Maternal Adversity, Vulnerability and Neurodevelopment
Conditions: Mental Health Issue (E.G., Depression, Psychosis, Personality Disorder, Substance Abuse), Infant Development, Infant Behavior
Sponsor: Douglas Mental Health University Institute

 
 
 
Maternal Adversity, Vulnerability and Neurodevelopment (MAVAN) 
Project 
 
 
 
Investigators: 
Principle Investigator: Michael Meaney; Co-Investigators: John Lydon, Sonia 
Lupien, Jens Prussner, Louise Seguin, Mark Daniel, Michael Kramer, Alan 
Evans, Tomas Paus, Stephen Matthews, Alison Fleming, Meir Steiner, Leslie 
Atkinson, James Kennedy, Susan Goldberg, Marla Sokolowski, Robert 
Levitan. 
 
Project funded August 1, 2004 through a CIHR Strategic Grant (750,000 per 
year for 5 years) 
 
 
 
 
 
 
 
 
Research Project 
Submitted for Approval by Douglas Hospital REB 
 
 
 
February 25th, 2004 
 
 

 
2
I. Introduction.   
 
Objectives: The probability of chronic illness is strongly influenced by 
environmental conditions prevailing during development (Hertzman 1999).  
The frequency of heart disease, diabetes, and mental illness is substantially 
greater amongst those born and raised in poverty, regardless of social class 
in adulthood.  Adversity associated with poverty produces incomplete, 
dysfunctional families often rife with domestic violence, malnutrition, drug 
use, child abuse and neglect.  Reproduction within this context is associated 
with maternal stress, increased risks for infection and thus pre-term labour, 
perinatal deaths, birth insults, poor nutrition for mother and offspring, and 
serious compromises in the quality of parent-child interactions.  These 
conditions define high-risk families.  For the child, these conditions bear the 
potential to influence the development of physiological systems that regulate 
metabolism and cardiovascular function, as well as neural processes 
underlying emotion and cognition.  These effects form the basis for 
vulnerability for illness.  
Perhaps the most dramatic illustration of the relation between 
adversity in early life and the risk for later illness emerges from studies on 
birth weight, early growth and health in adulthood.  Individuals that were 
small for gestational age, suggesting some degree of intrauterine growth 
restriction, are at significantly greater risk for type II diabetes, visceral 
obesity and hypertension (collectively referred to as the metabolic 
syndrome).  The major predictors of fetal growth restriction and pre-term 
labour, are maternal stress, infections, malnutrition, and tobacco/alcohol 
consumption.  These risk factors are far more prevalent in low socio-
economic status (SES) families and, predictably, low SES is a major risk 
factor for both intrauterine growth retardation (IUGR) and pre-term labour.     
It is increasingly clear that growth restriction also predicts an 
increased risk for mood disorders (Thompson et al. 1997, and see Kelly et 
al. 2001).  Additionally, the risk factors (i.e., maternal stress, 
tobacco/alcohol use, nutritional deprivation) for IUGR are also the major 
predictors for Attentional Deficit Disorder (ADD) and, predictably, ADD is far 
more prevalent in low SES environments (Biederman  et al., 1990, 1995; 
Barkley 2000).  Follow up studies of growth retarded infants reveal evidence 
for problems associated with attention and impulse control, functions that 
are heavily dependent on the hippocampus and prefrontal cortex.  These 
same brain regions are also among the major sites implicated in both 
depression and anxiety disorders.  Interestingly, growth restriction is also 
associated with increased behavioural inhibition, shyness and timidity in 
childhood, all of which appear to be predictors of mood disorders in later life.  
Studies with primate and rodent models show that the development of the 
hippocampus is impaired by fetal glucocorticoid exposure or by prenatal 
stress, and glucocorticoids are a mechanism for fetal growth restriction.  

 
3
Glucocorticoids are a major class of stress hormones and the release of 
these hormones is activated by stress, as well as by protein deprivation, 
tobacco and alcohol.  Thus, we propose that impairments in the 
development of the hippocampus and prefrontal cortex serve as the 
mechanism for the relation between fetal growth restriction and impaired 
cognitive and emotional development.   
These studies suggest that endocrine conditions that promote fetal 
growth restriction can also compromise neural development.  However, 
follow-up studies with even very low-birth weight babies reveal an 
impressive level of variability in cognitive outcomes.  Evidence from clinical 
intervention studies with high-risk infants and developmental neurobiology 
suggests that neurocognitive development is influenced by the quality of the 
postnatal environment.  Of particular relevance are the results of studies 
with primate and rodent models indicating that nurturing forms of maternal 
care can enhance neuronal survival and synaptic growth in regions such as 
the hippocampus (see below).  Thus we propose that the developmental 
outcomes associated with fetal adversity, reflected in growth retardation, are 
determined by the quality of the postnatal environment.   
Longitudinal studies reveal early life markers of poor health outcomes 
over the lifespan that include low birth weight, irritable temperament in early 
childhood and poor frustration tolerance, parental stress, attentional deficits 
and even increased blood pressure. These conditions can be quantified and 
we propose to use such measures in the development of longitudinal studies 
on the interactions between prenatal and postnatal environmental conditions 
in predicting health outcomes. Specifically, we will investigate influences 
of 
the 
early 
environment 
(prenatal 
and 
early 
neonatal) 
on 
neuropsychological development.  Our focus for the study of 
postnatal environment is on maternal well-being and mother-infant 
interactions.  Hence our measures include not only functional 
assessment of the offspring, but also measures focusing on the 
mother.   We feel that this study will provide a crucial basis for the 
development of focused, early intervention programs.   
 
 
Adverse Perinatal Environment: Development of Disease 
There is a dramatic increase in the risk for coronary heart disease, 
obesity and diabetes (metabolic syndrome) among individuals who were small 
for gestational age, a condition that implies some measure of intrauterine 
growth retardation (IUGR) and adverse fetal environment (Matthews 2001; 
Barker 2002; Seckl et al. 1999). The health risk appears linked to the 
programming effects on gene expression, especially that of hepatic genes. 
The conditions of risk associated with impoverished fetal life are not restricted 
to cardiovascular or metabolic disease. Adverse intrauterine environment has 
also been linked to neurodevelopmental disorders. Both prematurity and IUGR 

 
4
are consistently associated with cognitive impairments; the existing data 
suggest that cognitive outcomes are more seriously compromised by growth 
restriction than by prematurity (Lagercrantz 1997).  Studies using more 
global measures of cognitive development, such as IQ tests, reported 
significant impairments among IUGR children (e.g., Breslau et al. 1996; 
Fattal-Valevski et al. 1999; Leitner  et al. 2000;). van der Reijden-Lakeman 
et al. (1997) found that at 2 years of age, IUGR children were impaired on 
tests of divided, focused and sustained attention.  On such tests, the IUGR 
population was less accurate and more impulsive than controls.  These 
findings suggest that low-birth weight children might be at greater risk for the 
development of Attentional Deficit Disorder (ADD).  Indeed, the risk factors 
for IUGR, including maternal stress, maternal psychopathology, protein 
malnutrition, tobacco/alcohol consumption are identical to those for ADD.  
Likewise, maternal stress during gestation is a predictor of both fetal growth 
restriction and negative temperament (irritability, negative emotionality) and 
anxiety in children (O’Connor et al. 2000; Glover et al. 2002). Behavioural 
disorders, characterized by poor impulsive control, shyness, timidity and 
negative temperament (greater frequency of negative emotional states) are 
positively related to the degree of growth restriction (e.g., Szatmari et al. 
1990; Pharoah et al 1994; Sykes et al. 1997). 
Adverse fetal environment affects the risk for chronic illness via direct 
and indirect pathways.  In the case of the metabolic syndrome, direct effects 
include modification of the expression of enzymes involved in fat (PEPCK) and 
glucose 
(glucose 
kinases) 
metabolism. 
Intellectual 
and 
emotional 
development is affected by direct early environmental effects on neuronal 
proliferation and synaptogenesis in regions such as the hippocampus, 
amygdala and the frontal cortex.  Indirect effects on metabolic and 
neurological function include programmed modification of neuroendocrine 
function, 
particularly 
the 
hypothalamo-pituitary-adrenal 
(HPA) 
axis, 
throughout the lifespan. Indeed, many of the pathologies associated with the 
metabolic syndrome are identical to those observed in patients with Cushing’s 
syndrome (hypersecretion of cortisol; see McEwen et al. 1999; Lupien & 
Meaney 2001 for reviews).  Furthermore, Cushing’s patients are at increased 
risk of depression and cognitive impairment; both directly linked to 
dysregulation of HPA function. These observations indicate the central role of 
HPA function in perinatally programmed disease. In rodents, fetal adversity 
permanently increases corticotropin-releasing factor expression in the 
hypothalamus and amygdala; such effects appear to be mediated by 
alterations in the hippocampus and prefrontal cortex (Meaney 2001). These 
changes are linked to life-long enhancement of stress reactivity, which serves 
to exacerbate the risk of developing metabolic and neurological disorders.  
Fetal growth retardation is associated with problems of impulse control 
and attention. The preliminary results of recent imaging studies of low-birth 
weight children reveal significantly decreased hippocampal volume.  Indeed, 

