Prenatal cocaine exposure: the role of cumulative environmental risk and maternal harshness in the development of child internalizing behavior problems in kindergarten

The effects of a music enrichment program on parent-infant interactions during mealtime: A randomized controlled trial

BACKGROUND

Parent-child interactions are linked to childhood obesity. Music enrichment programs enhance parent-child interactions and may be a strategy for early childhood obesity prevention.

OBJECTIVE

We implemented a 2-year randomized, controlled trial to assess the effects of a music enrichment program (music, n = 45) vs. active play date control (control, n = 45) on parent-child interactional quality and infant weight status.

METHODS

Typically developing infants aged 9-to 15-months were enrolled with a primary caregiver in the Music Together ® or a play date program. Participants attended once per week group meetings for 12 months and once per month group meetings for an additional 12 months. Parent-child interaction was measured using the Parent Child Early Relational Assessment (PCERA) at baseline, month 6, 12, and 24. We used a modified intent-to-treat mixed model regression to test group differences in parent-child interactions and Weight for length z-score (zWFL) growth trajectories were modeled.

RESULTS

There were significant differential group changes across time for negative affect during feeding (group*month; p = 0.02) in that those parents in the music group significantly decreased their negative affect score compared with the control group from baseline to month 12 (music change = -0.279 ± 0.129; control change = +0.254 ± 0.131.; p = 0.00). Additionally, we also observed significant differential group changes across time for parent intrusiveness during feeding (group*month; p = 0.04) in that those parents in the music group significantly decreased their intrusiveness score compared with the control group from month 6 to month 12 (music change = -0.209 ± 0.121; control change = 0.326 ± 0.141; p = 0.01). We did not find a significant association between any of the changes in parental negative affect and intrusiveness with child zWFL trajectories.

CONCLUSION

Participating in a music enrichment program from an early age may promote positive parent-child interactions during feeding, although this improvement in the quality of parent-child interactions during feeding was not associated with weight gain trajectories.

Prenatal substance exposure, early-life adversity, and parenting: Associations with adolescent stress response

We tested a conceptual model examining associations between prenatal substance exposure and adolescent cortisol reactivity profiles in response to an acute social evaluative stressor. We included cortisol reactivity in infancy, and direct and interactive effects of early-life adversity and parenting behaviors (sensitivity, harshness) from infancy to early school age on adolescent cortisol reactivity profiles in model testing. Participants were 216 families (51% female children; 116 cocaine-exposed) recruited at birth, oversampled for prenatal substance exposure, and assessed from infancy to early adolescence (EA). Majority of participants self-identified as Black (72% mothers, 57.2% adolescents), and caregivers were primarily from low-income families (76%), were single (86%), and had high school or below education (70%) at recruitment. Latent profile analyses identified three cortisol reactivity patterns including elevated (20.4%), moderate (63.1%), and blunted (16.5%) reactivity groups. Prenatal tobacco exposure was associated with higher likelihood of membership in the elevated reactivity compared to the moderate reactivity group. Higher caregiver sensitivity in early life was associated with lower likelihood of membership in the elevated reactivity group. Prenatal cocaine exposure was associated with higher maternal harshness. Interaction effects among early-life adversity and parenting indicated that caregiver sensitivity buffered, and harshness exacerbated, the likelihood that high early adversity would be associated with the elevated and blunted reactivity groups. Results highlight the potential importance of prenatal alcohol and tobacco exposure for cortisol reactivity and the role of parenting as exacerbating or buffering the impact of early-life adversity on adolescent stress response.

Effects of an attachment-based intervention on autonomic regulation among opioid-exposed infants

Little is known about whether postnatal intervention enhances autonomic regulation among infants at risk for dysregulation due to prenatal opioid exposure. The present study evaluated the effects of modified Attachment Behavioral Catch-up (mABC) on autonomic regulation for opioid-exposed infants in a pilot randomized clinical trial. We hypothesized that, compared to a control intervention (modified Developmental Education for Families [mDEF]), mABC would be associated with higher resting respiratory sinus arrhythmia (RSA) and pre-ejection period (PEP) as well as greater reactivity to and recovery from a social stressor (Still-Face Paradigm). Pregnant or peripartum women receiving opioid agonist therapy (61 mothers of 64 infants; final N = 36 infants) were randomly assigned to mABC or mDEF, 12-session home visiting programs beginning in the third trimester; mABC targets sensitive parenting, and mDEF targets cognitive and motor development. mABC was associated with significantly greater RSA reactivity and marginally greater PEP reactivity. In models accommodating missing data, mABC was additionally associated with significantly greater RSA recovery. In sensitivity analyses removing siblings, mABC predicted significantly enhanced PEP reactivity. Overall, in these preliminary analyses, mABC was associated with healthier autonomic regulation during a social stressor than mDEF. Thus, mABC may be a promising strategy to promote autonomic regulation among opioid-exposed infants through parenting intervention.

