Prenatal stress is the exposure of a developing fetus to maternal psychological distress during pregnancy. It has been linked to an increased risk of offspring exhibiting externalizing behaviors, such as aggression, hyperactivity, and conduct problems, throughout childhood and adolescence.
Tung, I., Hipwell, A. E., Grosse, P., Battaglia, L., Cannova, E., English, G., Quick, A. D., Llamas, B., Taylor, M., & Foust, J. E. (2024). Prenatal stress and externalizing behaviors in childhood and adolescence: A systematic review and meta-analysis. Psychological Bulletin, 150(2), 107–131. https://doi.org/10.1037/bul0000407
Key Points
- This meta-analysis found that prenatal psychological distress (anxiety, depression, perceived stress) has a significant but small effect (r = .160) on offspring externalizing behaviors in childhood and adolescence.
- The effect of prenatal distress remained significant (r = .159) even after controlling for postnatal distress, suggesting prenatal distress uniquely contributes to externalizing outcomes beyond postnatal exposures.
- Stability of distress from prenatal to postnatal periods moderated the effect, with greater instability predicting larger effects of prenatal distress on externalizing behaviors.
- Prenatal distress effects were generally comparable across externalizing outcomes, although effects appeared smaller for nonaggressive rule-breaking vs aggressive behaviors.
- Significant associations between prenatal distress and externalizing behaviors persisted from early childhood through adolescence.
- The research highlights the importance of prenatal mental health screening and intervention as an early prevention strategy but has limitations in the diversity of study samples.
Rationale
Externalizing behaviors like aggression, hyperactivity, and impulsivity often emerge in early childhood and are the most common reason for children’s referral to mental health services (Hansen et al., 2021; Pikard et al., 2018).
While most research has focused on childhood adversity as a predictor of externalizing problems (Busso et al., 2017; Doom et al., 2016), accumulating evidence suggests exposure to stress as early as the prenatal period may alter offspring neurodevelopment and increase vulnerability to externalizing behaviors (Glover, 2011; Monk et al., 2019).
However, studies have varied widely in the magnitude of reported prenatal stress effects, likely due to methodological differences in controlling for continuation of parental distress postnatally.
This meta-analysis synthesized findings across the most rigorously controlled longitudinal studies to clarify the unique contribution of prenatal psychological distress to offspring externalizing outcomes.
Method
The authors conducted a systematic review and meta-analysis following PRISMA guidelines. They searched bibliographic databases for eligible longitudinal studies and extracted correlations between prenatal distress, postnatal distress, and offspring externalizing behaviors.
The meta-analysis included 55 studies (36 distinct longitudinal samples) totaling 200 unique effect sizes. Samples were predominantly White, higher socioeconomic status, and from Western countries.
Prenatal psychological distress included anxiety, depression, and perceived stress measured prospectively during pregnancy.
Offspring externalizing behaviors included aggressive behavior, rule-breaking, ADHD, oppositional defiant disorder (ODD), and conduct disorder (CD), measured between ages 2-18, primarily using parent-report rating scales.
The inclusion criteria were:
- Described human subjects
- Written in English
- Published since 2000
- Empirical observational study with a longitudinal design
- Included at least one measure of psychological distress during pregnancy and after childbirth
- Included at least one measure of offspring externalizing behavior assessed during childhood or adolescence (ages 2-18)
- Reported an effect size (Pearson correlation) between prenatal psychological distress and externalizing outcome or reported data that could be used to calculate an unbiased estimate of effect size
The exclusion criteria were:
- Intervention study, case study, review article, or non-empirical study
- Measured externalizing outcome using a legal proxy (e.g., arrested) without specific measurement of actual behavioral outcome
- Did not measure psychological distress during pregnancy (e.g., used retrospective measures collected after childbirth or used a proxy for prenatal stress like birth weight)
- Did not include an identical measure of postnatal distress
- Effect size was based on the same data as another citation in the meta-analysis (duplicate effect size from the same sample)
Results
- The meta-analysis found a significant pooled correlation between prenatal psychological distress and offspring externalizing behaviors (r = .160).
- Adjusting for postnatal distress only slightly reduced the effect size (r=.159), suggesting prenatal distress uniquely predicted externalizing outcomes beyond postnatal exposures.
- Instability of distress from prenatal to postnatal periods significantly moderated the effect size, with studies showing lower stability having larger effects of prenatal distress on externalizing behaviors.
- Type and timing of prenatal distress did not moderate effects.
- Prenatal distress effects were significant for aggressive behaviors, ADHD, and ODD/CD outcomes, but not for nonaggressive rule-breaking behaviors.
- Effect sizes were significant across developmental periods but appeared slightly larger in early childhood vs. middle childhood.
Insight
This meta-analysis provides the strongest evidence to date that prenatal psychological distress is a significant, albeit modest, contributor to child and adolescent externalizing behaviors, even after accounting for postnatal distress exposures.
The persistence of a significant prenatal effect after covarying postnatal distress points to the unique role of the prenatal environment in shaping offspring behavioral risk, consistent with fetal programming theories. Interestingly, studies with greater instability in parental distress from prenatal to postnatal periods showed larger effects of prenatal distress on externalizing outcomes.
