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.
Illustration of a pregnant woman sat on a chair looking sad and stressed with a rain cloud above her head
Key Points
Rationale
Externalizing behaviors like aggression, hyperactivity, andimpulsivityoften 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 onchildhood adversityas 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 asystematic reviewandmeta-analysisfollowing 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 includedanxiety, 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:
The exclusion criteria were:
Results
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
Limitations
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.
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.
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Olivia Guy-Evans, MSc
BSc (Hons) Psychology, MSc Psychology of Education
Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.
Saul McLeod, PhD
BSc (Hons) Psychology, MRes, PhD, University of Manchester
Saul McLeod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.
