Research paperThe influence of pre and postnatal adversity on depression and anxiety over two decades
Introduction
The Developmental Origins of Health and Disease (DOHaD) hypothesis posits that exposure to adversity during the perinatal period can have enduring implications for the developing brain (Barker, 2007; Gillman, 2005). Over the past several decades, studies have linked pre and early postnatal adversities to a range of chronic illnesses later in life (Heindel and Vandenberg, 2015). Relatively less is known about the effects of both pre and postnatal stressors on mental health, as research in this area has largely focussed on postnatal stress (Heim et al., 2008; Raymond et al., 2017). Moreover, most of the studies that have linked perinatal adversity to psychopathology have been cross-sectional in nature, limiting our understanding of how these exposures affect the developmental trajectories of mental health across the lifespan. This is important because of the normative reductions in internalizing and externalizing symptomatology that occur in general population samples over time (Galambos et al., 2006; Rawana and Morgan, 2014).
Individuals born preterm are a unique group of individuals who are exposed to significant physiological stress during gestation and the early postnatal period. They also appear to be at increased risk for psychopathology over time, with particular difficulties with attention, anxiety, and social skills in childhood, and anxiety and depression in adolescence and adulthood (Mathewson et al., 2017). This may be linked to the fact that as a group, preterm survivors tend to have more cerebral white matter damage (Volpe, 2009), reductions in the size of the corpus callosum (Woodward et al., 2006), and alterations in hypothalamus-pituitary-adrenal (HPA) axis functioning (Finken et al., 2017; Waxman, Van Lieshout, Boyle, Saigal, and Schmidt, 2015).
Studies testing the DOHaD hypothesis have not only highlighted links between prenatal adversity and adult health outcomes, but have also shown that prenatal adversity can lead to an underlying vulnerability that is “programmed” prenatally and that emerges or is amplified by postnatal stressors (Grant, Sandman, Wing, Dmitrieva, Davis, 2015). Based on the DOHaD hypothesis, one would expect that exposure to pre and early postnatal stress disrupts normative development of physiological stress response systems. Such disruptions may “program” a particular vulnerability that increases the susceptibility to psychopathology in the face of significant childhood adversities like child sexual abuse (CSA). CSA is one of the most detrimental forms of early adversity due to its propensity to increase the risk for psychopathology across the lifespan. It is associated with disruptions in the normative development of the HPA axis (Heim et al., 2008; Miller et al., 2007), and subsequent internalizing (depression and anxiety) and externalizing behaviors (aggression, conduct and oppositional problems) throughout adolescence and adulthood (Chen et al., 2010; Cutajar et al., al.,2010; Hillberg et al., 2011; Papalia et al., 2017).
Even though very early adversity is known to affect stress response systems, it remains unclear if the type and timing of stressors produces a general propensity to psychopathology or if the risk of internalizing or externalizing problems are specifically increased. Individuals born at lower birth weights appear to be at risk for both internalizing and externalizing problems in childhood; however, by adolescence and adulthood, internalizing problems remain elevated while externalizing problems do not appear to persist (Mathewson et al., 2017). Meanwhile, individuals who have been exposed to CSA are at an increased risk for both internalizing and externalizing psychopathology in adulthood (Cutajar et al., 2010; Papalia et al., 2017). It is important therefore to examine how the joint effects of perinatal and later postnatal stressors like CSA affect psychiatric risk in the longer term.
To date, very few studies have examined associations between pre and postnatal forms of adversity on psychopathology. Costello et al. (2007) found that childhood adversity increased the risk of depression in adolescent girls born at LBW (<2500 g) more than those born at normal birth weight (NBW). Similarly, Favaro and colleagues (2009) found that the interaction between perinatal complications and childhood abuse increased the risk for anorexia nervosa in a sample of adult women, such that childhood abuse only put individuals at elevated risk for anorexia nervosa if they had also been exposed to stress perinatally. Meanwhile, Nomura and Chemtob (2007) found that adolescents born at LBW and also exposed to childhood abuse were at a heightened risk for depression in adolescence compared to adolescents born at LBW and not exposed. Given the paucity of studies in this area, it remains uncertain how and if joint exposure to perinatal and later postnatal adversities affect not only the development of mental health problems, but their evolution and maintenance over time.