 
5
alterations in hippocampal and prefrontal development might explain the 
unusually high level of comorbidity between attentional deficits - impulse 
control disorders and affective disorders.  The hippocampus and prefrontal 
cortex are also critical structures for impulse control and emotional states 
such as fear.  Importantly, each of the risk factors for IUGR is known to 
increase fetal adrenal release of glucocorticoids.  Thus adversity during fetal 
development increases exposure to glucocorticoids, which are known to 
promote growth restriction and compromise neural development, resulting in 
vulnerability for both cognitive and emotional disorders (Fig. 1). For example, 
fetal exposure to glucocorticoids decreases neuronal proliferation in the 
hippocampus (Ono et al., 1989; McEwen 1999; Liu & Matthews 2001).  
Interestingly, fetal dexamethasone administration in humans for congenital 
adrenal hyperplasia was associated with increased shyness and timidity in 
children.  Both anxiety disorders and depression are accompanied by 
significant decreases in hippocampal volume and, in the case of depression, 
dramatically reduced volume and activity in the prefrontal cortex. The 
hippocampus and the prefrontal cortex are primary targets for both 
antidepressant and anti-anxiety medications. 
The influence of environmental adversity on offspring development is 
not limited to the prenatal period.  There is clear evidence for the importance 
of postnatal poverty and family dysfunction on child development and health. 
Importantly, the effects of socioeconomic status (SES) on emotional and 
cognitive development in children are mediated by variations in parental care 
(Conger et al., 1994; McLoyd et al. 1998). Indeed, when parental care factors 
are statistically controlled, the effect of SES is eliminated. Likewise, low SES 
is associated with elevated cortisol levels in children, and these effects are 
mediated by parental factors. This suggests that stress of poverty, which is 
linked to increased risk of adverse fetal development, also compromises the 
quality of childcare.  In rodent and nonhuman primate models, mother-pup 
interactions regulate neurodevelopment and disruptions to mother-infant 
interactions are associated with impaired neurodevelopment and exaggerated 
HPA and emotional responses to stress (Meaney 2001).   
The influence of the postnatal environment is a sword that can, 
potentially, cut both ways.  In the rat, more intense forms of maternal care, 
characterized by increased pup licking, promote hippocampal synaptic 
development and dampen HPA responses to stress (Meaney 2001).  In the 
rat, maternal licking causes an increase in neurotrophic factor expression, 
enhancing both neuronal survival and synaptic outgrowth (Liu et al. 2000; 
Bredy et al. in press).  Increased maternal licking over the first week of life is 
also directly linked to more modest HPA and behavioral responses to stress 
(Francis et al., 1999; Caldji et al., 1998, in press).  Likewise, in humans, 
nurturing family environments dampen stress reactivity and promote 
resistance to chronic illness. Such findings raise the possibility that conditions 
of the postnatal environment could offset or reverse the risk created during 

 
6
fetal development.  Indeed, in animal studies there is clear evidence that 
postnatal enrichment, for example, can serve to eliminate the effects of fetal 
adversity.  This issue is obviously of profound significance for the 
development of early intervention studies.   
 
 
II. Hypotheses. 
 
Statement of the Problem: There is increasing evidence that many forms of 
chronic illness in child- and adulthood have perinatal origins. Developmental 
studies in both human and nonhuman subjects, have only very rarely 
examined the effects of environmental events at one stage of development in 
the context of previous experience.    
Hypotheses: There is significant interaction between the prenatal and 
postnatal environment in programming child- and adulthood disease, and that 
careful manipulation of the infant environment can ameliorate or reverse the 
negative health outcomes associated with adverse intrauterine experience.  
We hypothesize that the effects of fetal adversity on neurodevelopment are 
determined by the quality of the postnatal environment, particularly by 
mother-infant interactions.  Moreover, we propose that the quality of mother-
infant interactions is strongly influenced by maternal emotional well-being. 
 
III. Methods 
 
Participants.  Our approach will be to develop a human cohort derived from 
a study already nearing completion in Montreal (The Montreal Prematurity 
Study funded by the March of Dimes; PI: Dr. Michael Kramer). Dr. Kramer is 
a collaborator on the MAVAN project, and Drs. Meaney and Lydon are 
collaborators on the Prematurity Study. The Prematurity study involves 
measures of psychosocial stress, nutrition, and family and community living 
conditions as predictors of gestational length, which is the outcome measure 
in this project.  This project will recruit 5000 women at 13-15 weeks 
gestation, of which approximately 4000 have been recruited and will have 
given birth before the start of our project, leaving a population of 1200 
potential subjects. Currently, 100 women each month are assessed at 24-26 
weeks gestation. There is currently in place an infrastructure for follow-up of 
women from the Montreal Prematurity Study.   
 
The cohort for the current MAVAN project will be derived from 
the same population used in the Prematurity Study.  In essence the 
MAVAN Project will serve as a follow-up study derived from the Prematurity 
Study focusing on a substantially smaller population. The strategy for the 
MAVAN Project is to take advantage of the multivariate assessment of 
prenatal adversity in The Montreal Prematurity Study.  We will follow infants 
born at normal weight (controls, n= 120; 3000-3500 g at birth) and low-

 
7
birth weight babies exhibiting evidence for intrauterine growth retardation 
(IUGR, n= 120; 2200-2750 g at birth).  These groups are based on the 
recently published Canadian standards for fetal growth (Kramer, M. S., R. W. 
Platt, S. W. Wen, K. S. Joseph, A. Allen, M Abrahamowicz, B. Blondel, and G. 
Bréart. 2001. "A new and improved population-based canadian reference for 
birth weight for gestational age." Pediatrics 108:), which indicates that the 
birth weight of 2,750 g represents the 10th percentile, with a weight of 3750 
g at the 70th percentile.  Our intent is to avoid extreme cases of growth 
retardation (i.e., < 2,200 g).  All babies in this study will be born at > 37 
weeks gestation to avoid the complication of prematurity and growth 
restriction. We will recruit two cases for each case (i.e., two infants of 
normal birth weight for each infant that is small for gestational age).  
The method of recruitment for the MAVAN Study will follow the same 
procedures as another CIHR-funded follow-up study of the Prematurity 
Study.   The New Mothers Study (John Lydon, PI, M Kramer, L Seguin, S 
Lupien, and M Meaney co-investigators) examines the physical and 
psychological well being of mothers during the first year post-partum with 
particular attention to mothers of babies born with health problems and 
mothers of low socio-economic status.  The New Mothers Study is in its 
fourth year. Letters are sent to the mothers about the follow-up to the 
Prematurity Study with a rejection card and postage paid envelope.  Women 
who do not wish to receive a phone call for the follow-up study simply put 
the rejection card in the envelope and in the mail.  About 2 women per 
month choose this option.  With a 9% prevalence rate of IUGR, we can 
expect that 126 IUGR babies from the Montreal Prematurity Study will be 
available as potential participants.  Current recruitment rates (~70% 
participation) suggest that we will obtain a sample of 88 IUGR children and 
their mothers.  Two, normal weight for age babies born on the same or 
closest day to the IUGR baby will be used as controls with a target of 252. 
Based on the differential prevalence rates of IUGR among low and high SES 
mothers, we can expect a sample of 31 low SES mothers and babies in the 
IUGR group and 57 high SES.  Because SES (and associated chronic 
stressors and depression) may have an   adverse effect on child 
development mediated by postnatal growth delay rather than by IUGR, we 
will oversample low SES babies who are normal weight for age at birth and 
consider their postnatal growth as an additional factor predicting cognitive 
development. 
 
Overview 
 
The measures described here assess the following domains: general 
development, attention/ impulsivity, social/emotional development, 
temperament, and basal and stimulated hypothalamic-pituitary-adrenal 
activity. Methods include measures of parental reports of infant behaviour; 

 
8
direct testing of the infant, questionnaires for the mother, and observation of 
mother and infant. Direct testing of the infant occurs with the mother 
present up to the age of 36 months. At 18-months, 30-45 minutes of 
maternal testing will be conducted while the infant is cared for by a familiar 
laboratory assistant, after infant assessment (attention/impulsivity) is 
completed. By 36-months, infants can be assessed alone and therefore 
mother and infant assessments can occur simultaneously.  Note, that 
individual research assistants are assigned to specific mother-infant pairs for 
which they will be responsible for the duration of the study.  Our intention 
here is to allow individual assistants to become familiar with mothers/infants 
and thus ease the level of apprehension associated with testing.   
 
The measures and procedures described here for the infants occur in 
parallel with those of the mothers. In this plan, we have considered the joint 
burden of assessment on mother and infant to ensure that: 1) home rather 
than laboratory visits predominate in the first year; 2) questionnaires are 
distributed over time; 3) no session is longer than 2 hours total; 4) the time 
required for individual infant tasks is within the limits appropriate to the age 
of assessment and 4) mother-child separations do not occur in the first 18 
months, are no more than 30-45 minutes at 18 months, and no more than 
an hour at 36 months. During mother-infant separations, infants will remain 
with a familiar assistant. Few of the test materials included in this protocol 
comprise diagnostic tools. However, where appropriate (e.g. depression 
scales), subjects will be immediately notified if test scores suggest pathology 
and offered a referral to an appropriate mental health specialist. 
 
