers of life events for each domain. However, men reported more victimization and more employment/financial problems; women reported more illness/death events. Women reported experiencing more distress per life event for the domains of interpersonal problems, illness/death and pregnancy/parenthood. Men and women reported similar distress per life event for the victimization and employment/finance domains. The results were robust to control for: child and adolescent factors (childhood abuse exposure; adolescent personality; mental health) and adult factors (mental health; self-esteem). CONCLUSION: These findings are consistent with a growing body of evidence indicating that some life events including interpersonal problems, illness/death and pregnancy/parenthood may be intrinsically more distressing for women. Detection of life event distress is important to aid in the prevention of mental/physical health problems.

Life satisfaction and mental health problems (18 to 35 years).

BACKGROUND: Previous research has found that mental health is strongly associated with life satisfaction. In this study we examine associations between mental health problems and life satisfaction in a birth cohort studied from 18 to 35 years. METHOD: Data were gathered during the Christchurch Health and Development Study, which is a longitudinal study of a birth cohort of 1265 children, born in Christchurch, New Zealand, in 1977. Assessments of psychiatric disorder (major depression, anxiety disorder, suicidality, alcohol dependence and illicit substance dependence) using DSM diagnostic criteria and life satisfaction were obtained at 18, 21, 25, 30 and 35 years. RESULTS: Significant associations (p < 0.01) were found between repeated measures of life satisfaction and the psychiatric disorders major depression, anxiety disorder, suicidality, alcohol dependence and substance dependence. After adjustment for non-observed sources of confounding by fixed effects, statistically significant associations (p < 0.05) remained between life satisfaction and major depression, anxiety disorder, suicidality and substance dependence. Overall, those reporting three or more mental health disorders had mean life satisfaction scores that were nearly 0.60 standard deviations below those without mental health problems. A structural equation model examined the direction of causation between life satisfaction and mental health problems. Statistically significant (p < 0.05) reciprocal associations were found between life satisfaction and mental health problems. CONCLUSIONS: After adjustment for confounding, robust and reciprocal associations were found between mental health problems and life satisfaction. Overall, this study showed evidence that life satisfaction influences mental disorder, and that mental disorder influences life satisfaction.

Substance abuse and criminal activities following traumatic brain injury in childhood, adolescence, and early adulthood.

OBJECTIVE: Use a longitudinal birth cohort to evaluate the association of traumatic brain injury at ages 0 to 5, 6 to 15, and 16 to 21 years with drug and alcohol abuse and engagement in criminal activities. MAIN MEASURES: Follow-up over 21 to 25 years using self-report of drug and alcohol use, arrests, and violent and property offenses. Outcomes were assessed for 2 levels of severity (inpatient, hospitalized; outpatient, seen by general practitioner or at emergency department). PARTICIPANTS: Members of the Christchurch Health and Development Study, a longitudinal birth cohort. SETTING: Christchurch, New Zealand. RESULTS: Adjusted for child and family factors, compared with noninjured individuals, inpatients injured at 0 to 5 years or 16 to 21 years were more likely to have symptoms consistent with drug dependence. All inpatient groups had increased risk of arrest, with the age groups of 0 to 5 and 6 to 15 years more likely to be involved in violent offenses and the age group of 0 to 5 years more likely to engage in property offenses. Outpatient group had an increased risk of violent offenses for first injury 0 to 5 years, arrests and property offenses for injury 6 to 15 years, and increased risk of arrests and violent offenses for injury 16 to 21 years of age. However, when alcohol dependence and drug dependence were added as an additional covariate, traumatic brain injury was no longer associated with criminal behavior for the age group of 0 to 5 years. CONCLUSIONS: Traumatic brain injury is associated with increased criminal behavior and may represent a risk factor for offending. However, early substance use is a mediating factor for those injured early in life.

Childhood exposure to sexual abuse and partnership outcomes at age 30.

BACKGROUND: In this study, 30-year longitudinal data from the Christchurch Health and Development Study (CHDS) were used to examine the associations between childhood exposure to sexual abuse and intimate relationship outcomes at age 30. In addition, a broad range of early childhood and family confounding factors were tested, and the role of intervening factors from adolescence was explored. METHOD: The investigation analyzed data from a birth cohort of over 900 New Zealand adults studied to the age of 30. At ages 18 and 21 cohort members reported on any exposure to sexual abuse prior to age 16. This information, along with prospective data gathered in childhood and adolescence, was used to predict partnership outcomes at age 30. RESULTS: After adjustment for early childhood and family factors, exposure to more severe forms of childhood sexual abuse (CSA) was associated with earlier and more frequent cohabitation, higher rates of perpetrated interpartner violence (IPV), and early parenthood, lower relationship satisfaction and investment. Several factors from adolescence partially or fully mediated these associations, notably a history of early consensual sexual intercourse, higher number of sexual partnerships, substance abuse problems, and self-esteem. After adjustment for intervening factors, exposure to CSA remained significantly associated with IPV. CONCLUSIONS: The findings support a causal chain process, whereby early childhood and family factors place some individuals at risk for CSA. The extent of CSA exposure is related to adolescent risk taking, which in turn leads to early and more frequent cohabitation, risk of IPV, and lower relationship satisfaction and investment.

