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| Maternal Alcohol Drinking During Pregnancy Linked to Conduct Problems in Children |
| Date : - 08/11/2007 |
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News Author: Laurie Barclay, MD CME Author: Désirée Lie, MD, MSEd November 8, 2007 — Maternal alcohol drinking during pregnancy seems to be associated with conduct problems in children, according to the results of a longitudinal survey reported in the November issue of the Archives of General Psychiatry. "Existing research on the neurobehavioral consequences of prenatal alcohol exposure (PAE) has not adequately accounted for genetic and environmental confounds," write Brian M. D'Onofrio, PhD, from Indiana University in Bloomington, and colleagues. "PAE has been associated with offspring externalizing problems, such as conduct problems (CPs), criminality, attention/impulsivity problems, and alcohol disorders." Based on data from the National Longitudinal Survey of Youth and the Children of the National Longitudinal Survey of Youth, the goal of this study was to examine the association between prenatal alcohol exposure and offspring externalizing problems in a large representative sample of families in the United States, with measured covariates and a quasi-experimental design to account for unmeasured genetic and environmental confounding factors. The investigators compared siblings with different prenatal alcohol exposures, after controlling for measured characteristics of the mothers and families and exposure to other prenatal psychoactive substances. A stratified and clustered probability sample of 4912 mothers recruited from the community and their 8621 offspring were observed longitudinally. Primary endpoints included maternal report of conduct problems and attention/impulsivity problems in their offspring during childhood (ages 4 - 11 years), with use of standardized evaluations related to psychiatric diagnoses. Independent of confounded genetic and fixed environmental effects and the measured covariates, prenatal alcohol exposure was associated with conduct problems in offspring. Compared with children whose mothers never drank during pregnancy, the children of mothers who drank daily during pregnancy had conduct problems that were 0.35 SD greater. When unrelated offspring were compared, attention/impulsivity problems were associated with prenatal alcohol exposure. However, children whose mothers drank more frequently during pregnancy did not have more attention/impulsivity problems than siblings who had less exposure. Maternal polysubstance use during pregnancy may account for the associations between prenatal alcohol exposure and attention/impulsivity problems, according to the results of additional subsample analyses. "These results are consistent with PAE exerting an environmentally mediated causal effect on childhood CPs, but the relation between PAE and AIPs [attention/impulsivity problems] is more likely to be caused by other factors correlated with maternal drinking during pregnancy," the study authors write. "Prevention efforts should continue to target alcohol consumption during pregnancy." Limitations of the study include quasi-experimental design that cannot prove causality, failure to account for every possible variable that could confound the relationship, the frequency measure of drinking during each pregnancy may not precisely measure prenatal alcohol exposure, retrospective assessment of prenatal substance use, design based on variations in alcohol consumption across pregnancies, findings relevant to the general population only if women who vary their consumption of alcohol across pregnancies are not different from mothers who consistently drank the same amount during each pregnancy, possibly unmeasured characteristics that could moderate the effects of prenatal alcohol exposure, inability to determine whether the confounding factors for attention/impulsivity problems were genetic or environmental in origin, results limited to externalizing problems during childhood reported by the mothers, and use of a sample in which the prevalence of children with extremely high levels of prenatal alcohol exposure was low. "The present study, which was based on a representative sample, a rigorous design, and a sophisticated analytical approach to identify possible confounds, strengthens the inference that PAE has a causal effect on the risk of CPs in offspring," the study authors conclude. "In contrast, the finding that unmeasured confounds related to PAE may be responsible for greater AIPs in offspring suggests that the research community needs to focus on putative environmental risk factors that are correlated with maternal substance use during pregnancy, particularly ones that vary across siblings. The results are consistent with research using different methods but further emphasize the need for additional quasi-experimental studies of prenatal substance exposure." The National Institute of Mental Health supported this study. One of the study authors has received a grant from the National Institute of Mental Health. The remaining study authors have disclosed no relevant financial relationships. Arch Gen Psychiatry. 