Early Adversity, Socioemotional Development, and Stress in Urban 1-Year-Old Children Frederick B. Palmer, MD1,2, Kanwaljeet J. S. Anand, MBBS, DPhil1,3,4, J. Carolyn Graff, PhD2,5, Laura E. Murphy, EdD2,6, Yanhua Qu, PhD7, Eszter V€olgyi, PhD7, Cynthia R. Rovnaghi, MS1,4, Angela Moore, MPH7, Quynh T. Tran, PhD7, and Frances A. Tylavsky, DrPH7 Objective To determine demographic, maternal, and child factors associated with socioemotional (SE) problems and chronic stress in 1-year-old children. Study design This was a prospective, longitudinal, community-based study, which followed mother-infant dyads (n = 1070; representative of race, education, and income status of Memphis/Shelby County, Tennessee) from midges- tation into early childhood. Child SE development was measured using the Brief Infant-Toddler Social and Emotional Assessment in all 1097 1-year-olds. Chronic stress was assessed by hair cortisol in a subsample of 1-year-olds (n = 297). Multivariate regression models were developed to predict SE problems and hair cortisol levels. Results More black mothers than white mothers reported SE problems in their 1-year-olds (32.9% vs 10.2%; P < .001). In multivariate regression, SE problems in blacks were predicted by lower maternal education, greater parenting stress and maternal psychological distress, and higher cyclothymic personality score. In whites, predictors of SE problems were Medicaid insurance, higher maternal depression score at 1 year, greater parenting stress and maternal psycho- logical distress, higher dysthymic personality score, and male sex. SE problem scores were associated with higher hair cortisol levels (P = .01). Blacks had higher hair cortisol levels than whites (P < .001). In the entire subsample, increased hair cortisol levels were associated with higher parenting stress (P = .001), lower maternal depression score (P = .01), lower birth length (P < .001), and greater length at 1 year of age (P = .003). Conclusion Differences in maternal education, insurance, mental health, and early stress may disrupt SE devel- opment in children. Complex relationships between hair cortisol level in 1-year-olds and maternal parenting stress and depression symptoms suggest dysregulation of the child’s hypothalamic-pituitary-adrenal axis. (J Pediatr 2013;163:1733-39). hild socioemotional (SE) development is defined as “the developing capacity of the child from birth through 5 years of Cage to form close and secure adult and peer relationships; experience, regulate, and express emotions in socially and culturally appropriate ways; and explore the environment and learn—all in the context of family, community, and culture.”1 Complex interactions of biological, environmental, social, cultural, and community factors operating from precon- ception through childhood shape neurodevelopment, and thereby SE development, in early life.2 SE competence facilitates cognitive development and school readiness,3 improved school performance,4 and subsequent lifespan outcomes, such as adult health5 and employment success.6 Socioeconomic variables, such as family income and wealth, parent education and occupation,7 and related factors such as home and neighborhood8 influence child SE development. Maternal depression or anxiety are associated with diminished SE competence in children.9-11 Stressful life events, such as intimate partner violence or chronic stress related to poverty or neigh- borhood crime and instability, can diminish a parent’s ability to interact and nurture the developing child.10,12,13 The physiological changes involved in the response to recurrent stressors alter the regulation of the hypothalamic-pituitary-adrenal (HPA) axis, often referred to as “allostatic load.”14 HPA axis responses in early life are particularly detri- From the 1Department of Pediatrics, 2Boling Center for mental because of the wide-ranging effects during the sensitive periods of brain Developmental Disabilities, 3Department of Anatomy and Neurobiology, and 4Pain Neurobiology Laboratory, development, as well as the encoding of impaired ability to respond to future 5 15 College of Medicine; and College of Nursing; stressors. Early adverse experiences lead to dysregulation of the HPA axis, 6Departments of Psychiatry, and 7Preventive Medicine, College of Medicine, University of Tennessee Health characterized by exaggerated or ineffective responses, prolonged reactivity, and Science Center, Memphis, TN Supported by a grant from The Urban Child Institute to the University of Tennessee Health Science Center Department of Preventive Medicine. F.P., J.G., and L.M. BITSEA Brief Infant-Toddler Social and Emotional Assessment were supported in part by the Health Resources and BSI Brief Symptom Inventory Services Administration’s Maternal and