An investigation of the pre-injury risk factors associated with children who experience traumatic brain injury.

BACKGROUND AND OBJECTIVE: Traumatic brain injury (TBI) is a frequently occurring event in childhood that may have significant ongoing effects. Little is known about the child and family characteristics that predispose children to these injuries. A greater understanding of the risk factors associated with childhood TBI may provide an opportunity to prevent their occurrence. METHODS: Information provided by a large birth cohort study (n=1265) was used to determine the child and family risk factors of TBI in children aged 0-15 years (n=187). All information regarding child, family, and injury events were collected prospectively and unrelated to the injury event itself. Child variables included in the analysis were sex and the level of behavioural problems. Parental variables included were family socioeconomic status, mother's age, education level, depressive symptoms, number of adverse life events experienced by the family, and parenting style. RESULTS: The most important risk factors were sex, adverse life events, and parenting style. The results suggest evidence of modest increases in the rate of TBI for those in the highest risk categories (male, >or=4 life events per annum, high maternal punitiveness) compared to the lowest risk categories, with hazard ratios in the region of 1.4-1.6. CONCLUSIONS: Overall characteristics of both the family and child predicted a TBI event. An increased understanding of risks associated with TBI in childhood will provide an avenue to prevent these injuries by targeting at-risk families and aiding the development of appropriate intervention strategies.

Long-term behavioural outcomes of pre-school mild traumatic brain injury.

Abstract Background Mild traumatic brain injury (MTBI) is a leading cause of injury for children during their pre-school years. However, there is little information regarding the long-term outcomes of these injuries. Method We used fully prospective data from an epidemiological study of a birth cohort to examine behavioural effects associated with MTBI during the pre-school years. Cases of confirmed MTBI were divided into two groups, those that had received outpatient medical attention, and those that had been admitted to hospital for a brief period of observation (inpatient cases). The remainder of the cohort served as a reference control group. Results Mother/teacher ratings for behaviours associated with attention deficit/hyperactivity disorder and oppositional defiant/conduct disorder, obtained yearly from age 7 to 13, revealed evidence of deficits after inpatient MTBI (n = 21), relative to more minor outpatient injury MTBI (n = 55) and the reference control group (n = 852). For the inpatient group there was evidence of increasing deficits over years 7-13. Conclusions More severe pre-school MTBI may be associated with persistent negative effects in terms of psychosocial development. The vulnerability of pre-school children to MTBI signals a pressing need to identify high-risk cases that may benefit from monitoring and early intervention.

Comparison of methods to identify significant proteinuria in pregnancy in the outpatient setting.

The efficacy of the albumin/creatinine ratio (ACR) measurement in detection of significant proteinuria when performed in a high-risk antenatal clinic was compared with automated dipstick, protein/creatinine ratio (PCR), and 24-hour urine protein measurements. Both the ACR (DCA 2000) and PCR were strongly predictive for the presence or absence of significant proteinuria, with positive likelihood ratios (LRs) of 27.4 and 31.6 and negative LRs of 0.0 and 0.1, respectively. Both the ACR (DCA 2000) and PCR are effective tests for both identifying and excluding significant proteinuria in the outpatient setting. The ACR (DCA 2000) has the advantage of providing an immediate result.

Comorbidity between depressive disorders and nicotine dependence in a cohort of 16-year-olds.

BACKGROUND: There has been growing interest in the associations between cigarette smoking and symptoms of depression. This study documents the comorbidity between depression and nicotine dependence in a birth cohort of 16-year-olds and examines the extent to which comorbidity between depression and nicotine dependence could be explained by risk factors associated with both outcomes. METHODS: Data were gathered during the course of a 16-year longitudinal study of a birth cohort of 947 New Zealand children for (1) depressive disorders and nicotine dependence at age 16 years; and (2) prospectively measured risk factors including family social position, family history of criminality, parental smoking, life events, parental attachment, conduct problems, self-esteem, and affiliations with delinquent peers. RESULTS: There was evidence of moderate to strong comorbidity between depression and nicotine dependence at age 16 years; teenagers with a depressive disorder had odds of nicotine dependence that were 4.6 times those of teenagers without depressive disorder. Analyses using logistic regression and log-linear modeling methods revealed that a substantial component of the comorbidity between depression and nicotine dependence was explained by common or correlated risk factors associated with both outcomes. After adjustment for common or correlated risk factors, the adjusted odds ratio between depression and nicotine dependence was 2.3. CONCLUSIONS: Comorbidities between depression and nicotine dependence seem to be well established by the age of 16 years. Much of this comorbidity can be explained by common or correlated risk factors associated with depression or nicotine dependence.