Finally, we mention the possibility of brain imaging in children. 
However, the details of the procedure have not yet been finalized and would 
pertain only to the children of 36 months of age.  Please note that we will 
conduct imaging only in unanesthetized subjects. Under no conditions would 
we consider the possibility of any sedative agent. The Montreal Consortium 
for Brain Imaging Research, of which Lupien, Pruessner, Meaney, and Paus 
are members and Evans the Director, is the lead site for the NIH 
Developmental Brain Mapping project.  The lead site for neuroimaging 
(structural MRI) of younger children is at Washington University in St. Louis.  
To date, this site has imaged ~150 children using no anesthetic or sedative 
and is the most experienced site in the world.  We have had extensive 
consultation with this team and the information provided suggested that our 
original plan to image infants was unlikely to be feasible with the current 
CIHR budget.  In contrast, they report remarkable success with children 
above 24 months (i.e., >70%), especially when children are prepared for 
scanning with experience in a Mock Scanner, which simulates the imaging 
conditions (noise, confinement, etc.) with the exception of the actual 

 
9
magnets.  The Douglas Hospital Research Centre will be purchasing such a 
scanner over the next 8 months.   
 
 
General procedure 
 
 
Six-month home interview: First visit (90 minutes) 
 
Mother 
 
1. Questionnaires  (Time required for completion is approximately 90 
minutes) 
 
1.1 Stress: 
 
1.1.1. Perceived Stress Scale. Maternal stress measures are assessed at 6 
and 12 months postpartum. Perceived stress is assessed using the short 
form of the Perceived Stress Scale (4 items) (Cohen et al. 1983).  The short 
form has an internal consistency of .72 (coefficient alpha) and two month 
test-retest reliability of .55.  
 
1.1.2. The Parental Stress Scale, (Berry and Jones, 1995) is an 18-item 
scale, which has good internal reliability (alpha = .83) and good 6-week 
test-retest stability (.81). This scale is much shorter than the Parenting 
Stress Index and is especially useful when samples include parents whose 
child does not have a developmental disability.   
 
1.1.4 Chronic stressors are assessed via measures of money problems, food 
security, housing problems, work stress, negative interactions with others 
and conjugal violence.  The money problem questions were drawn from the 
Daily Hassles Scale (Kanner et al., 1981). Each woman is asked if, since the 
beginning of their pregnancy, they have lacked money to: (1) pay for 
housing, (2) pay for electricity, hot water or heating, (3) buy food, (4) buy 
prescription medications, (5) buy or pay for anything else that she or her 
family needs. 
 
 
1.1.5. Work stress is assessed with a 13-item abbreviated version (Fenster 
et al.,1995) of the Karasek Job Content Questionnaire (Karasek et al., 
1986).  This measure includes four items on job demands and five items on 
job control as well as four items on social support at work. 
 

 
10
1.1.6.The negative interactions measure asks the first name and relationship 
of each person with whom the woman can expect to have unpleasant 
disagreements or to be made angry or upset.  The woman also indicates the 
number of times in the past two weeks that she has had a disagreement 
with each of these people. This is taken from the Arizona Social Support 
Interview Schedule (ASSIS) (Barrera M., 1981). 
 
1.1.7. The Marital Strain Scale (Pearlin et al., 1978) is used to assess 
chronic stress with one’s romantic partner.  The 9 items represent the three 
items with the highest factor loadings for each of the three factors 
contributing to the measure of marital strain.  In addition, the Abuse 
Assessment Screen is used to assess conjugal violence.  This five-item 
instrument assesses the frequency, severity, perpetrator, and body sites of 
injury (McFarlane et al., 1992; Parker et al., 1993). 
 
1.1.8 Lazarus and Folkman’s measure of primary appraisals (of challenge, 
threat, and centrality) is administered (14 items) (Folkman and Lazarus, 
1985).   
 
1.1.9 Reactive responding.  This is a 9 items scale that we obtained from 
Shelley Taylor based on her work with the MacArthur Network on 
socioeconomic status and health.  The idea is that those who have 
experienced chronic stress develop a hypervigilant response style to 
ambiguous environmental stimuli. 
 
1.2. Resilience 
The three core measures of personal resilience are self-esteem, 
optimism and beliefs about control. In addition, just world beliefs, life 
changes, motives for maternal caregiving (maternal care regulation), and 
commitment (willingness to sacrifice) are assessed.   
 
1.2.1. Personal Resilience.  Self-esteem is assessed using the short form (4 
items) of the Rosenberg Self-Esteem Scale (Major et al., 1998), the most 
widely used instrument to assess self esteem (Rosenberg M., 1965; Valliéres 
and Vallerand, 1990).   
 
1.2.2 Optimism is assessed using a short form of the Life Orientation Test 
(Scheier and Carver, 1985). The full scale has good internal consistency, 
(alpha = .76) and good test-retest stability (.79).  The short form we are 
using includes all 8 items from the original scale and deletes the four filler 
items. 
 
1.2.3 Beliefs of control is assessed using the 7 items mastery beliefs scales 
(Pearlin and Schooler, 1978).     

 
11
 
1.2.4 Life changes. This is an open-ended question at the end of the 
interview that elicits qualitative data from the woman. “Sometimes after 
having a baby, people think about life in a different way.  In what ways, if 
any, do you think about life differently now?”  The woman’s response is tape 
recorded and transcribed. 
 
1.2.5 Belief in a just world.  Theoretical and empirical work has suggested 
that this represents a core belief that is fundamentally challenged by major 
negative life events.  A prospective study of coping with the loss of a spouse 
found that a belief in a just world buffered the effects of spousal loss on 
psychological distress (8 items) (Bonanno et al., 2002). 
 
1.2.6 Maternal care regulation.  This is derived from self determination 
theory (Deci and Ryan, 1991) and corresponds with the work of one of the 
team members showing that the motivational bases for caregiving was 
associated with caregiver well-being among those caring for a loved one with 
Alzheimer’s.  The idea is to differentiate between caregiving driven by guilt 
vs. more self determined motives for caregiving (8 items).  The latter type 
should be more nurturing and promote greater autonomy in the child. 
 
1.2.7 Sacrifice scale.  These three questions measure the extent to which a 
woman is having to sacrifice other things for caregiving.  It is an indicator of 
commitment to the caregiving relationship. 
 
1.3. Social resources: 
 
1.3.1 Social support is assessed with five items from the ASSIS (Barrera M., 
1981). This assesses private feelings, material aid, advice, positive 
feedback, and physical assistance. The social participation domain (have fun 
or relax with) was not assessed.  Included are questions assessing the 
number of people available “in time of need” and to “confide in or talk freely 
about your problems.”  It then assesses whether the woman has needed 
support in the past two weeks in each of the five areas specified above.  For 
each need, the woman is then asked if she received help, and if not, how 
many times she was left without anyone to help her in this way. 
 
1.3.2. Relationship quality is assessed with the six item Quality of 
MarriageIndex ( Norton R., 1983).  The QMI has been found comparable to 
the Dyadic Adjustment Scale (DAS), correlating with the DAS at .90 
(Heyman et al., 1994). Moreover, one of the items in the QMI (and retained 
in our study) is Magical Question 31 from the DAS.  That is the question that 
correlates with the other 31 items of the 32-item DAS at .70 (Goodwin R., 
1992). In addition, the one-item Inclusion of Other in Self Scale is given to 

 
12
assess the degree of relationship closeness. Finally, the McGill Assessment of 
Relationship Commitment (Lydon and Gagné) is assessed. In total, 11 
questions are administered to assess relationship quality. 
 
1.3.3. Attachment is assessed with items from Brennan and colleagues’ 
comprehensive review and distillation of the most commonly used measures 
of adult attachment (Brennan et al., 1998). Their analysis of responses from 
1,076 respondents generated two subscales representing the two theoretical 
dimensions of adult attachment: avoidance of closeness and anxiety about 
relationships. Earlier versions of attachment measures included measures of 
both fear of closeness and fear of dependency.  Because both of these fold 
into the avoidance of closeness measure, four items loading on this subscale 
were chosen (2 fear of closeness and 2 fear of dependency items).  Because 
anxiety has stood alone as a measure even in earlier versions, only three 
items with the highest factor loadings for this subscale were retained. We 
have successfully used this 7-item measure in a series of three experiments 
(Bartz and Lydon, 2003).  
 
1.3.4. Parental Bonding Inventory  (PBI, Parker et al., 1979) is a standard in 
retrospective assessment of parental educational style (48 items) (Parker 
and Lipscombe, 1980).   
 
 
1.4. Health Behaviors:   
Health Behaviors are taken at 6, 12, 24 and 36 months post-partum 
using a 9 items questionnaire.  Questions assess cigarette smoking, use 
alcohol, prescribed medications and non-medicinal drugs (“recreational” or 
“hard” drugs).  Breastfeeding will be assessed at 6 and 12 months.   
 
1.5. Depression:   
Maternal depression measures are taken at 6, 12, 24 and 36 months 
postpartum.  The Center for Epidemiological Studies, Depression Scale (CES-
D) is a 20-item instrument that has excellent internal consistency (.90) and 
reasonable test-retest reliability (.54) for a scale that should be sensitive to 
adverse changes in the respondent’s environment (Radloff 1997; Fuhrer & 
Roullion 1989). For the current project, the scale is being used primarily as a 
continuous measure of change in depression (from the prenatal interview to 
the one year post partum interview).  Although there are cutoff points for 
classification purposes, caution is needed to avoid a high false positive rate 
(Santor et al. 1995). These mood factors are reliable and valid for the post-
partum population and show consistency across time, (Fleming et al., 
1988,1990). Correlations between the current experience scale (CES) and 
standardized mood scales (e.g. the MAACL, Zuckerman, 1985 and the BDI, 
Beck et al.,1961) are highly significant (range .55 to .80; Fleming et 
al.,1988,1990). 