Examining the longitudinal trajectories of psychopathology in those exposed to perinatal stress is a relatively novel way to test the DOHaD hypothesis as it applies to mental health. To date, no known research has examined the cumulative effect of perinatal stress and postnatal adversity on mental health outcomes over several decades of life in the same sample. Such longitudinal studies have a number of advantages over cross-sectional surveys, as the latter cannot speak to the progression of mental health, nor be used to identify sensitive periods of exposure. Examining the interaction between pre and postnatal adversity on psychopathology from adolescence through adulthood can also provide important insights into the etiology of psychiatric problems, as well as useful clinical information to survivors of prenatal adversity, their families, and healthcare providers in terms of how mental health problems might emerge, develop, and evolve over time. Such findings can then be used to highlight optimal timing of interventions, both preventive and therapeutic.
In the present study, we examined the effects of birth weight status, CSA, and their joint impact on the trajectories of internalizing and externalizing problems from adolescence through adulthood. CSA is a particularly deleterious form of postnatal adversity, and so it is important to examine as it is may be associated with the highest risk for internalizing and externalizing outcomes relative to other forms of maltreatment (Lewis et al., 2016; Lindert et al., 2013). Because extremely low birth weight (ELBW; <1000 g) survivors appear to be at an increased risk for depression and anxiety in adolescence and adulthood, we predicted a significant interaction between birth weight status and CSA, such that internalizing problems among ELBW survivors exposed to CSA would be consistently greater across time (from adolescence to adulthood) than the internalizing problems in NBW control participants exposed to CSA. We adjusted in our analyses for maternal negative affect, physical abuse, and family function, as these are thought to confound associations between prenatal adversity and/or CSA and mental health outcomes (Costello et al., 2007; Goodman et al., 2011; Hillberg et al., 2011; Lindert et al., 2014; Plant et al., 2015; Repetti et al., 2002). We also predicted that the internalizing outcomes of ELBW survivors exposed to CSA would be worse over time than the internalizing outcomes of ELBW survivors not exposed to CSA.
Section snippets
Participants and procedures
This study was comprised of participants enrolled in the McMaster ELBW Cohort, a longitudinally followed sample initially consisting of 179 ELBW survivors born between 1977 and 1982 in southwestern Ontario. All participants who survived until hospital discharge were included in the study, and no other inclusion or exclusion criteria were applied. The sample was primarily Caucasian (89%). One-hundred and forty-five NBW participants matched to the ELBW sample on age, sex, and socioeconomic status
Results
The sociodemographic and birth characteristics of the study sample are presented in Table 1. The mean birth weight for the ELBW and NBW groups were 841.5 gs and 3387.6 gs, respectively. The average gestational age at birth was 28.4 weeks for the ELBW participants and 40 weeks for NBW participants. Both groups completed similar amount of years of education. A significant interaction between birth weight status and child sexual abuse predicted intercept (baseline level of symptoms) for
Discussion
We utilized data from the oldest known, continuously followed ELBW cohort in the world to examine how perinatal adversity interacted with CSA to predict longitudinal trajectories of internalizing and externalizing problems from adolescence to adulthood. We report that ELBW birth status plus exposure to CSA predicts stably higher levels of internalizing problems over two decades than being born at an NBW and being exposed to CSA. Similarly, the joint effect of perinatal (ELBW) and postnatal
Conclusions
Interactions between CSA and ELBW were observed in the present study for internalizing outcomes, whereby exposure to both perinatal and postnatal adversity was related to a stable, increased risk of internalizing problems from adolescence through adulthood compared to exposure to either adversity alone. Such findings support and extend the DOHaD hypothesis, highlighting that perinatal adversity may put individuals at elevated risk for internalizing problems when also exposed to childhood
Role of funding
The study design and data collection were supported by the Canadian Institutes of Health Research Team Grant and National Institute of Child Health and Human Development Grant.
CRediT authorship contribution statement
Jessie I. Lund: Conceptualization, Methodology, Formal analysis, Writing - original draft, Writing - review & editing. Calan Savoy: Conceptualization, Methodology, Writing - original draft, Writing - review & editing. Louis A. Schmidt: Data curation, Funding acquisition, Methodology, Supervision, Writing - review & editing. Mark A. Ferro: Conceptualization, Methodology, Writing - review & editing. Saroj Saigal: Methodology, Data curation, Funding acquisition, Project administration. Ryan J. Van
Declaration of Competing Interest
All authors declare that they have no conflicts of interest.
Acknowledgements
The authors thank the many participants and their families for their continued participation. This work was supported by a Canadian Institutes of Health Research (CIHR) Team Grant (TMH-103145, awarded to LAS) and a National Institute of Child Health and Human Development (NICHD) Grant (R01HD40219, awarded to SS).
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