Is sexual orientation related to mental health problems and suicidality in young people?

BACKGROUND: This study examines the extent to which gay, lesbian, and bisexual young people are at increased risk of psychiatric disorder and suicidal behaviors using data gathered on a New Zealand birth cohort studied to age 21 years. METHODS: Data were gathered during the course of the Christchurch Health and Development Study, a 21-year longitudinal study of a birth cohort of 1265 children born in Christchurch, New Zealand. At 21 years of age, 1007 sample members were questioned about their sexual orientation and relationships with same-sex partners since the age of 16 years. Twenty-eight subjects (2.8%) were classified as being of gay, lesbian, or bisexual sexual orientation. Over the period from age 14 to 21 years, data were gathered on a range of psychiatric disorders that included major depression, generalized anxiety disorder, conduct disorder, and substance use disorders. Data were also gathered on suicidal ideation and suicide attempts. RESULTS: Gay, lesbian, and bisexual young people were at increased risks of major depression (odds ratio [OR], 4.0; 95% confidence interval [CI], 1.8-9.3), generalized anxiety disorder (OR, 2.8; 95% CI, 1.2-6.5), conduct disorder (OR, 3.8; 95% CI, 1.7-8.7), nicotine dependence (OR, 5.0; 95%, CI, 2.3-10.9), other substance abuse and/or dependence (OR, 1.9; 95% CI, 0.9-4.2), multiple disorders (OR, 5.9; 95% CI, 2.4-14.8), suicidal ideation (OR, 5.4; 95% CI, 2.4-12.2), and suicide attempts (OR, 6.2; 95% CI, 2.7-14.3). CONCLUSIONS: Findings support recent evidence suggesting that gay, lesbian, and bisexual young people are at increased risk of mental health problems, with these associations being particularly evident for measures of suicidal behavior and multiple disorder.

Maternal smoking during pregnancy and psychiatric adjustment in late adolescence.

BACKGROUND: This study assessed the extent to which exposure to maternal smoking during pregnancy was associated with increased risks of psychiatric symptoms in late adolescence (adolescents aged 16-18 years) when due allowance was made for confounding or selection factors associated with maternal smoking during pregnancy. METHODS: Data were gathered during an 18-year longitudinal study of a birth cohort of 1265 children born in New Zealand. The measures collected included (1) maternal smoking during pregnancy; (2) assessments of psychiatric problems (conduct disorder, major depression, and anxiety and substance use disorders) at age 16 to 18 years; and (3) measures of potentially confounding social, family, and parental factors. RESULTS: Children exposed to maternal smoking during pregnancy had higher psychiatric symptom rates for conduct disorder, alcohol abuse, substance abuse, and depression. Those children whose mothers smoked at least 1 pack of cigarettes per day during their pregnancy had symptom rates that were between 1.4 and 2.5 (median, 2.0) times higher than the children of nonsmokers. Smoking during pregnancy was also associated with a series of adverse or disadvantageous factors that included (1) socioeconomic disadvantage, (2) impaired child-rearing behaviors, and (3) parental and family problems. After adjustment for these confounding and selection factors, smoking during pregnancy was significantly associated with an increased rate of conduct disorder symptoms in late adolescence (P<.001). This effect was more pronounced for male than female adolescents. CONCLUSIONS: This study suggests that maternal smoking during pregnancy may contribute to childrens' risk of later externalizing problems. There is a need to further explore the moderating effect of the sex of the child and to clarify the underlying pathophysiological features of this relationship.

Nocturnal enuresis and behavioral problems in adolescence: a 15-year longitudinal study.