 
13
 
 
Six-month home interview: Second visit (Time: 60 minutes) 
 
Mother 
 
1. Basal salivary cortisol: 
 
Maternal basal cortisol levels are assessed over the diurnal cycle using 
salivary samples obtained at 0800, 0830,1000, 1200 (with the sample taken 
prior to lunch), 1600, 1800 and 2200 hours.  The samples will be taken over 
two consecutive days using salivettes at 6, 12, and 24 months postpartum.  
The samples, which are stable at room temperature for 3-4 days, will be 
collected by the subject over the course of their normal daytime activity 
using portable PalmPilot devices as prompts to ensure accurate sample 
collection.  The subject will be asked to enter the exact time in the recorder.  
Samples will be collected and processed for radioimmunoassay in Meaney’s 
lab, which has considerable experience with salivary hormone assays (e.g., 
Lupien et al. 1998, 2002). Time: 2 minutes. 
 
 
2. Home environment evaluation     
 
Household observations checklist/ household satisfaction index.   
 
The household observations checklist is completed by research assistant 
immediately following home visit and the household satisfaction index 
requires research assistant to ask specific questions of mother. Both 
measures provide a basis for understanding the nature of the home setting. 
The "household observations checklist" is largely extracted from household 
assessment guides used in other studies. Responses to Questions 1-5 relate 
to socio-economic position; responses to Question 6 will be key in relation to 
subsequent neighborhood level surveys. The literature base for Q1-6 is 
housing and urban planning. 
      The "household satisfaction index" derives from epidemiological, health 
sciences and urban studies research. This literature establishes a link 
between perceived satisfaction with housing and infant respiratory problems 
and residents' emotional/affect and behavioural measures. Items given here 
have "good" Cronbach's alpha (better than 0.65, quite high for this 
literature) and demonstrated utility in relation to health status, broadly 
defined. Time: 2 minutes. 
 
Infants 
 

 
14
1. Questionnaires  
 
Health of the baby and breastfeeding questionnaire     
 
This 30 items questionnaire will be assessing the health of the infant  
since his birth and also breastfeeding. For the most part, these are yes/no 
questions. Time: 7 minutes. 
 
 
2. Standardized assessment and experimental tasks 
 
Psychomotor Development. The Bayley Scales of infant Development 
(BSID II, Bayley, 1993) are administered at 6, 12 and 36 months. This 1993 
revision of the most widely used infant development assessment consists of 
three scales: the Mental Scale and Motor Scale assess current level of 
cognitive, language, personal-social, fine and gross motor development; the 
Behavior Rating Scale assesses behavior during testing. The BSID II is 
appropriate for 1 to 42 months of age. Normative data were updated in 1993 
and data are available for children with Down syndrome, prematurity and 
prenatal drug exposure. The assessment is conducted by a trained individual 
and takes 30 minutes at 6 months and 45 minutes at 12 and 36 months. 
Training for the Bayley assessment is supervised by Renée Séguin, from the 
“Laboratoire d’étude du nourrisson” at Université du Québec à Montréal. 
 
 
3. Mother-infant interactions (behavioral observations)  
 
Videotaped Mother-Infant Interaction.  Once questionnaires are 
completed, the researcher sets up equipment for  a 20-minute video of 
mother-infant interactions and takes baseline salivary samples from mother 
and baby (see below).  During the video, mother and infant are alone in the 
room. Upon completion of the video, at 20 and 40 minutes after the start of 
the interaction, the researcher takes the second and then third saliva 
sample.   
 
 
Observations: Infants are given the opportunity to feed and be changed 
prior to the video. Mothers are seated on a comfortable stationary chair/sofa 
and asked to interact as they would if alone with the infant but to remain 
within the camera's view and not to feed the infant.  Behaviours are later 
coded from videotape using the BEST system. The coded behaviours on each 
occasion are adjusted to the age of the infant. For example, at 6 months 
they include attending to baby  (enface, looking over baby), affectionate 
contact  (affectionate burping, stroking, poking or hugging), in proximity to 
infant  (with nose within 2 cm on infant’s body), vocalizing to infant  (talking 
or singing to infant), and instrumental activities (instrumental burping, 

 
15
wiping face, adjusting blanket), and infant activities (hands waving, 
squirming, feet waving, crying, vocalizations).    
 
Inter-observer reliability is estimated by having two independent 
observers code 6 to 10 videotapes. In prior studies, percent agreement 
ranged from 70% to 100% for different behaviors. 
 
4. Salivary cortisol 
 
Basal salivary samples are taken at two time points over the day. Saliva will 
be collected by swabbing the child’s cheek with cotton applicator (Q-tips). 
Once wetted, the Q-tip is placed in a plastic eppendorf. The eppendorf is 
then stored at -20°C.  Samples are taken at 0800h (AM) and at 1600h (PM), 
for two consecutive days at 6, 12, and 24 months of age. These samples will 
be coordinated with the maternal samples using the PalmPilot probes that 
provide cues for sampling for the mother.  Only two samples are taken from 
the children because of the difficulty posed by daycare sampling. Salivary 
samples will be analyzed in the Meaney lab using radioimmunoassay 
procedures that are routine for this group.   
 
 
 Six-month laboratory visit (25 minutes) 
 
Infants 
 
1. Standardized assessment and experimental tasks 
 
1.1. Attention/Impulsivity.  
 
These tasks are laboratory-based experimental tasks designed for infants. 
Because abilities of infants change dramatically over the first few years, 
most cannot be used across ages. Instead, we use analogous tasks to tap 
the same abilities. At 6 and 18 months the infant is in a curtained enclosure, 
in an infant seat or highchair, or on mother's lap, facing a display of three 
monitors (Fig. 2). For a given task all or only some of the monitors are used. 
A peephole in the center allows a camera to film the infant's face so that 
gaze can be scored from the resulting recording. At 36 months the infant is 
seated at a low table facing the experimenter.  
 
 
1.1.1. Habituation of visual attention (6 months). This is one of the few 
paradigms applicable to assess attention control in very young infants. The 
basic paradigm involves repeated presentation of a stimulus. With repetition, 
attention normally decreases and the rate of decrease reflects ability to take 
in and organize information. The rate of decreased attention as well as 
patterns of attention (e.g. number of looks in a trial, duration of discrete 

 
16
looks) are related to later cognitive abilities (see Fagen & Ohr, 2001 for a 
review). Typically, to ensure that attention decrease is specific to the 
stimulus (i.e., not a result of fatigue) a novel stimulus or modification of the 
original is presented at the end of the habituation sequence. Many forms of 
this paradigm with variation in similarity and dimensions of change for the 
habituated and novel stimuli are used to study questions about infant 
cognitive abilities. In the present study, two sets of stimuli are used with all 
trials appearing on the central monitor. In one, five brightly colored 
stationary fish appear, all facing in the same direction for 8 trials of 15 
second each, with three seconds between trials. On the 9th trial the same 
fish are presented facing in the opposite direction. The other sequence 
presents a schematic face that changes orientation (upside down) on the 
novel trial. Measures are based on change in 1) total looking over trials, 
number of looks per trial, and duration of longest look on each trial.  Time: 
10 mins.   
 
1.1.2 Visual Expectation Paradigm, (Haith, Hazan, & Goodman, 1988, 6 and 
18 months) Learning of context dependent sequences requires development 
of the frontal structure underlying ability to guide behavior using new 
information available in the context and to inhibit old responses (Clohessy, 
Posner and Rothbart, 2001). Visual expectation tasks are a classic measure 
of this type of learning. In our version of the visual expectation paradigm, a 
single computer-generated stimulus is presented on one of the three 
monitors according to predetermined sequences, until the infant orients to it 
(Interstimulus interval = 600 milliseconds). Simple sequences have a 
repeating pattern in which associations between target locations are unique. 
Each event reliably predicts the next in the sequence. (e.g., 1-2-1-2-1-2). 
Complex sequences have a repeating pattern in which some events reliably 
predict the next target location but others do not (e.g., 1-2-2-1-2-2-1). 
Infants as young as 3 months learn to anticipate this latter complex 
sequence (Canfield & Haith, 1991). The presented stimuli are either colorful 
looming shapes that alternate between squares and diamonds, or human 
faces alternating between neutral and angry expressions. Six-month-old 
infants see sequences that use only the lower two monitors; 18-month-olds 
see sequences using all three monitors. The measures derived are: 1) the 
number of correctly anticipated trials; 2) latency to anticipate or respond to 
an image on correct trials and 3) the difference between the number of 
correctly anticipated trials in the complex sequence and the simple 
sequence. Time: 10-15 mins (longer for the older group). 
 
2. Questionnaires 
The mother will fill out questionnaires about her child while he/she is 
undergoing evaluation. 
 

 
17
2.1. Temperament.   
 
Although there are laboratory-based observational procedures for assessing 
infant temperament (e.g., Goldsmith & Rothbart, 1996) these are labour 
intensive and therefore not as widely used as parent report instruments. The 
Infant Behavior Questionnaire, Revised Version (IBQ, Garstein and Rothbart, 
2003) is completed at 6 and 12 months and the toddler version at 36 
months. This is a widely used parent-report measure of infant temperament. 
The items represent 14 scales but factor analysis reveals three primary 
factors: a) impulsivity, b) negative affectivity and c) effortful control. We 
chose this instrument, partly because of interest in impulsivity as a key 
outcome variable and partly because this measure is well researched and 
has internal and external validity.  The questionnaire is completed by the 
mother.  Time: 15 minutes. 
 
