CENTER ON BEHAVIORAL MEDICINE
Behavioral Genetics: Research Article
Sood, B., Delaney-Black, V., et al. (2001) Prenatal Alcohol
Exposure and Childhood Behavior at Age 6 to 7 Years:
Effect. Pediatrics Vol. 108 No. 2 August 2001.
Objective. Moderate to heavy levels of prenatal alcohol exposure have been associated with alterations in child behavior, but limited data are available on adverse effects after low levels of exposure. The objective of this study was to evaluate the dose-response effect of prenatal alcohol exposure for adverse child behavior outcomes at 6 to 7 years of age.
Methods. Beginning in 1986, women
the urban university-based maternity clinic were routinely screened at their first prenatal visit
for alcohol and drug use by trained research assistants from the Fetal
Alcohol Research Center. All women reporting alcohol consumption at
of at least 0.5 oz absolute alcohol/day and a 5% random sample of lower
level drinkers and abstainers were invited to participate to be able to
identify the associations between alcohol intake and child development.
Maternal alcohol, cigarette, and illicit drug use were prospectively
during pregnancy and postnatally. The independent variable in this
prenatal alcohol exposure, was computed as the average absolute alcohol
intake (oz) per day across pregnancy. At each prenatal visit,
were interviewed about alcohol use during the previous 2 weeks.
and types of alcohol consumed were converted to fluid ounces of
alcohol and averaged across visits to generate a summary measure of
exposure throughout pregnancy. Alcohol was initially used as a
variable comparing children with no prenatal alcohol exposure to
with any exposure. To evaluate the effects of different levels of
the average absolute alcohol intake was relatively arbitrarily
into no, low (>0 but <0.3 fl oz of absolute alcohol/day), and
(>0.3 fl oz of absolute alcohol/day) for the purpose of this study.
years later, 665 families were contacted. Ninety-four percent agreed to
testing. Exclusions included children who missed multiple test
had major congenital malformations (other than fetal alcohol syndrome),
possessed an IQ >2 standard deviations from the sample mean, or had
data. The Achenbach Child Behavior Checklist (CBCL) was used to assess
child behavior. The CBCL is a parent questionnaire applicable to
Statistical Analyses. Statistical
were performed using the SPSS statistical package. Frequency distribution, cross-tabulation, odds ratio,
and x2 tests were used for analyzing categorical data. Continuous
data were analyzed using t tests,
of variance (ANOVAs) with posthoc tests, and regression analysis.
Results. Testing was available for 501 parent–children dyads. Almost one fourth of the women denied alcohol use during pregnancy. Low levels of alcohol use were reported in 63.8% and moderate/heavy use in 13% of pregnancies. Increasing prenatal alcohol exposure was associated with lower birth weight and gestational age, higher lead levels, higher maternal age, and lower education level, prenatal exposure to cocaine and smoking, custody changes, lower socioeconomic status, and paternal drinking and drug use at the time of pregnancy. Children with any prenatal alcohol exposure were more likely to have higher CBCL scores on Externalizing (Aggressive and Delinquent) and Internalizing (Anxious/Depressed and Withdrawn) syndrome scales and the Total Problem Score. The odds ratio of scoring in the clinical range for Delinquent behavior was 3.2 (1.3–7.6) in children with any prenatal exposure to alcohol compared with nonexposed controls. The threshold dose was evaluated with the 3 prenatal alcohol exposure groups. Oneway ANOVA revealed a significant between group difference for Externalizing (Aggressive and Delinquent) and the Total Problem Score. Posthoc tests revealed the between group differences to be significant (no and ow-exposure group) for Aggressive and Externalizing behavior suggesting that the adverse effects of prenatal alcohol exposure on child behavior at age 6 to 7 years are evident even at low levels of exposure. For Delinquent and Total Problem behavior, the difference was significant between the no and moderate-heavy exposure group, suggesting a higher threshold for these behaviors. Prenatal alcohol exposure remained a significant predictor of behavior after adjusting for covariates. Although maternal psychopathology was the most important predictor of behavior, gender was also a significant predictor, with boys having higher scores on Externalizing (Delinquent) and Attention Problems. The amount of variance uniquely accounted for by prenatal alcohol exposure ranged between 0.6% to 1.7%.