Child Health Bureau (MC-00038-18) and the Administration on Intel- CANDLE Conditions Affecting Neurocognitive Development and Learning in Early Childhood lectual and Developmental Disabilities (90DD0657). K.A. EPDS Edinburgh Postnatal Depression Scale was supported in part by the European Commission (FP7 HPA Hypothalamic-pituitary-adrenal Programmed-2007-4.2-1) and the Oxnard Foundation. The authors declare no conflicts of interest. SE Socioemotional TEMPS Temperament Evaluation of Memphis, Pisa, Paris, and San Diego 0022-3476/$ - see front matter. Copyright ª 2013 Mosby Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2013.08.030 1733 THE JOURNAL OF PEDIATRICS www.jpeds.com Vol. 163, No. 6 delayed recovery after stress. Exposure to direct or indirect maternal depression score at 12 months, maternal age, or (ie, maternal) stressors in infancy seems to promote maternal education. emotional or cognitive problems in toddlerhood,16 later childhood,17 and adolescence.18 Although maternal depres- Maternal Psychosocial Measures 22 sion,17 poverty, and related stress are often associated with The Brief Symptom Inventory (BSI), a 53-item self-report a dysregulated HPA axis in offspring,19 how these factors scale measuring the nature and intensity of psychological affect early SE development is not clear. Chronic or cumula- symptoms, was completed by mothers during the third tive stress can be measured by hair cortisol level, a better trimester of pregnancy and at the 1-year child visit. The measure of chronic stress than cortisol level in plasma, saliva BSI Global Severity Index T score served as an overall or urine.20 We hypothesized that adverse maternal and socio- measure of the severity of psychological symptoms. economic risk factors may lead to cumulative stress in Maternal depression was screened using the 10-item Edin- 23 infancy, manifested in elevated hair cortisol levels,21 which burgh Postnatal Depression Scale (EPDS) at 4 weeks post- may influence early SE outcomes. partum and the 1-year visit. Continuous EPDS scores were analyzed. Methods Maternal temperament was measured during gestation with the 84-item Temperament Evaluation of Memphis, Pisa, Paris, and San Diego (TEMPS)24 to identify the following personal- The Conditions Affecting Neurocognitive Development and ity styles: hyperthymic (intrusive, cheerful, overoptimistic or Learning in Early Childhood (CANDLE) study has enrolled exuberant, extroverted, overly talkative), irritable (angry, 1503 healthy 16- to 40-year-old women in their second impulsive, snapping or cursing often, unpleasant), cyclo- trimester of pregnancy in Shelby County, Tennessee, and will thymic (lethargy alternating with activity, marked unevenness follow them until their children reach age 54 months. Women in quantity and quality of productivity, mental confusion were enrolled at an urban hospital obstetric clinic and at com- alternating with sharp and creative thinking), or dysthymic munity obstetric practices. Exclusion criteria included existing (gloomy, pessimistic, incapable of fun, self-critical, self-derog- chronic disease requiring medication (eg, hypertension, dia- atory, brooding, worried, feelings of inadequacy).24 Contin- betes, sickle cell disease), known pregnancy complications uous TEMPS scores were used for this analysis. (eg, complete placenta previa, oligohydramnios), and plans Mothers’ reports of parenting stress were assessed at the to deliver at a nonparticipating hospital. The Figure shows 1-year visit using the 36-item Parenting Stress Index Short the participants available for this investigation. Informed Form to identify parents at risk for dysfunctional parenting consent was provided by the participants or their legally and parenting characteristics not promoting typical develop- authorized representatives. A financial incentive of a $100 ment in children.25 Total parenting stress percentiles were gift card was offered to each participant for each visit. The used in this analysis. study was approved by the University of Tennessee Health The risk for physical child abuse was assessed at the 1-year Science Center’s Institutional Review Board. visit using the 160-item Child Abuse Potential Inventory Demographic and Socioeconomic Measures parent questionnaire. A score $166 was considered to indi- 26 Participants provided information on health insurance, race, cate a mother at risk for abuse. ethnicity, marital status, parity, and household composition via self-administered questionnaires. Prepregnancy height Child Measures and weight were based on self-report and used to calculate pre- Gestational age was determined by ultrasound or by the pregnancy body mass index as weight in kilograms divided by mother’s report of the last menstrual cycle. Age- and