Prenatal alcohol exposure and childhood behavior at age 6 to 7 years: I. Dose-response effect
Prenatal alcohol exposure and childhood behavior at age 6 to 7 years: I. Dose-response effect
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DOI：
10.1542/peds.108.2.e34
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发表时间：
2001-08-01
期刊：
影响因子：
8
通讯作者：
Sokol, RJ
中科院分区：
文献类型：
--
作者：
Sood, B;Delaney-Black, V;Sokol, RJ
客观的。中度至重度的产前酒精暴露与儿童行为的改变有关，但关于低水平暴露后的不良影响的数据有限。本研究的目的是评估产前酒精暴露对 6 至 7 岁儿童不良行为结果的剂量反应效应。方法。从 1986 年开始，胎儿酒精研究中心训练有素的研究助理在城市大学妇产诊所就诊的女性在第一次产前检查时，定期对酒精和药物使用情况进行筛查。所有在受孕时报告饮酒量至少为 0.5 盎司无水酒精/天的女性以及 5% 的低水平饮酒者和戒酒者的随机样本均被邀请参与，以便能够确定酒精摄入量与儿童发育之间的关联。在怀孕期间和产后对母亲饮酒、吸烟和非法药物的使用进行了前瞻性评估。本研究中的自变量，即产前酒精暴露，计算为整个怀孕期间每天的平均绝对酒精摄入量（盎司）。每次产前检查时，母亲都会接受有关前两周饮酒情况的访谈。饮酒的数量和类型被转换为液体盎司的无水酒精，并在每次访问中进行平均，以生成整个怀孕期间酒精暴露的汇总测量值。酒精最初被用作二分变量，将没有产前酒精暴露的儿童与有任何暴露的儿童进行比较。为了评估不同暴露水平的影响，出于本研究的目的，平均无水酒精摄入量相对任意地分为无、低（>0 但 0.3 液量盎司无水酒精/天）。六年后，我们联系了 665 个家庭。百分之九十四同意进行测试。排除包括错过多次测试预约、患有严重先天畸形（胎儿酒精综合症除外）、智商与样本平均值相差>2个标准差或数据不完整的儿童。阿亨巴赫儿童行为检查表（CBCL）用于评估儿童行为。 CBCL是一份适用于4至16岁儿童的家长问卷。它广泛应用于儿童行为问题的临床评估，并在研究中得到广泛应用。八个综合症量表进一步分为外化或控制不足（攻击性和犯罪）行为和内化或过度控制（焦虑/抑郁、躯体抱怨和退缩）行为。三种综合症（社交、思维和注意力问题）都不适合这两组。分数越高，问题行为越多。经过培训且对暴露状况不知情的研究助理独立采访了孩子和看护人。收集了一系列已知影响儿童行为和/或与产前酒精暴露相关的控制变量的数据。这些因素包括母亲年龄、教育程度、香烟、可卡因和其他滥用物质以及婴儿的胎龄等围产期因素。研究的产后因素包括母亲的精神病理学、持续酗酒和吸毒、家庭结构、社会经济地位、儿童的全血铅水平和暴力暴露。由于其他种族群体的代表性不足，数据仅从黑人女性中收集。统计分析。使用SPSS统计软件包进行统计分析。使用频率分布、交叉制表、比值比和卡 (2) 检验来分析分类数据。使用 t 检验、事后检验方差分析 (ANOVA) 以及回归分析对连续数据进行分析。结果。测试对象为 501 名亲子情侣。近四分之一的女性否认在怀孕期间饮酒。据报道，63.8% 的孕妇有低度饮酒，13% 的孕妇有中度/重度饮酒。产前酒精暴露增加与较低的出生体重和胎龄、较高的铅含量、较高的产妇年龄和较低的教育水平、产前接触可卡因和吸烟、监护权变化、较低的社会经济地位以及父亲在怀孕时饮酒和吸毒有关。产前接触过酒精的儿童更有可能在外化（攻击性和犯罪）和内化（焦虑/抑郁和退缩）综合征量表以及总问题评分上获得更高的 CBCL 分数。与未接触过酒精的对照组相比，产前接触过酒精的儿童的犯罪行为临床评分范围的比值比为 3.2 (1.3-7.6)。对 3 个产前酒精暴露组进行阈剂量评估。单向方差分析显示，外在化（攻击性和违法行为）和总问题得分方面存在显着的组间差异。事后测试显示，攻击性和外化行为的组间差异显着（无暴露组和低暴露组），这表明产前酒精暴露对 6 至 7 岁儿童行为的不利影响即使在低水平暴露的情况下也很明显。对于违法行为和完全问题行为，无接触组和中重度接触组之间存在显着差异，表明这些行为的阈值较高。调整协变量后，产前酒精暴露仍然是行为的重要预测因素。虽然母亲的精神病理学是行为最重要的预测因素，但性别也是一个重要的预测因素，男孩在外化（犯罪）和注意力问题方面得分较高。产前酒精暴露所造成的差异量在 0.6% 至 1.7% 之间。结论。母亲的饮酒量即使是低水平也与儿童行为呈负相关；还确定了剂量-反应关系。在平均每周饮酒 1 次的情况下就可以观察到这种效果。虽然在低水平的产前酒精暴露下观察到对外化和攻击行为平均得分的影响，但在中度/重度暴露水平下观察到对犯罪行为和总问题得分的影响。与未接触过酒精的儿童相比，产前接触过酒精的儿童出现临床违法行为评分的可能性是未接触过酒精的儿童的 3.2 倍。在控制了与不良行为结果相关的其他因素后，产前酒精暴露与不良儿童行为结果之间的关系仍然存在。孕妇经常询问临床医生在怀孕期间是否可以接受少量饮酒。这些数据表明，怀孕期间不饮酒仍然是最好的医疗建议。