Conclusions. Maternal alcohol consumption even at low levels was adversely related to child behavior; a dose-response relationship was also identified. The effect was observed at average levels of exposure of as low as 1 drink per week. Although effects on mean scores for Externalizing and Aggressive behaviors were observed at low levels of prenatal alcohol exposure, effects on Delinquent behavior and Total Problem Scores were observed at moderate/heavy levels of exposure. Children with any prenatal alcohol exposure were 3.2 times as likely to have Delinquent behavior scores in the clinical range compared with nonexposed children. The relationship between prenatal alcohol exposure and adverse childhood behavior outcome persisted after controlling for other factors associated with adverse behavioral outcomes. Clinicians are often asked by pregnant women if small amounts of alcohol intake are acceptable during pregnancy. These data suggest that no alcohol during pregnancy remains the best medical advice.
1. Centers for Disease Control
2. Smith DW. Alcohol effects on
In: Schwartz RH, Yaffe SJ, eds.
3. Jones KL, Smith DW. The fetal
syndrome. Teratology. 1975;12:
4. Streissguth AP, Herman CS,
Intelligence, behavior and
5. Aronson M, Kyllerman M, Sabel
B, Olegard R. Children of
6. Landesman-Dwyer S, Ragozin AS.
correlates of prenatal
7. Streissguth AP, Barr HM,
Alcohol Exposure in Utero and
8. Brown RT, Coles CD, Smith IE,
Effects of prenatal alcohol exposure
9. Jacobson JL, Jacobson SW.
exposure and neurobehavioral
10. Derogatis LR, Lipman RS, Covi
an outpatient psychiatric
11. Norbeck JS, Lindsay AM,
The development of an instrument
12. Caldwell BM, Bradley RH. Home
for Measurement of the
13. Wechsler D. Weschler
Primary Scale Of Intelligence–Revised
14. Richters JE, Martinez P. The
Violence Project. I.
15. Achenbach TM. Manual for the
Behavior Checklist/4–18 and 1991
16. Sokol RJ, Martier S, Ernhart
of alcohol abuse in the
17. Achenbach TM, Brown JS.
of Published Studies Using the
18. Achenbach TM. Integrative
the 1991 CBCL/4–18, YSR, and TRF
19. Weinberg NZ. Cognitive and
deficits associated with parental
20. Russell M. Prevalence of
among children of alcoholics. In:
21. Ernhart CB, Morrow-Tlulack M,
RJ, Martier S. Underreporting of
22. Jacobson SW, Jacobson JL,
Martier SS, Ager JW, Kaplan MG.
23. Jacobson JL, Jacobson SW,
Martier SS, Ager JW, Kaplan-Estrin
24. Carmichael Olson H,
Sampson PD, Barr HM, Bookstein
25. Streissguth AP, Barr HM,
Parrish-Johnson JC, Kirchner
26. Nanson JL, Hiscock M.
in children exposed to alcohol
27. Jacobson SW, Jacobson JL,
Effects of fetal alcohol exposure in
28. Driscoll CD, Streissguth AP,
EP. Prenatal alcohol exposure: comparability
29. Vorhees CV. Principles of
teratology. In: Riley EP, Vorhees
30. Coles CD, Brown RT, Smith IE,
KA, Erickson S, Falek A.
31. Fried PA, Watkinson B, Gray
R. A follow-up
study of attentional
32. Bird HR, Gould MS,
Staghezza BM, Canino G.
33. Verhulst FC, van der Ende J.
of child psychopathology:
34. Horwitz SM, Leaf PJ,
Forsyth BWC, Speechley KN.
35. Jensen PS, Blodeau L, Degroot
T, Davis H. Children at risk: I.
36. Sampson PD, Bookstein FL,
Streissguth AP. Prenatal alcohol
37. McGee R, Silva PA, Williams
38. O’Callaghan MJ, Williams GM,
MJ, Bor W, Najman JM.
39. Boyle MH, Offord DR, Racine
G. Ontario Child Health Study