Prenatal drug exposure and executive function in early adolescence

PURPOSE

Study of the relationship between prenatal cocaine exposure (PCE) and executive function (EF) has yielded inconsistent results. The purpose of the current study is to examine whether PCE, biological sex, environmental risk, and their interaction predicted EF in early adolescence.

METHODS

135 12-year-old adolescents (40.7% with PCE), who were followed prospectively from birth, attempted up to 8 Tower of Hanoi (ToH) puzzle trials of increasing complexity. The number of correctly completed puzzles served as the main outcome measure. Survival analysis was used to examine predictors of the number of successfully completed trials.

RESULTS

As trial difficulty increased, fewer adolescents were able to solve the TOH puzzle. Adolescents from high risk environments and with either prenatal alcohol or prenatal cannabis exposure completed fewer puzzles (p < .05). In addition, a hypothesized 3-way interaction of PCE x sex x environmental risk was found such that cocaine-exposed males with high environmental risk had the worst performance (p < .01).

CONCLUSIONS

The current findings are consistent with prior research indicating that males with PCE may be at particular risk of poorer functioning and highlight the potential importance of examining adolescent's sex and environmental risk as moderators of PCE effects.

Prenatal Substance Exposure and Developmental Trajectories of Internalizing Symptoms: Toddlerhood to Preadolescence

BACKGROUND

Little is known about how prenatal exposure to substances (alcohol, tobacco, marijuana, and cocaine) may contribute to heterogeneous childhood trajectories of internalizing symptoms (i.e., depression, withdrawal, anxiety). The present study aimed to identify developmental trajectories of internalizing symptoms in children using gender-separate analyses and to examine whether trajectories differ by prenatal substance exposure (PSE) and other environmental and biological correlates.

METHODS

Data from two large community-based birth cohorts with PSE were integrated (N = 1,651, 848 boys, 803 girls): the Cleveland cohort and the Maternal Lifestyle Study (MLS). Internalizing symptoms were assessed with the Child Behavior Checklist at ages 2, 4, 6, 9, 10, 11, and 12 in the Cleveland study and at ages 3, 5, 7, 9, 11, and 13 in the MLS.

RESULTS

Gender-separate group-based trajectory modeling yielded five distinctive developmental trajectories of internalizing symptoms from ages 2 to 13 in both boys and girls: low-risk group (14.4% girls, 28.8% boys); normative-decreasing group (35.3% girls, 33.1% boys); increasing risk group (14.4% girls, 13.0% boys); early-high group (22.3% girls, 17.9% boys); and chronic group (13.8% girls, 7.2% boys). Prenatal tobacco exposure, maternal psychological distress, and postnatal maternal alcohol use differentiated the longitudinal courses of internalizing symptoms. Boys were more likely to follow the low-risk trajectory, whereas girls were more likely to follow the chronic trajectory.

CONCLUSIONS

Prenatal tobacco exposure was associated with suboptimal developmental trajectories of internalizing symptoms in the context of prenatal poly-drug exposure, highlighting a need for continued and increased effort toward prevention of prenatal tobacco use.

Video feedback for parental sensitivity and attachment security in children under five years

BACKGROUND

Children who are securely attached to at least one parent are able to be comforted by that parent when they are distressed and explore the world confidently by using that parent as a 'secure base'. Research suggests that a secure attachment enables children to function better across all aspects of their development. Promoting secure attachment, therefore, is a goal of many early interventions. Attachment is mediated through parental sensitivity to signals of distress from the child. One means of improving parental sensitivity is through video feedback, which involves showing a parent brief moments of their interaction with their child, to strengthen their sensitivity and responsiveness to their child's signals.

OBJECTIVES

To assess the effects of video feedback on parental sensitivity and attachment security in children aged under five years who are at risk for poor attachment outcomes.

SEARCH METHODS

In November 2018 we searched CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, nine other databases and two trials registers. We also handsearched the reference lists of included studies, relevant systematic reviews, and several relevant websites SELECTION CRITERIA: Randomised controlled trials (RCTs) and quasi-RCTs that assessed the effects of video feedback versus no treatment, inactive alternative intervention, or treatment as usual for parental sensitivity, parental reflective functioning, attachment security and adverse effects in children aged from birth to four years 11 months.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