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 attending 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 conception 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 assessed during pregnancy and postnatally. The independent variable in this study, prenatal alcohol exposure, was computed as the average absolute alcohol intake (oz) per day across pregnancy. At each prenatal visit, mothers were interviewed about alcohol use during the previous 2 weeks. Quantities and types of alcohol consumed were converted to fluid ounces of absolute alcohol and averaged across visits to generate a summary measure of alcohol exposure throughout pregnancy. Alcohol was initially used as a dichotomous variable comparing children with no prenatal alcohol exposure to children with any exposure. To evaluate the effects of different levels of exposure, the average absolute alcohol intake was relatively arbitrarily categorized into no, low (>0 but 0.3 fl oz of absolute alcohol/day) for the purpose of this study. Six years later, 665 families were contacted. Ninety-four percent agreed to testing. Exclusions included children who missed multiple test appointments, had major congenital malformations (other than fetal alcohol syndrome), possessed an IQ >2 standard deviations from the sample mean, or had incomplete data. The Achenbach Child Behavior Check-list (CBCL) was used to assess child behavior. The CBCL is a parent questionnaire applicable to children ages 4 to 16 years. It is widely used in the clinical assessment of children's behavior problems and has been extensively used in research. Eight syndrome scales are further grouped into Externalizing or undercontrolled (Aggressive and Delinquent) behavior and Internalizing or overcontrolled (Anxious/Depressed, Somatic Complaints, and Withdrawn) behaviors. Three syndromes (Social, Thought, and Attention Problems) fit neither group. Higher scores are associated with more problem behaviors. Research assistants who were trained and blinded to exposure status independently interviewed the child and caretaker. Data were collected on a broad range of control variables known to influence childhood behavior and/or to be associated with prenatal alcohol exposure. These included perinatal factors of maternal age, education, cigarette, cocaine, and other substances of abuse and the gestational age of the baby. Postnatal factors studied included maternal psychopathology, continuing alcohol and drug use, family structure, socioeconomic status, children's whole blood lead level, and exposure to violence. Data were collected only from black women as there was inadequate representation of other racial groups.Statistical Analyses. Statistical analyses were performed using the SPSS statistical package. Frequency distribution, cross-tabulation, odds ratio, and chi (2) tests were used for analyzing categorical data. Continuous data were analyzed using t tests, analyses 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. One-way 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 low-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.