2.2 Childbearing Attitudes questionnaires (CAQ).  
 
The Childbearing Attitudes Questionnaire (CAQ), assessed at 6 and 18 
postpartum, is a 76-item scale concerning attitudes toward pregnancy and 
birth, self-esteem, and other interpersonal relationships. Items include 3-6 
items for each of 19 different issues important to infants and childbirth, 
counterbalanced for direction to minimize response bias. Participants 
respond to each item on a 7-point scale from disagree strongly (1) to agree 
strongly (7). The attitude factors for the present study were derived from 
these items by factor analysis (Ruble et al., 1990). Attitude clusters assess 
1) feelings of attachment towards her own infant (attachment), 2) feelings 
of nurturance towards infants in general (other infants), 3) feelings about 
caretaking activities, 4) feelings of adequacy in the maternal role (maternal 
adequacy), 5) feelings towards partner/spouse (relationship with partner) 
and 6) feelings towards their own mothers (relationship with mother). For 
the present study, we will use 4 subscales: maternal worries, maternal self-
confidence, identification with pregnancy, and feelings about children (20 
items total). Time: 7 minutes. 
 
 
 Twelve-month home interview: First visit (90 minutes) 
 
Mother 
 
1. Questionnaires 
 
1.1 Interview: Same as described in the 6 months mother evaluation (See 
first visit, section 1).  
 

 
18
1.2 Experience sampling of Mother-infant interactions (for 7 days)  
A computer program has been developed to use personal digital 
assistants (PDAs, e.g. PalmPilot) to collect experience sampling data from 
the mother for one week when the baby turns one year of age. The PDA will 
page the mother three times a day and ask her a series of 10 questions 
about her most recent interaction with the baby. Questions will ask about 
their most recent interaction with the baby, about the last time the baby 
cried and finally, the last time during the day, they were doing something 
else and the baby wanted their attention.  For the evening paging, they will 
be ask whether they wanted and received social support from their partner 
and felt understood and cared for by him. Other question will ask about their 
positive and negative affect at the end of the day.  This procedure has been 
tried successfully for the past 4 months as part of the Montreal New Mothers 
Study. Time: 5 minutes per paging. 
 
 
 Twelve-month home interview: Second visit (50 minutes) 
 
Mother 
 
1. Baseline salivary cortisol 
 
Procedures described in the 6 months mother evaluation (See second home 
visit, section 1). 
 
 
Infants 
 
1. Questionnaires. 
 
1.1 Health of the baby and breastfeeding questionnaire. Time: 7 
minutes.    
 
 
2. Standardized assessment and experimental tasks 
 
Psychomotor Development. The Bayley Scales of infant Development 
(BSID II, Bayley, 1993) are administered at 12 months. The assessment 
takes 45 minutes. 
 
 
3. Baseline salivary cortisol 
 

 
19
Procedures described in the 6 months infant evaluation (See second home 
visit, section 4). 
 
 
 Eighteen-month home visit (90 minutes) 
 
 
Infants 
 
1. Questionnaires. 
 
1.1 Health of the baby questionnaire. Time: 7 minutes.     
 
1.2. Social/Emotional Development.  
The Infant-Toddler Social and Emotional Assessment (ITSEA, Briggs-Gowan 
& Carter, 1998, 18, 24 months) is a parent-report questionnaire, designed 
as a developmentally and clinically sensitive measure of social-emotional 
competencies and problems in 1-2 year-olds. It consists of 140 items to 
evaluate four independent behavioral domains: 1) externalizing, (e.g., high-
activity, aggression, defiance, and negative emotional reactivity); 2) 
internalizing, (e.g., mood regulation problems, social withdrawal and 
extreme inhibition/shyness); 3) dysregulation (e.g., sleep and eating 
problems, mood regulation); and 4) maladaptation (e.g., repetitive and 
stereotypic behaviors). Items are rated on a 3-point scale. Low ITSEA scores 
are associated with maternal depression and other psychiatric comorbidities 
(Carter et al, 2001). Low social-emotional competencies are also related to 
attachment insecurity, poor task mastery and emotion regulation, ineffective 
coping behaviors (Carter et al, 1999) as well as delayed linguistic 
development (Irwin et al, 2002). Time to complete: 40 minutes. 
 
2. Behavioral observations 
 
2.1. Mother-Infant Interactions : Home Observation with Q Sort 
(MBQS 18 months) (Duration ± 45 minutes) 
Maternal sensitivity, considered a key quality in establishing secure 
attachment, is assessed with the Maternal Behaviour Q-set (Pederson et al, 
1990).  The MBQS yields a single score reflecting the mother’s responsivity 
to infant signals.  Two observers are needed because one distracts the 
mother while the other observes.  This allows observation of the mother 
under conditions of multiple attentional demands.  MBQS scores correlate 
with other maternal sensitivity ratings and measures of attachment 
(Atkinson et al, 1995, 2000, Moran et al, 1992, Pederson et al, 1990). Meta-
analysis (Atkinson et al, 2000b) demonstrated that MBQS scores correlate 

 
20
with infant attachment security significantly more highly than other 
observational techniques (r=.48 vs .21). 
 
 
 Eighteen-month laboratory visit (90 minutes) 
 
Infants 
 
1. Questionnaires 
The mother will fill out questionnaires about her child while he/she is 
undergoing evaluation. 
 
1.1. Temperament.      
The Early Childhood Behavior Questionnaire, (Rothbart et al., 200?) is 
completed at 18 months. Time: 15 minutes.  
 
1.2. Childbearing Attitudes questionnaires (CAQ).  
At 18 months, we will use the same 4 subscales of the original 
questionnaire: maternal worries, maternal self-confidence, identification with 
pregnancy, and feelings about children (20 items total). Time: 7 minutes. 
 
 
2.Standardized assessments and experimental tasks 
 
2.1 Attention/impulsivity 
 
2.1.1 The Attention Network Test (ANT, Fan et al., 2002; 18 months) 
Assesses executive functions based on latency of response to the direction 
cued by the middle stimulus in a set. Sets are either congruent (all items 
point in the same direction) or incongruent (the middle item points in a 
different direction from the others). Although originally designed for adults, 
this task has been successfully adapted for children (Swanson et al, 2000; 
Fan et al, 2002). The current project adapts the standard ANT to study 
infant attention functions by pairing the middle stimulus with an interesting 
event (an animated videoclip on one of the lower two monitors) presented 
subsequently in the location cued by the middle stimulus. In the current 
study, the cues are sets of five looming fish facing left or right on the central 
monitor. In congruent sets, all fish face the same side and loom in the same 
direction. In incongruent sets, the middle fish faces and looms in the 
opposite direction. The middle fish is a reliable cue to the location of the 
animation clip, and is also colored more brightly than the others to 
strengthen the association. During each trial, the cue set is presented for 2 
seconds at the top monitor of the triangular array. After a 600-millisecond 
interval, a 3.5 second animated clip appears in one of the lower two 

 
21
monitors. The locations where the sets of fish prompt and where the 
animations appear follow a previously determined random sequence. The 
training session consists of 10 trials, with all cues congruent, facing left or 
right in a previously determined random sequence. To facilitate initial pairing 
between the cue and the location of the animated clip, only the middle fish 
looms during training; the others are motionless. The test session is a 
previously determined random sequence of 24 trials in which five fish within 
the set loom, but only the middle one reliably indicates the location of the 
subsequent animation clip. The difference between latency to anticipate or 
respond to the animation clips for congruent and incongruent cues is the 
measure. Time: 15 min.  
 
2.1.2. Visual Expectation Paradigm, (Haith, Hazan, & Goodman, 1988, 18 
months). Time: 15 minutes.   
 
3. Behavioral observations 
 
3.1. Social/Emotional Development. 
 
3.1.1. Attachment (18 months): The Strange situation (SS; Ainsworth et al., 
1978) is a standard videotaped or filmed laboratory assessment consisting of 
eight episodes wherein the infant is alone, with mother, with a stranger, or 
both, in an unfamiliar setting. Episodes are ordered to increase stress in 
standardized increments that are manageable for the baby. The primary 
purpose of this paradigm is to assess the establishment and quality of 
infant-mother attachment, an important early social milestone. Trained 
coders use standardized coding schemes  (Ainsworth et al., 1978; Main & 
Solomon, 1990) to assign the infant/toddler to one of 4 categories (secure, 
avoidant, resistant/dependant, disorganized) reflecting the quality of 
attachment. These categories are differentially associated with later 
outcomes with the "secure" pattern predicting the most optimal outcomes 
(e.g., Arend et al, 1979; Renken et al, 1989) and the disorganized pattern 
having links to later psychopathology (e.g., Carlson, 1998). 
In the present study, the strange situation serves additional multiple 
purposes. It 1) is a stressor that reliably elicits a cortisol stress response 
(e.g., Nachmias et al, 1996; Spangler & Grossmann, 1993; Goldberg et al, 
in press). For this purpose, it is necessary to administer the strange situation 
in a separate session on its own.  Note salivary cortisol samples are taken as 
described below.  2) allows assessment of social inhibition/impulsitivity by 
coding infant response to the stranger (Greenberg & Marvin, 1982) and 3) 
allows coding of maternal behaviours known to disrupt formation of 
attachment (considered markers of risk for child emotional disturbance) 
using the Atypical Maternal Behavior Instrument for Assessment and 
Classification (AMBIANCE, Lyons-Ruth & Block, 1996; Lyons-Ruth et al, 
1999). The AMBIANCE will also be applied to other videotaped mother-infant 
interaction sequences.  Time: 60 minutes. 
  

