The Effect of Maternal PTSD Following
in Utero Trauma Exposure on Behavior
and Temperament in the 9-Month-Old
SARAH R. BRAND,aSTEPHANIE M. ENGEL,bRICHARD L. CANFIELD,c
AND RACHEL YEHUDAa,b
aJames J. Peters Veterans Affairs Medical Center, Bronx, New York 10468, USA
bMount Sinai School of Medicine, New York, New York 10029,USA
cCornell University, Ithica, New York 14853,USA
ABSTRACT: In view of evidence of in utero glucocorticoid programming,
and our prior observation of lower cortisol levels in 9-month-old in-
fants of mothers with posttraumatic stress disorder (PTSD) compared
to mothers without PTSD, we undertook an examination of the effect
of in utero maternal stress, as determined by PTSD symptom severity,
and maternal cortisol levels on behavioral outcomes in the infant. Meth-
ods: Ninety-eight pregnant women directly exposed to the World Trade
Center (WTC) collapse on 9/11 provided salivary cortisol samples and
completed a PTSD symptom questionnaire and a behavior rating scale
to measure infant temperament, including distress to limitations, and
response to novelty. Results: Mothers who developed PTSD in response
to mothers who did not develop PTSD. Maternal morning cortisol levels
were inversely related to their rating of infant distress and response to
novelty (i.e., loud noises, new foods, unfamiliar people). Also, mothers
who had PTSD rated their infants as having greater distress to novelty
than did mothers without PTSD (t = 2.77, df = 61, P = 0.007). Conclu-
sion: Longitudinal studies are needed to determine how the association
ament reflect genetic and/or epigenetic mechanisms of intergenerational
KEYWORDS: Maternal PTSD; infant behavior; 9/11; cortisol
Bronx, NY 10468. Voice: 718-584-9000 ext. 6964; fax: 718-741-4775.
Ann. N.Y. Acad. Sci. 1071: 454–458 (2006). C ?2006 New York Academy of Sciences.
BRAND et al.: THE EFFECT OF MATERNAL PTSD455
Parental posttraumatic stress disorder (PTSD) has been shown to be a
salient risk factor in the development of PTSD in offspring of Holocaust sur-
velopment of this disorder.2The effect of maternal PTSD symptoms related to
cortisol has been shown to be associated with infant cortisol levels as early as
the first year of life, and may be associated with in utero effects of maternal
stress.3Indeed, in a previous report we showed that infants of mothers who
developed PTSD in response to direct exposure to the World Trade Center
(WTC) attacks showed decreased salivary cortisol levels early in life, com-
pared to infants of WTC-exposed mothers who did not develop PTSD. This
effect was most apparent in infants whose mothers were exposed during their
third trimester of pregnancy.3
A subsample of women for whom salivary samples were obtained (n =
98) participated in this study. This cohort was part of a larger prospective
epidemiologic study of 187 women4who were pregnant on September 11,
2001 and present in one of five “exposure” zones at or near the WTC at 9 AM
or for a substantial amount of time within the next 3 weeks.
At the baseline assessment, participants were given the PTSD Checklist
2003. Demographic and pregnancy outcome information was assessed at the
their infant’s temperament using the Infant Behavior Questionnaire (IBQ)6
an IBQ for each infant.
Salivary samples were collected at wake-up and bedtime into prelabeled
Salivette tubes (Starstedt, Nuembrecht, Germany), and were immediately
frozen until assay. Free cortisol levels were determined by radioimmunoas-
say (RIA) as described in Goenjian.7The detection limit was 10 ng/dL, and
intra- and interassay variability were 3.9% and 12.0%, respectively.
Analyses were conducted on the log-transformed cortisol due to the skewed
and kurtotic nature of the data. Potential confounds, including maternal age at
biological assessment and body mass index were tested for association with
456 ANNALS NEW YORK ACADEMY OF SCIENCES
time cortisol levels (r = 0.32, n = 92, P = 0.002) and was therefore included
as a covariate in the analyses involving nighttime cortisol.
Using PCL criteria, 47 women developed PTSD to 9/11 and 55 did not. The
two groups did not differ in maternal age at time of exposure (t = 1.61, df =
96,P =0.111),ethnicity(X2=5.18,df =5,P =0.394),durationofgestation
(t = 0.42, df = 96, P = 0.678), height (t = 0.08, df = 93, P = 0.934), weight
(t = 1.31, df = 96, P = 0.249), or zone of exposure (X2= 3.44, df = 4, P =
Mothers who developed PTSD rated their infants as having greater distress
to novelty (mean 46.1 ± 10.8) than did mothers who did not (39.3 ± 8.5) (t
= 2.77, df = 61, P = 0.007) (FIG. 1, Panel A). Maternal PTSD symptoms
were positively correlated with infant distress (r = 0.450, n = 53, P = 0.001),
as is shown in FIGURE 2, and maternal morning cortisol levels were inversely
related to infant distress to novelty (r = −0.274, df = 57, P = 0.036).
Consistent with other reports reviewed in Yehuda,2mothers who developed
and 151.96 ± 216.34, respectively), compared to those who did not develop
PTSD (810.55 ± 325.00 and 262.55 ± 341.23, respectively), when salivary
cortisol was measured 1 year after the trauma (t = 2.349, df = 96, P = 0.021
and t = 2.893, df = 90, P = 0.005) (FIG. 1, Panel B).
Panel A Panel B
Presence of Maternal PTSD
Infant Distress Level
Presence of Maternal PTSD
Log Morning Salivary
FIGURE 1. Maternal PTSD status and infant behavior and maternal cortisol.
The darkened vertical lines in each box represent the median values for the data with the
boxes representing data points within the upper and lower hinges (25th and 75th percentile,
BRAND et al.: THE EFFECT OF MATERNAL PTSD 457
0 20 406080
Maternal Symptoms, Baseline Assessment
Infant Distress at 9 months
FIGURE 2. Maternal PTSD symptoms and infant distress. Correlation between ma-
ternal PTSD symptoms and infant distress. r = 0.450, n = 53, P = 0.001.
These findings suggest that mothers with a greater susceptibility for devel-
oping PTSD may produce infants who are more easily distressed by novelty
than are infants of mothers who are less prone to develop PTSD. Alterna-
tively, mothers who more readily develop PTSD may perceive and then rate
however, because these mothers only rated their infants as having greater dis-
tress to novelty but not as having other negative temperamental traits. The
for future inquiry.
This research was supported by grants from the National Institute of Envi-
ronmental Health Sciences (NIEHS P42 ES07384) and The September 11th
Fund created by The United Way of New York City and The New York Com-
munity Trust, and the National Center for Environmental Research (NCER)
STAR Program, EPA (RD 83082701). Support for Dr. Yehuda was provided
by the National Institute of Mental Health (5 R01 MH64675–03 and NIMH
R01 MH64675–01). The authors would like to thank the participants of the
WTC Pregnancy Study for their continued cooperation, and the WTC staff for
their dedication, especially Joan Golub, Kelly Nichols, and Martha Malagon.
The authors would like to thank Dr. Mary Wolff and Dr. Trudy Berkowitz for
458 ANNALS NEW YORK ACADEMY OF SCIENCES Download full-text
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