OBJECTIVE: This study examines the relationships between nocturnal enuresis in childhood and measures of behavioral adjustment in adolescence using data collected during the course of a 15-year longitudinal study of a birth cohort of New Zealand children. METHOD: Data was collected on patterns of nocturnal bladder control at annual intervals to the age of 13 years. At ages 11, 13, and 15 years measures of conduct problems, attention deficit behaviors, and anxiety/withdrawal were gathered. RESULTS: The analysis showed that children who were bed-wetting after the age of 10 years as a result of either primary or secondary enuresis had increased rates of behavioral problems up to the age of 15 years with these children having mean behavior scores that were between .30 to .65 standard deviations higher than children who ceased bed-wetting before the age of 5 years. Regression analysis indicated that these associations were largely spurious and arose because the age of cessation of bedwetting was correlated with a series of factors (gender, social maturity, childhood IQ, family social background, family stress, and parental conflict) that were also associated with increased rates of adolescent behavior problems. However, even after adjusting for these factors, children who were bed-wetting after the age of 10 years showed slight increases in rates of conduct problems and attention deficit behaviors up to the age of 13 years and increases rates of anxiety/withdrawal up to the age of 15 years. CONCLUSIONS: It is concluded that bed-wetting after the age of 10 years is associated with small but detectable increases in risks of conduct problems, attention deficit behaviors, and anxiety/withdrawal in early adolescence. These results show that although it is not the case that children showing nocturnal enuresis are at markedly increased risks of serious psychiatric problems, it may be prudent to determine the extent to which children who are bed-wetting after the age of 10 years show increases in anxious or problem behaviors.

Early solid feeding and recurrent childhood eczema: a 10-year longitudinal study.

The relationship between early solid feeding practices and risks of recurrent or chronic eczema in childhood was examined in a birth cohort of New Zealand children studied to the age of 10. By the age of 10 years, 7.5% of children had chronic or recurrent eczema. There were clear and consistent associations between the diversity of the child's diet during the first 4 months and risks of eczema. Even when due allowance was made for a range of confounding factors--including parental atopic illness, atopic illness in siblings, the child's early milk diet, and family social background--children exposed to four or more different types of solid food before 4 months had risks of recurrent or chronic eczema that were 2.9 times those of children who were not exposed to early solid feeding. It is concluded that early exposure to a diet diverse in potential food antigens may act to predispose susceptible children to recurrent or chronic childhood eczema.

Social and familial factors in the development of early childhood asthma.

The role of social and familial factors in the development of childhood asthma by age 6 years was studied in a birth cohort of New Zealand children. Rates of asthma varied markedly with the child's sex; boys had twice the rate of asthma as girls. In addition, the factors associated with asthma varied with the child's sex. For boys, wheeze during infancy, early eczema, and parental asthma were all significant risk factors; for girls, the only risk factor was early eczema. Proportional hazards modeling of the data failed to show any significant associations between the development of asthma and a large range of other social and familial factors including breast-feeding, parental smoking habits, pets in the child's family, stress in the family, or family social background. It was concluded that asthma in early childhood appeared to be inherited to some extent, its age of expression was related to the child's sex, and it had a complex interaction with other forms of allergic disease. There was no evidence to suggest that the structure, practices, or dynamics of the child's family played a significant role in the development of asthma for children in this birth cohort.

Maternal smoking before and after pregnancy: effects on behavioral outcomes in middle childhood.

OBJECTIVE: The aim of this research was to examine the extent to which maternal smoking before and after pregnancy was associated with childhood disruptive behaviors when due allowance was made for potentially confounding factors which may have been associated with both maternal smoking habits and childhood problem behaviors. METHODS: During the course of a 15-year longitudinal study of a birth cohort of 1265 New Zealand children, the following measures were obtained: (1) measures of daily cigarette intake during pregnancy and after pregnancy; (2) measures of childhood disruptive behaviors including conduct problems and attention deficit behaviors based on both maternal and teacher report data; and (3) measures of a series of potentially confounding family, social, parental, and related factors. RESULTS: Before adjustments for confounding, maternal smoking both before and after pregnancy was found to be associated with significant increases in rates of childhood problem behaviors: children whose mothers smoked in excess of 20 cigarettes per day had mean problem behavior scores that were between 0.16 and 0.56 standard deviations higher than those of children whose mothers were nonsmokers. The results were then adjusted using regression methods to take account of (1) correlations between pregnancy and postpregnancy smoking and (2) potentially confounding factors. The results of regression adjustment suggested that maternal smoking during pregnancy was associated with small but statistically detectable increases in rates of childhood problem behaviors, with children whose mothers smoked in excess of 20 cigarettes per day having mean scores that were 0.10 to 0.36 standard deviations higher than those of the offspring of nonsmokers, even after adjustment for a series of confounding factors. However, smoking after pregnancy was not significantly associated with increased rates of childhood problem behavior after adjustment for sources of confounding. CONCLUSION: The results are generally consistent with the hypothesis that smoking during pregnancy may be associated with small but detectable increases in the risks of problem behaviors in childhood. This suggests that possible adverse effects on childhood behavioral adjustment should be added to the growing list of adverse consequences of parental smoking for childhood health and well-being.