2007;64:1296-1304. Clinical Context Studies linking prenatal alcohol exposure to conduct and attention-deficit disorders in children are confounded by family processes, parental characteristics, and other maternal substance use, and the contribution of prenatal alcohol exposure to these problems in the offspring of women is unclear. Because alcohol use in mothers during pregnancy is relatively common, it is important to attribute the effect of prenatal alcohol independent of covariates on children. This is a quasi-experimental prospective study examining the offspring of a female cohort within the National Youth Longitudinal Survey begun in 1979, who reported their alcohol and substance use during pregnancy. This sample included 6111 youth with an oversampling of African American and Hispanic youth, of whom 4912 were female sampled who had a child at least 4 years old by 2004. Study Highlights Overall, the cohort of the National Youth Longitudinal Survey male and female youth had biennial assessments between 1979 and 1994 with retention rates of more than 90%. Women were recruited with use of a stratified and clustered probability sample and were observed longitudinally until after giving birth. At ages 15 to 22 years, mothers were asked about their participation in 12 delinquent behaviors with the Self-Reported Delinquency interview, to determine maternal characteristics of conduct problems. Based on self-report of mothers for this study, 17.1% were Hispanic, 25.9% were African American, and 57.1% were non-Hispanic white. Starting in 1986, biennial assessments of offspring of the female cohort were performed in a new longitudinal cohort called Children of the Longitudinal Survey of Youth. Maternal reports of 8621 children between 4 and 11 years old with a history of prenatal alcohol exposure were documented after birth. The analysis statistically accounted for measured characteristics of mothers and families and prenatal exposure to other substances (cigarettes, marijuana, and cocaine). Mean age of mothers at time of first birth was 23 years, mean alcohol frequency was 2.7 days per month, mean number of drinks per day was 1.1, and mean years of education were 12.9. Mothers reported their consumption of alcohol, cigarettes, and substances (marijuana and cocaine) during their pregnancies within 2 years of the birth. 1.6% of the sample of children was exposed to prenatal marijuana and 0.6% to cocaine. Mothers rated their offspring on the Behavior Problem Index including 13 items from the Child Behavior Checklist, which loaded on 3 factors: conduct, oppositional, and attention/impulsivity problems; conduct and attention/impulsivity problems were linked to alcohol exposure in this study. Mean attention/impulsivity problems were found in this cohort to relate to standardized measures of academic achievement at age 10 years, and attention/impulsivity scores correlated with full measures of attention-deficit hyperactivity disorders. Mean prenatal alcohol exposure was associated with maternal delinquency at ages 15 to 22 years and younger age at first birth. Exposure was associated with binge drinking, alcohol frequency, and higher likelihood of having children with different biological fathers. For each additional day of exposure per week, the offspring had an increase of 0.09 SD in conduct problems (P < .001). Offspring exposed to prenatal alcohol every day of the week had an increase of 0.35 SD in conduct problems vs those not exposed to alcohol. Adjustment for siblings differentially exposed to alcohol did not affect the association. Comparisons of cousins with prenatal alcohol exposure suggested that the exposure was independently associated with conduct problems. Children with more prenatal alcohol exposure had more conduct problems than their siblings with less exposure. After controlling for covariates, the investigators saw no association between prenatal alcohol exposure and attention/impulsivity problems. When exposure to nicotine, marijuana, and cocaine was examined, there was a suggestion that an association existed between polysubstance abuse and attention/impulsivity problems. The study authors concluded that there was an association between prenatal alcohol exposure and conduct problems that was not from genetic factors and was associated with alcohol consumption by mothers. They also concluded that the exposure was not a causal factor for attention/impulsivity problems but that polysubstance abuse is likely to contribute to such problems. Pearls for Practice Prenatal alcohol exposure is associated with increased conduct problems in offspring, independent of genetic factors. Prenatal alcohol exposure is not independently associated with attention/impulsivity problems, but polysubstance abuse is likely to be associated with such problems. |
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