 
22
3.1.2. Social Inhibition/Impulsivity: As noted above (3.1.1) behaviour to the 
stranger in the strange situation is coded from video.  
   
 
4. Cortisol Stress reactivity 
 
Saliva samples are collected from infants for cortisol assays at baseline 
(arrival), and 20 and 40 minutes after the end of the designated stressor. At 
18 months, the stressor is the Strange situation.   
 
 
 Twenty-four month home visit (50 minutes) 
 
Mother 
 
1. Questionnaires 
 
1.1 Interview 
Short version of the questionnaire described in the 6 months mother 
evaluation (See first home visit, section 1). We will assess the sources of 
stress in the mother’s life, marital quality and health. We expect the 
interview to take about 45 minutes to complete.  
    
 
2. Baseline salivary cortisol 
 
Procedures described in the 6 months mother evaluation (See second home 
visit, section 1). 
 
 
Infants 
 
1. Questionnaires 
 
1.1. Health of the baby questionnaire. Time: 5 minutes. 
 
 
2. Baseline salivary cortisol 
 
Procedures described in the 6 months infant evaluation (See second home 
visit, section 4). 
 
 

 
23
 Thirty-six month home interview (50 minutes) 
 
Infants 
 
1. Questionnaires. 
 
1.1 Health of the baby questionnaire. Time: 5 minutes.     
 
 
2. Standardized assessments and experimental tasks 
 
2.1 Psychomotor Development. The Bayley Scales of Infant Development 
(BSID II, Bayley, 1993) are administered at 36 months. The assessment 
takes 45 minutes. 
 
 
 Thirty-six month laboratory visit (90 minutes) 
 
 
Infants 
 
1. Standardized assessments and experimental tasks 
 
1.1. Attention/Impulsivity. 
 
1.1.1. Snack Delay (Goldsmith & Rothbart, 1996, 36 months): After placing 
a single Cheerio or M&M under a clear plastic cup, the experimenter instructs 
the child to wait for the bell to ring before lifting the glass and eating the 
snack. Four trials follow with timed durations of 10, 20, 30 and 15seconds. 
Halfway through each timed period, the experimenter lifts but does not ring 
the bell. Children hear the instructions again following trials 1-3. Score (from 
film or videotape) is the length of time the child is able to delay before lifting 
the glass.  Time: 5 min. 
 
1.1.2. Whisper Task (Goldsmith & Rothbart, 1996, 36 months) The 
experimenter instructs the child as follows: 'Let's try to talk very very 
quietly, just like I am - can you whisper your name to me? OK, let's play this 
whisper game I know. I have some pictures of some cartoon characters - 
let's see if you can tell me their names (it's okay if you don't know, it's just 
for fun). Remember to whisper because that is how you play the game." 
Cards are presented in fixed order, the experimenter asks for a color label or 
a description of what the character is doing. A reminder to whisper occurs 
after the first five cards. Scored from film or videotape, based on number of 
times child speaks above a whisper. Time: 15 min. 

 
24
 
1.1.3. Tower Task (Goldsmith & Rothbart, 1996, 36 months). The 
experimenter explains how to take turns while building a tower out of 
wooden alphabet blocks. Children are encouraged to keep adding blocks 
until the tower falls over. Three towers are built. Coded from videotape, 
based on the number of times the child violates the rule of "turns." Time: 10 
min. 
 
 
2. Behavioral observations 
 
2.1. Social/ Emotional Development. 
 
2.1.1. Attachment (36-months): Reunion behaviour. The strange situation 
was originally designed for 12-18 month-old infants. Adaptations have been 
developed for 2-5 year-old children based on evidence (Ainsworth et al, 
1978) that the key information is obtained in reunion episodes. At this 
assessment, mother and infant are separated during the testing 
period (approximately 1h). The mother then returns to the child's testing 
room and the reunion and free play following it are coded using the scheme 
for preschool attachment (Cassidy & Marvin, 1987). 
  
2.1.2. Social Inhibition/Impulsivity: As noted above (2.1.1, in the 18-month 
Strange situation section) behaviour to the stranger in the strange 
situation is coded from video. At 36 months, response to the 
experimenter is coded using the same coding scheme. In addition, at 
36 months, latency to speak to the experimenter and to engage in 
each task is coded as additional measures of social inhibition.  
   
 
3. Cortisol Stress reactivity 
 
Saliva samples are collected from infants for cortisol assays at baseline 
(arrival), and 20 and 40 minutes after the end of the designated stressor. At 
36 months, the stressor is the separation of mother and child during testing.  
 
 
4. Questionnaire 
The mother will fill out the questionnaire about her child while he/she 
is undergoing evaluation. 

 
25
 
4.1. Temperament.      
The Early Childhood Behavior Questionnaire (Rothbart et al., 
200?) is completed at 36 months. Time: 15 minutes. 
 
IV. Statistical analysis 
Power analysis for maternal sensitivity/infant cortisol response.   
 
We hypothesize that decreased maternal sensitivity will be associated 
with increased cortisol stress responses (obtained with salivary cortisol 
measures) in infants in the strange situation test at both 18 and 36 months 
of age.  Published work on infant’s attachment and cortisol stress responses 
shows strong effects sizes (consistently significant differences despite small 
sample sizes).  However, we propose to address the influence of mothers’ 
behaviour on infants’ cortisol stress response.  Because infants’ behaviour 
may be more strongly related to their own cortisol stress response than 
would be the mother’s behaviour, we reduced expected effect size to the 
moderate range (r = .30; Cohen, 1988).  We based our power analysis on 
two continuous variables (maternal sensitivity and net area under the curve, 
?2 = .008 and a .80 probability of rejecting H0 if it is actually false.  Under 
these conditions, we need a sample size of 130 (Cohen, 1988).  Assuming 
that 13% of participant subjects do not complete the study (based on data 
from a previous project drawing on the same recruitment source and 
requiring similar levels of commitment), we need 145 mother-infant dyads 
to assess the influence of maternal sensitivity of infant cortisol stress 
response.  Hence the sample size of 240 subjects should be sufficient.   
 
We identified measures that are indicators of stress and potential 
mediators and moderators of the effects stress on well-being.  Most 
measures are shortened versions of well -documented and widely used 
measures in the literature.  A few are measures that members of the team 
have obtained from colleagues who are leading researchers internationally.  
For example,  the reactive responding measure was developed by Shelley 
Taylor of UCLA in collaboration with the MacArthur Network on the study of 
socioeconomic status and health. 
The secondary level of analyses will involve a preliminary structural 
equation modeling, but please note that this is intended as a “value added” 
approach to the primary analyses described above that are derived from 
specific hypotheses. Quantitatively, as was noted in the review, we face a 
challenge, especially concerning the issue of moderating effects vis-a-vis 
structural equation modeling.  We will draw on the expertise of statisticians 
from the Montreal Prematurity Team. 
The analyses will be performed in two stages: first regression and 
analysis of variance type models and in the second stage structural equation 

 
26
modeling.  Regression analyses and ANOVA analyses will be used to test the 
stated hypotheses.  In particular, tests of interaction effects will be used to 
assess effect modification (moderating variables).  Longitudinal analyses to 
assess chronicity of effects will be done using multilevel regression models 
to take into account intra-subject correlation. 
 
In the second stage, structural equation modeling (SEM) will be used 
to test a structural model expressing the nature and strength of each link 
between pairs of constructs, integrated in a comprehensive and detailed 
model that can be statistically tested for fit. In order to identify the “best” 
model,  a sequence of nested comprehensive models will be formulated.  
Each will be separately analyzed by SEM. The formulation of each model will 
be based on the conceptual framework presented in the proposal and will be 
complemented by the results of the statistical analyses of the first stage. 
Each model is assessed according to well-known statistical criteria pertaining 
to (1) the overall statistical fit, (2) tests of significance relative to each link, 
(3) estimation of direct and indirect effects in the network of causal 
pathways, and (4) the residuals. A comparison of competing models is 
possible within SEM, provided these models are nested.  Hence, among 
similar (nested) models that are equally meaningful, the most parsimonious 
can be identified and is considered as “best”. Our hypotheses are essentially 
based on mediating and moderating variables and causal pathways, rather 
than simple associations 
No standard procedure or formulae are available to estimate sample 
sizes and power for structural models.  Recent simulation studies140-
141indicate that a sample size larger than 200 will reduce the chances of 
nonconvergence (of the estimation algorithm),  of improper solutions (illegal 
estimations such as a negative variance)  and of unacceptable bias of 
estimators.  The size of the available sample will likely range from 210 (all 
time points and cortisol) to 292 (all time points no cortisol) to 366 (6 month 
data) to 1 year only (440) and hence will prove sufficient to meet the 
preceding guidelines.  As recommended by Boomsma and Hoogland,  newly 
developed corrective robust statistics will be used to correct the effect of 
possible nonnormality of our data.  