This review includes 22 studies from seven countries in Europe and two countries in North America, with a total of 1889 randomised parent-child dyads or family units. Interventions targeted parents of children aged under five years, experiencing a wide range of difficulties (such as deafness or prematurity), or facing challenges that put them at risk of attachment issues (for example, parental depression). Nearly all studies reported some form of external funding, from a charitable organisation (n = 7) or public body, or both (n = 18). We considered most studies as being at low or unclear risk of bias across the majority of domains, with the exception of blinding of participants and personnel, where we assessed all studies as being at high risk of performance bias. For outcomes where self-report measures were used, such as parental stress and anxiety, we rated all studies at high risk of bias for blinding of outcome assessors. Parental sensitivity. A meta-analysis of 20 studies (1757 parent-child dyads) reported evidence of that video feedback improved parental sensitivity compared with a control or no intervention from postintervention to six months' follow-up (standardised mean difference (SMD) 0.34, 95% confidence interval (CI) 0.20 to 0.49, moderate-certainty evidence). The size of the observed impact compares favourably to other, similar interventions. Parental reflective functioning. No studies reported this outcome. Attachment security. A meta-analysis of two studies (166 parent-child dyads) indicated that video feedback increased the odds of being securely attached, measured using the Strange Situation Procedure, at postintervention (odds ratio 3.04, 95% CI 1.39 to 6.67, very low-certainty evidence). A second meta-analysis of two studies (131 parent-child dyads) that assessed attachment security using a different measure (Attachment Q-sort) found no effect of video feedback compared with the comparator groups (SMD 0.02, 95% CI -0.33 to 0.38, very low-certainty evidence). Adverse events. Eight studies (537 parent-child dyads) contributed data at postintervention or short-term follow-up to a meta-analysis of parental stress, and two studies (311 parent-child dyads) contributed short-term follow-up data to a meta-analysis of parental anxiety. There was no difference between intervention and comparator groups for either outcome. For parental stress the SMD between video feedback and control was -0.09 (95% CI -0.26 to 0.09, low-certainty evidence), while for parental anxiety the SMD was -0.28 (95% CI -0.87 to 0.31, very low-certainty evidence). Child behaviour. A meta-analysis of two studies (119 parent-child dyads) at long-term follow-up found no evidence of the effectiveness of video feedback on child behaviour (SMD 0.04, 95% CI -0.33 to 0.42, very low-certainty evidence). A moderator analysis found no evidence of an effect for the three prespecified variables (intervention type, number of feedback sessions and participating carer) when jointly tested. However, parent gender (both parents versus only mothers or only fathers) potentially has a statistically significant negative moderation effect, though only at α (alpha) = 0.1 AUTHORS' CONCLUSIONS: There is moderate-certainty evidence that video feedback may improve sensitivity in parents of children who are at risk for poor attachment outcomes due to a range of difficulties. There is currently only little, very low-certainty evidence regarding the impact of video feedback on attachment security, compared with control: results differed based on the type of measure used, and follow-up was limited in duration. There is no evidence that video feedback has an impact on parental stress or anxiety (low- and very low-certainty evidence, respectively). Further evidence is needed regarding the longer-term impact of video feedback on attachment and more distal outcomes such as children's behaviour (very low-certainty evidence). Further research is needed on the impact of video-feedback on paternal sensitivity and parental reflective functioning, as no study measured these outcomes. This review is limited by the fact that the majority of included parents were mothers.

An Investigation of the Impact of Childhood Trauma on Quality of Caregiving in High Risk Mothers: Does Maternal Substance Misuse Confer Additional Risk?

The quality of caregiving is often compromised when mothers have co-occurring difficulties such as substance misuse and problems associated with extreme emotional dysregulation. These, in turn, are associated with poor child outcomes. The aim of the current study was twofold. First, to investigate the potential differences in risk factors associated with poor child outcome by comparing three groups: substance misusing mothers (Substance Misusing Mothers; SMM); mothers matched on demographic characteristics (Matched Comparison Mothers; MCM) and mothers recruited from the community (Matched Control Comparison; MCC). Second, to investigate the underlying mechanisms which are associated with poor child outcome by testing a mediated moderation model to ascertain (i) whether environmental risk and borderline psychopathology was a mediator between maternal childhood trauma and quality of caregiving and (ii) maternal substance misuse status moderated outcome. There were no significant differences found between the SMM and MCM groups on the key variables, but significant differences on all variables for both SMM and MCM compared to CCM. The moderated mediation analysis found that while there was significant mediation of environmental risk and borderline pathology between maternal childhood trauma and child outcome, this was not moderated by maternal substance abuse status. The importance of environmental-risk as a mechanism leading to reduced caregiving quality suggest treatment programs need to consider targeting these factors in high risk families.

Characterizing adverse prenatal and postnatal experiences in children

BACKGROUND

Prenatal and postnatal adversities, including prenatal alcohol exposure (PAE), prenatal exposure to other substances, toxic stress, lack of adequate resources, and postnatal abuse or neglect, often co-occur. These exposures can have cumulative effects, or interact with each other, leading to worse outcomes than single exposures. However, given their complexity and heterogeneity, exposures can be difficult to characterize. Clinical services and research often overlook additional exposures and attribute outcomes solely to one factor.