This pattern appears consistent with “mismatch” hypotheses from evolutionary biology suggesting prenatal stress adaptively calibrates offspring physiology for an expected stressful postnatal environment, with greater impact when the postnatal environment doesn’t match prenatal predictions.
The significant effects across externalizing domains and developmental periods underscore the potentially pervasive impact of prenatal distress on behavioral health.
Future longitudinal studies examining physiological mechanisms and interactions with postnatal risks can further elucidate developmental pathways.
Strengths
- Focused on prospective, longitudinal studies that measured prenatal distress prior to offspring outcomes
- Required studies to covary the same distress measure in the postnatal period to isolate prenatal timing
- Used multilevel meta-analytic models to account for correlated effects within samples
- Compared multiple types and timings of prenatal distress exposure and offspring behavior outcomes
- Included unpublished studies and studies that didn’t primarily examine externalizing outcomes to reduce publication bias
Limitations
- The meta-analysis was limited by the demographics of the original study samples, which were predominantly White, higher socioeconomic status, and from Western countries.
- This constraint impacts the generalizability of the findings, especially since structural and systemic inequities are known contributors to disparities in prenatal stress exposure and birth outcomes.
- The study was also limited to analyzing bivariate correlations reported in original studies.
- A lack of consistency in how studies measured and covaried other pre- and postnatal risk factors precluded meta-analytically testing potential confounds, interactions, and mechanisms that may further explain heterogeneity in prenatal stress effects.
Clinical Implications
While effect sizes were modest, the meta-analytic results suggest reducing prenatal psychological distress could be an impactful early strategy for preventing offspring externalizing problems at the population level.
Integrating mental health support into prenatal care may promote health equity and have important public health implications for preventing the intergenerational transmission of psychopathology.
Still, clinical applications should be considered cautiously given the current study samples are not representative of the populations most impacted by structural and systemic inequities in maternal health.
Expanding research on prenatal stress and offspring development within racially, ethnically, and socioeconomically diverse families is critical for informing culturally-responsive perinatal interventions with the potential for generational impact.
References
Primary reference
Tung, I., Hipwell, A. E., Grosse, P., Battaglia, L., Cannova, E., English, G., Quick, A. D., Llamas, B., Taylor, M., & Foust, J. E. (2024). Prenatal stress and externalizing behaviors in childhood and adolescence: A systematic review and meta-analysis. Psychological Bulletin, 150(2), 107–131. https://doi.org/10.1037/bul0000407
Other references
Busso, D. S., McLaughlin, K. A., & Sheridan, M. A. (2017). Dimensions of adversity, physiological reactivity, and externalizing psychopathology in adolescence: Deprivation and threat. Psychosomatic Medicine, 79(2), 162–171.
Doom, J. R., Vanzomeren-Dohm, A. A., & Simpson, J. A. (2016). Early unpredictability predicts increased adolescent externalizing behaviors and substance use: A life history perspective. Development and Psychopathology,28(4pt2), 1505-1516.
Glover, V. (2011). Annual research review: prenatal stress and the origins of psychopathology: an evolutionary perspective. Journal of Child Psychology and Psychiatry, 52(4), 356-367.
Hansen, A. S., Christoffersen, C. H., Telléus, G. K., & Lauritsen, M. B. (2021). Referral patterns to outpatient child and adolescent mental health services and factors associated with referrals being rejected. A cross-sectional observational study. BMC Health Services Research, 21(1), 1-11.
Monk, C., Lugo-Candelas, C., & Trumpff, C. (2019). Prenatal developmental origins of future psychopathology: mechanisms and pathways. Annual Review of Clinical Psychology, 15, 317-344.
Pikard, J., Roberts, N., & Groll, D. (2018). Pediatric referrals for urgent psychiatric consultation: Clinical characteristics, diagnoses and outcome of 4 to 12 year old children. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 27(4), 245-251.
Keep Learning
- How do the concepts of allostatic load and fetal programming help explain the meta-analytic finding that prenatal distress predicts offspring externalizing behaviors even after accounting for postnatal exposures? What physiological mechanisms might underlie these effects?
- The meta-analysis found that greater instability in psychological distress from prenatal to postnatal periods predicted larger effects of prenatal distress on offspring externalizing behaviors. How does this finding relate to cumulative stress vs. match-mismatch models of the impact of prenatal stress? What evolutionary pressures might explain these patterns?
- The original studies in this meta-analysis relied predominantly on parent-reported measures of externalizing behaviors. How might shared method variance impact the interpretation of prenatal stress effects in these studies? What are some ways researchers could strengthen the measurement of offspring behavioral outcomes in future work?
- The demographics of the study samples in this meta-analysis were predominantly White, higher-SES, and Western. Why is it important for researchers to examine prenatal stress and offspring development in more diverse populations? How might social and structural determinants of health impact the experience and impact of prenatal distress?
- While this meta-analysis suggests prenatal mental health could be an important target for preventing offspring externalizing problems, the effect sizes were relatively modest. What other factors should prevention programs consider alongside prenatal distress? How early in development should we intervene to have the greatest impact on externalizing trajectories?