 
27
Nevertheless, please note that the primary statistical analyses are designed 
to test specific hypotheses concerning infant outcome measures that are 
assessed using laboratory-based measures such as the Rothbart  tests for 
cognitive testing, behavior in the strange situation,  salivary cortisol 
responses to the strange situation as well as basal cortisol levels,  etc.  In 
the literature, the sample sizes for studies of such outcomes rarely exceed 
10-12 per group and yield significant effects of maternal sensitivity. 
 
V. Continuing Review process 
The principal investigator of the present research project along with 
the research team will continue to read the scientific literature related to the 
different variables studied in the present protocol. If there are new data 
showing that some of the protocols used are harmful for participants, or if 
one of the variables studied has been shown to be related to negative 
outcomes, the principal investigator will immediately contact the Research 
Ethics Committee of Douglas Hospital in order to submit these new issues to 
the committee.  Please note there are 15 investigators associated with this 
project, each of whom is a leading international expert in their field of study.  
This level of expertise ensures the use of state-of-the-art testing procedures 
as well as an awareness of emerging ethical issues with their area of 
research.  All procedures are reviewed on a regular basis by an Executive 
Committee comprised of Drs. Meaney, Matthews, Lupien, Atkinson, 
Sokolowski and Lydon.  The Executive meets every 2nd month, while 
members of the project meet twice annually.  The topics of ethics are 
reviewed at each meeting in order to verify adherence to approved 
procedures and to up-date protocols where necessary.   
 
VI. Literature 
 
Ainsworth, M.D.S., Blehar, M., Waters, E., & Wall, S. (1978). Patterns of 
attachment. Hillsdale, N.J.: Erlbaum. 
Arend, R. Gove, F. & Sroufe, L.A. (1979) Continuity of individual adaptation 
from infancy to kindergarten: A predictive study of ego resiliency and 
curiousity in preschoolers. Child Development, 50, 950-959. 
Atkinson, L., Paglia, A., Coolbear, J., Niccols, A., Poulton, L., Leung, E., & 
Chisholm, V.C. (2000a). Assessing maternal sensitivity in the context of 
attachment security: A meta-analysis. In G. M. Tarabulsy, S. Larose, D. 
R. Pederson, & G. Moran (Eds.), Attachement et développement: petite 
et jeune enfance. [Attachment and development: infancy and the 
preschool years.] Québec, Canada: Presses de l'Université du Québec. 

 
28
Atkinson, L., Paglia, A., Coolbear, J., Niccols, A., Parker, K. C. H., & Guger, 
S. (2000b). Infant attachment security: A meta-analysis of maternal 
mental health correlates. Clinical Psychology Review, 20, 1019-1040. 
Barker DJ. Fetal programming of coronary heart disease. Trends in 
Endocrinology & Metabolism. 13(9):364-8, 2002. 
Barkley RA, Anastopoulos AD, Guevremont DC, Fletcher KE. Adolescents 
with attention deficit hyperactivity disorder: mother-adolescent 
interactions, family beliefs and conflicts, and maternal psychopathology. 
J Abnorm Child Psychol 1992 :263-88. 
Barkley RA. Attention Deficit Hyperactivity Disorder : A Handbook for  
Diagnosis and Treatment. New York, NY : Guilford Press;1990. 
Bayley, N. (1993) Bayley Scales of Infant Development II. San 
Antonio, TX: Psychological Corporation. 
Barrera M. Social support in the adjustment of pregnant adolescents: 
Assessment issues. In: Social Network and Social Support (Ed. Gottieb 
BH.) Beverly Hills: Sage, 1981, pp. 69-96. 
Bartz JA, Lydon JE. Attachment goals and communal and exchange norms. 
Presented at the 4th annual meeting of the Society for Personality and 
Social Psychology, Los Angeles, California, 2003.  
Beck, A.T., Ward, C.H., Mendelson, M., Mock, J., & Erbaugh, J. (1961).  An 
inventory for measuring depressiion.  Archives of General Psychiatry, 4, 
561-571. 
Bentler, P. EQS Structural Equations. Encino, CA: Multivariate Software, Inc. 
1995. 
Berry JO, Jones WH. The parental stress scale: Initial psychometric 
evidence. Journal of Social and Personal Relationships 1995; 12:463-
472. 
Biederman J, Faraone SV, Keenan K, Knee D, Tsuang MT. Family-genetic 
and psychosocial risk factors in DSM-III attention deficit disorder. J Am 
Acad Child Adolesc Psychiatry 1990 29(4):526-33 
Biederman J, Milberger S, Faraone SV, Kiely K, Guite J, Mick E, Ablon S, 
Warburton R, Reed E. Family-environment risk factors for attention-
deficit hyperactivity disorder. A test of Rutter's indicators of adversity. 
Arch Gen Psychiatry. 1995 52:464-70. 
Biederman J, Milberger S, Faraone SV, Kiely K, Guite J, Mick E, Ablon JS, 
Warburton R, Reed E, Davis SG. Impact of adversity on functioning and 
comorbidity in children with attention-deficit hyperactivity disorder. J Am 
Acad Child Adolesc Psychiatry 1995 34:1495-503 
Blair, C. (2002). Early intervention for low birth weight preterm infants: The 
role of negative emotionality in the specification of effects. Development 
and Psychopathology.  

 
29
Bollen, K.A. Structural Equations with Latent Variables.  New York:  John 
Wiley, 1989; 514 p. 
Bonanno GA, Wortman CB, Lehman DR, Tweed RG, Haring M, Sonnega J, 
Carr, D, Hesse RM. Resilience to loss and chronic grief: A prospective 
study from preloss to 18-months postloss. Journal of Personality and 
Social Psychology,2002 
Brennan KA, Clark CL, Shaver PR. Self-report measurement of adult 
attachment: An integrative overview. In Attachment Theory and Close 
Relationships (Eds. Simpson JA, Rholes WS). Guilford Press, New York, 
1998, pp. 3-21. 
Breslau N, Klein N, Allen L. Very low birthweight: behavioural sequelae at 
nine years of age. J Am Acad Child Adolesc Psychiatry 1988 27:605–12. 
Briggs-Gowan, MJ. & Carter, AS. (1998). Preliminary acceptabilit 
Caldji C, Tannenbaum B, Sharma S, Francis D, Plotsky PM Meaney MJ. 1998. 
Maternal care during infancy regulates the development of neural 
systems mediating the expression of behavioral fearfulness in adulthood 
in the rat.  Proc. Nat.  Acad. Sci.  95:5335-40. 
Caldji  C, Francis D, Sharma S, Plotsky PM, Meaney MJ. 2000a.  The effects 
of early rearing environment on the development of GABAA and central 
benzodiazepine receptor levels and novelty-induced fearfulness in the 
rat.  Neuropsychopharmacology  22: 219-29. 
Caldji C, Diorio J, Meaney MJ. In press. Maternal behavior in infancy 
regulates the development of GABAA receptor levels, its subunit 
composition. Neuropsychopharmacology.  
Canetti L, Bachar E, Galili-Weisstub E, De-Nour AK, Shalev AY. 1997. 
Parental bonding and mental health in adolesence.  Adolesence  32:381-
394. 
Canfield, R.M. & Haith, M.M. (1991) Young infants expectations for 
symmetric 
and 
assymetric 
stimulus 
sequences. 
Developmental 
Psychologsy, 27, 198-209. 
Carlson, E.A. (1998) A prospective longitudinal study of attachment 
disorganization/ disorientation. Child Development, 69, 1107-1129. 
Carter, AS., Little, C., Briggs-Gowan, MJ. & Kogan, N. (1999). The infant-
toddler social and emotional assessment (ITSEA): Comparing parent 
ratings to laboratory observations of task mastery, emotion regulation, 
coping behaviors and attachment status. Infant Mental Health Journal, 
20, 375-392 
Carter, AS., Garrity-Rokous, FE., Chazan-Cohen, R. Little, C. & Briggs-
Gowan, MJ. (2001). Maternal depression and comorbidity: Predicting early 
parenting, attachment security, and toddler social-emotional problems and 
competencies. Journal of the American Academy of Child & Adolescent 
Psychiatry, 40, 18-26 

