The Transition to Parenthood in Obstetrics: Enhancing Prenatal Care for Two Generation Impact

Editorial: In Utero Exposure to Maternal Affective Symptoms: Prenatal Programming of Child Psychopathology Is Independent of Shared Genes of Risk

The womb is an influential first home. This felicitous phrase is attributed to David Barker, often called the father of the late 20th century developmental origins of health and disease hypothesis, which asserts that maternal experiences during pregnancy are biologically transmitted to, and embedded in, the fetus, shaping child development.1 Specifically, Barker focused on maternal inadequate nutrition as a key in utero exposure to which the fetus biologically adapts, leading to biologically programmed changes, meaning long-lasting, that potentially put the offspring at risk for future metabolic diseases.1 In more recent developmental origins of health and disease publications, the impact of affective symptoms in pregnant women-defined broadly to include perceived stress, depression, and anxiety-on fetal and infant brain and behavior development has been identified. There is a third pathway for the familial inheritance of risk for psychiatric illness beyond shared genes and compromised parental postnatal mental health and caregiving: prenatal programming of risk for psychopathology originating in mental health symptoms of mothers.1 However, despite decades of experimental preclinical studies demonstrating maternal prenatal stress predicting altered offspring outcomes,2 the alternative interpretation-that shared genes of risk account for the outcomes-has remained challenging to disprove for human studies, perhaps particularly when the mother reports on her own and her child's mental health (a common study design further addressed below). In this context, the article by Chen et al.3 using polygenic risk scores to provide a single measure of genomic risk for complex phenotypes reports rigorous and original results demonstrating effects of maternal affective symptoms on child psychiatric outcomes while controlling for genomic risk.

Current perspectives on perinatal mental health and neurobehavioral development: focus on regulation, coregulation and self-regulation

PURPOSE OF REVIEW

Perinatal mental health research provides an important perspective on neurobehavioral development. Here, we aim to review the association of maternal perinatal health with offspring neurodevelopment, providing an update on (self-)regulation problems, hypothesized mechanistic pathways, progress and challenges, and implications for mental health.

RECENT FINDINGS

(1) Meta-analyses confirm that maternal perinatal mental distress is associated with (self-)regulation problems which constitute cognitive, behavioral, and affective social-emotional problems, while exposure to positive parental mental health has a positive impact. However, effect sizes are small. (2) Hypothesized mechanistic pathways underlying this association are complex. Interactive and compensatory mechanisms across developmental time are neglected topics. (3) Progress has been made in multiexposure studies. However, challenges remain and these are shared by clinical, translational and public health sciences. (4) From a mental healthcare perspective, a multidisciplinary and system level approach employing developmentally-sensitive measures and timely treatment of (self-)regulation and coregulation problems in a dyadic caregiver-child and family level approach seems needed. The existing evidence-base is sparse.

SUMMARY

During the perinatal period, addressing vulnerable contexts and building resilient systems may promote neurobehavioral development. A pluralistic approach to research, taking a multidisciplinary approach to theoretical models and empirical investigation needs to be fostered.

A Two-Generation, Early Childhood Advanced Primary Care Model

It is well recognized that early experiences produce long-term impacts on health outcomes, yet many children are at risk of not achieving their full potential because of health and service disparities related largely to poverty and racism. Although many pediatric primary care (PPC) models address these needs, most are isolated, add-on efforts that struggle to be scalable and sustainable. We describe 3-2-1 IMPACT (Integrated Model for Parents and Children Together), an initiative to transform the model of PPC delivered within New York City Health + Hospitals, the largest public hospital system in the United States, to address the full range of child and family needs in early childhood. Taking advantage of the frequent contact with PPC in the early years and linking to prenatal services, the model assesses family mental, social, and physical health needs and offers evidence-based parenting supports and integrated mental health services. Launching and sustaining the model in our large health system has required coalition building and sustained advocacy at the state, city, and health system levels. Long-term sustainability of the IMPACT model will depend on the implementation of early childhood-focused advanced payment models, on which we have made substantial progress with our major contracted Medicaid managed care plans. By integrating multiple interventions into PPC and prenatal care across a large public-healthcare system, we hope to synergize evidence-based and evidence-informed interventions that individually have relatively small effect sizes, but combined, could substantially improve child and maternal health outcomes and positively impact health disparities.

Do dyadic interventions impact biomarkers of child health? A state-of-the-science narrative review

BACKGROUND

Early life adversity is related to numerous poor health outcomes in childhood; however, dyadic interventions that promote sensitive and responsive caregiving may protect children from the negative consequences of such exposures. To date, quasi-experimental and randomized controlled trials (RCTs) have examined the impact of dyadic interventions on a range of individual biomarkers in children, which may elucidate the relation between early stress exposure and transdiagnostic risk factors for prospective poor health. However, the content of interventions, analytic strategies, and findings vary widely across studies, obscuring key themes in the science and hindering policy and research efforts.

METHODS

We use a narrative approach to review findings from methodologically rigorous (predominantly RCT) studies of dyadic interventions' impacts on different biomarkers in children, including indicators of the hypothalamic-pituitary-adrenal (HPA) axis, parasympathetic (PNS) and sympathetic nervous systems (SNS), brain development, inflammation, and intracellular DNA processes. We contribute to this important area of inquiry through integrating findings across biological systems and identifying contextual and mechanistic factors to depict the current state of the field.

RESULTS

Evidence suggests dyadic interventions improved PNS functioning and advanced brain maturation. Some studies indicated interventions reduced hair cortisol concentrations, systemic inflammation, and resulted in differences in DNA methylation patterns. Findings did not support main effect-level change in salivary measures of HPA axis activity, SNS activity, or telomere length. Importantly, reviewed studies indicated significant heterogeneity in effects across biological systems, underscoring the importance of contextual factors (e.g., adversity subtype and severity) as potential moderators of effects. Further, findings suggested enhanced parenting behaviors may be a mechanism through which dyadic interventions operate on biomarkers.

CONCLUSIONS

We close with future policy and research directions, emphasizing the promise of biologically-informed dyadic interventions for understanding and ameliorating the effects of early adversity on transdiagnostic biomarkers of health.