METHODS

We propose a framework for characterizing adverse prenatal and postnatal exposures and apply it to a cohort of 77 children. Our approach considers type, timing, and frequency to quantify PAE, other prenatal substance exposure, prenatal toxic stress, postnatal threat (harm or threat of harm), and postnatal deprivation (failure to meet basic needs) using a 4-point Likert-type scale. Postnatal deprivation and harm were separated into early (<24 months of age) and late (≥24 months) time periods, giving seven exposure variables. Exposures were ascertained via health records, child welfare records, interviews with birth parents, caregivers, and/or close family/friends.

RESULTS

Nearly all children had co-occurring prenatal exposures, and two-thirds had both prenatal and postnatal adversities. Children with high PAE were more likely to experience late postnatal adversities, and children with other prenatal substance exposure were more likely to have early postnatal deprivation. Postnatal adversities were more likely to co-occur.

CONCLUSION

This framework provides a comprehensive picture of a child's adverse exposures, which can inform assessment and intervention approaches and policy and will be useful for future research.

Quality of Caregiving in Mothers With Illicit Substance Use: A Systematic Review and Meta-analysis

Background:

The quality of caregiving in mothers with substance abuse problems appears to be compromised. However, divergent findings, methodological variability, and sample characteristics point to the need for research synthesis.

Methods:

A comprehensive systematic search was undertaken. Studies were eligible if they (1) compared substance-misusing mothers with non–substance-misusing mothers, (2) involved children from birth to 3 years, and (3) maternal sensitivity and child responsiveness were measured using observational methodology.

Results:

A global meta-analysis for maternal sensitivity (n = 24 studies) and child responsiveness (n = 16 studies) on 3433 mother-infant dyads yielded significant population effect sizes and significant heterogeneity. Subgroup analyses found reduced heterogeneity when the meta-analysis was conducted on studies where groups were matched on key demographic characteristics; although the effect size was small, it was still significant for maternal sensitivity but not child responsiveness.

Conclusions:

Compromised quality of caregiving is found in high-risk, substance-misusing mothers, emphasising the importance of early intervention that draws from attachment-based interventions.

Thalamocortical functional connectivity and behavioral disruptions in neonates with prenatal cocaine exposure

Prenatal cocaine exposure (PCE) affects neurobehavioral development, however, disentangling direct drug-related mechanisms from contextual effects (e.g., socioeconomic status) has proven challenging in humans. The effects of environmental confounds are minimal immediately after birth thus we aimed to delineate neurobehavioral correlates of PCE in a large cohort of neonates (2-6weeks of age, N=152) with and without drug exposure using resting state functional magnetic resonance imaging (rsfMRI) and developmental assessments at 3months with the Bayley Scales of Infant & Toddler Development, 3rd edition. The cohort included healthy controls and neonates with similar poly-drug exposure±cocaine. We focused on the thalamus given its critical importance in early brain development and its unique positioning in the dopamine system. Our results revealed PCE-related hyper-connectivity between the thalamus and frontal regions and a drug-common hypo-connective signature between the thalamus and motor-related regions. PCE-specific neonatal thalamo-frontal connectivity was inversely related to cognitive and fine motor scores and thalamo-motor connectivity showed a positive relationship with composite (gross plus fine) motor scores. Finally, cocaine by selective-serotonin-reuptake-inhibitor (SSRI) interactions were detected, suggesting the combined use of these drugs during pregnancy could have additional consequences on fetal development. Overall, our findings provide the first delineation of PCE-related disruptions of thalamocortical functional connectivity, neurobehavioral correlations, and drug-drug interactions during infancy.

Prenatal drug exposure affects neonatal brain functional connectivity

Prenatal drug exposure, particularly prenatal cocaine exposure (PCE), incurs great public and scientific interest because of its associated neurodevelopmental consequences. However, the neural underpinnings of PCE remain essentially uncharted, and existing studies in school-aged children and adolescents are confounded greatly by postnatal environmental factors. In this study, leveraging a large neonate sample (N = 152) and non-invasive resting-state functional magnetic resonance imaging, we compared human infants with PCE comorbid with other drugs (such as nicotine, alcohol, marijuana, and antidepressant) with infants with similar non-cocaine poly drug exposure and drug-free controls. We aimed to characterize the neural correlates of PCE based on functional connectivity measurements of the amygdala and insula at the earliest stage of development. Our results revealed common drug exposure-related connectivity disruptions within the amygdala-frontal, insula-frontal, and insula-sensorimotor circuits. Moreover, a cocaine-specific effect was detected within a subregion of the amygdala-frontal network. This pathway is thought to play an important role in arousal regulation, which has been shown to be irregular in PCE infants and adolescents. These novel results provide the earliest human-based functional delineations of the neural-developmental consequences of prenatal drug exposure and thus open a new window for the advancement of effective strategies aimed at early risk identification and intervention.