 
30
Cassidy, J. & Marvin, R.S. with the MacArthur Working Group (1987, 1992) 
Attachment organization in preschool children: Procedures and coding 
manual. Unpublished document, University of Virginia. 
Champagne F, Meaney MJ. 2000.  Gestational stress effects on maternal 
behavior.  Soc. Neurosci. Abst. Vol. 26:2035. 
Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. 
Journal of Health and Social Behaviour 1983; 27:385-396. 
Clohessy, AB., Posner, MI. & Rothbart, MK. (2001). Development of the 
functional visual field. Acta Psychologica, 106, 51-68 
Conger R, Ge X, Elder G, Lorenz F, Simons R. 1994.  Economic stress, coerci 
ve family process and developmental probelms of adolescents.  Child 
Dev.  65:541-61. 
Deci EL, Ryan RM. A Motivational approach to self: Integration in 
personality. In Nebraska symposium on motivation: Vol 38. Perspectives 
on motivation. (Ed. Dienstbier R): University of Nebraska Press: Lincoln, 
1991; 237-288. 
Dunkel-Schetter C. Maternal stress and preterm delivery. Prenatal and 
Neonatal Medicine 1998; 3:39-42. 
Fagen, J.W. & Ohr, P. S. (2001) Learning and memory in infancy. In L. T. 
Singer and P.S. Zeskind (Eds.) Biobehavioral assessment of the infant. 
New York: Guilford, 233-274. 
Fan, J., McCandliss, BD., Sommer, T., Raz, A. & Posner, MI. (2002). Testing 
the efficiency and independence of attentional networks. Journal of 
Cognitive Neuroscience, 14, 340-347 
Fattal-Valevski A. Leitner Y. Kutai M. Tal-Posener E. Tomer A. Lieberman D. 
Jaffa A. Many A. Harel S. Neurodevelopmental outcome in children with 
intrauterine growth retardation: a 3-year follow-up. J Child Neurology 
1999 14:724-7. 
Fenster L, Schaefer C, Mathur A, Hiatt RA, Pieper C, Hubbard AE, Von 
Behren J, Swan SH. Psychologic stress in the workplace and 
spontaneous abortion. American Journal of Epidemiology 1995; 
142:1176-1183. 
Fleming AS.  1999. The neurobiology of mother-infant interactions: 
experience and central nervous system plasticity across development 
and generations.  Neursci. & Biobehv. Rev.  23:673-685. 
Fleming, A.S., Ruble, D.N., Flett, G.L., & Shaul, D. (1988). Postpartum 
adjustment in first-time mothers: Relations between mood, maternal 
attitudes and mother-infant interactions.  Developmental Psychology, 24, 
77-81. 
Fleming AS. 1988. Factors influencing maternal responsiveness in humans: 
Usefulness of an animal model.  Psychoneuroendocrinology 13:189-212. 
Fleming, A.S., Ruble, D.N., Flett, G.L., & Van Wagner, V. (1990). Postpartum 
adjustment in first-time mothers:  Changes in mood and mood content 

 
31
during the early postpartum months.  Developmental Psychology, 26, 
137-143. 
Folkman S, Lazarus RS. If it changes it must be a process: study of emotion 
and coping during three stages of a college examination. Journal of 
Personality and Social Psychology 1985; 48:150-170.  
 
Francis D, Meaney MJ. 1999a.  Maternal care and the development of stress 
responses.  Curr. Opin. Neurobiol.  9:128-34. 
Francis DD,  Caldji C,  Champagne F,  Plotsky PM,  Meaney MJ. 1999.  The 
role of corticotropin-releasing factor - norepinepherinie systems in 
mediating the effects of early experience on the development of 
behavioral and endocrine responses to stress.  Biol. Psychiatry  
46:1153-66. 
Francis DD, Diorio J, Liu D, Meaney MJ. 1999.  Nongenomic transmission 
across generations in maternal behavior and stress responses in the 
rat..  Science  286:1155-58. 
Glover V. O'Connor TG. Effects of antenatal stress and anxiety: Implications 
for development and psychiatry. British Journal of Psychiatry. 180:389-
91, 2002 May. 
 
Goldberg, S., Levitan, R., Leung, E., Masellis, M., Basile, V., Nemeroff, C.B. 
& Atkinson, L. (in press) Cortisol Concentrations in 12-18-month-old 
Infants: Stability over time, location, and stressor. Biological Psychiatry 
Goldsmith, H. & Rothbart, M. (1996) Laboratory Temperament Assessment 
Battery. unpublished manual, Department of Psychology, University of 
Wisconsin.  
Goldstein, L. H., Diener, M. L., & Mangelsdorf, S. C. (1996) Maternal 
characteristics and social support across the transition to motherhood: 
Associations with maternal behavior. Journal of Family Psychology, 10, 
60-71. 
Goodwin R. Overall, just how happy are you? The magical question 31of the 
Spanier Dyadic Adjustment Scale. Family Therapy 1992; 19:273-275. 
Gottman JM. 1998. Psychology and the study of marital processes.  Ann. 
Rev. Psychol. 49:169-97. 
Greenberg, M. T. & Marvin, R. S. (1982).  Reactions of Preschool Children to 
an Adult Stranger:  A Behavioral Systems Approach.  Child Development, 
53, 481-490. 
Haith, MM., Hazan, C. & Goodman, GS. (1988) Expectation and anticipation 
of dynamic visual events by 3.5-month-old babies.. Child Development, 
59, 467-479 

 
32
Hertzman C. The biological embedding of early experience and its effects on 
health in adulthood. Annals of the New York Academy of Sciences. 
896:85-95, 1999.  
Heyman RE, Sayers SL, Bellack AS. Global marital satisfaction versus marital 
adjustment: An empirical comparison of three measures. Journal of 
Family Psychology 1994; 8: 432-446. 
Irwin, JR., Carter, AS. & Briggs-Gowan, MJ. (2002). The social-emotional 
development of "late-talking' toddlers. Journal of the American Academy 
of Child & Adolescent Psychiatry. 41, 1324-1332 
Jöreskog, K., Sörbom, D. LISREL 8:  Structural Equation Modeling with the 
Simplis Command Language.  Hillsdale, NJ:  Lawrence Erlbaum 
Associates, Inc., 1993; 202 p.].  
Kagan J. Snidman N. McManis M. Woodward S. Temperamental contributions 
to the affect family of anxiety. Psychiatric Clinics of North America. 
24(4):677-88, 2001 Dec. 
Kanner AD, Coyne JC, Schaefer C, Lazarus RS. Comparison of two modes of 
stress measurement: daily hassles and uplifts versus major life events. 
Journal of Behavioural Medicine 1981; 4:1-39. 
Karasek R, Gordon G, Piotrowski C. The Job Content Instrument: 
Questionnaire and User’s Guide. Los Angeles: Department of Industrial 
and Systems Engineering. University of Southern California, 1986. 
Kelly YJ, Nazroo JY, McMunn A, Boreham R and Marmot M. Birthweight and 
behavioural problems in children: a modifiable effect? International 
Journal of Epidemiology 2001;30:88-94. 
Leitner Y, Fattal-Valevski A. Geva R. Bassan H. Posner E. Kutai M. Many A. 
Jaffa AJ. Harel S. Six-year follow-up of children with intrauterine growth 
retardation: long-term, prospective study.  J. Child Neurology. 2000 
15:781-86c.  
Lissau I, Sorensen TIA. 1994. Parental neglect during childhood and 
increased risk of obesity in young adulthood. Lancet 343:324-27. 
Liu L, Li A, Matthews SG. Maternal glucocorticoid treatment programs HPA 
regulation in adult offspring: sex-specific effects. Am J Physiol Endocrinol 
Metab 2001 May;280(5):E729-39 
Liu D, Tannenbaum B, Caldji C, Francis D, Freedman A, Sharma S, Pearson 
D, Plotsky PM, Meaney MJ .1997.  Maternal care, hippocampal 
glucocorticoid receptor gene expression and hypothalamic-pituitary-
adrenal responses to stress.  Science  277:1659-62. 
Lupien SJ, King S, Meaney MJ, McEwen BS. Can poverty get under your 
skin? basal cortisol levels and cognitive function in children from low and 
high socioeconomic status. Dev Psychopathol 2001 Summer;13(3):653-
76 
Lupien SJ, King S, Meaney MJ, McEwen BS. Child's stress hormone levels 
correlate with mother's socioeconomic status and depressive state. Biol 
Psychiatry 2000 Nov 15;48(10):976-80 

 
33
Lupien S, Sharma S, Nair NPV, Hauger R, McEwen BS, de Leon M, Meaney 
MJ. 1998.  Glucocorticoids and human brain aging. Nature (Neurosci.) 1: 
69-73. 
Lupien, S. and Meaney, M.J.  1998.  Stress, glucorticoids, and hippocampus 
aging in rat and human.  In Handbook of Human Aging.  eds. E Wang, S 
Snyder. pp. 19-50.  New York: Academic Press. 
Lyons-Ruth, K. & Block, D. (1996) The disturbed caregiving system: 
Relations among childhood trauma, maternal caregiving and infant affect 
and attachment. Infant Mental Health Journal, 17, 257-275. 
Lyons-Ruth-K. , Bronfman, E. & Atwood, G. (1999) A relational diathesis 
model of hostile-helpless states of mind: Expressions in mother-infant 
interaction. 
In 
J. 
Solomon 
& 
C. 
George 
(Eds.) 
Attachment 
disorganization. New York: Guilford, 33-70. 
Maccari S, Piazza PV, Kabbaj M, Barbazanges A, Simon H, Le Moal M. 1995.  
Adoption reverses the long-term impairments in glucocorticoid feedback 
induced by prenatal stress.  J. Neurosci. 15:110-16. 
Main, M. & Solomon, J. (1990) Procedures for identifying infants as 
disorganized/ disoriented during the Ainsworth Strange Situation. In M.T. 
Greenberg, D. Cicchetti, and E.M. Cummings (Eds.) Attachment in the 
preschool years. Chicago: University of Chicago Press, 121-160. 
McEwen BS. Stress and hippocampal plasticity. Annual Review of 
Neuroscience. 22:105-22, 1999.  
McFarlane J, Parker B, Soeken K, Bullock L. Assessing for abuse during 
pregnancy: Severity and frequency of injuries and associated entry into 
prenatal care. Journal of American Medical Association 1992; 267:2370-
2372. 
McLloyd VC. 1998. Socioeconomic disadvantage and child development.  
Am. Psychol.  53:185-204. 
Misra DP, O’Campo P, Strobino D. Testing a sociomedical model for preterm 
pregnancy. Paediatric and Perinatal Epidemiology, 2001;15:110-122 
Moran, G., Pederson, D.R., Pettit, P., & Krupka, A. (1992). Maternal 
sensitivity and infant-mother attachment in a developmentally delayed 
sample. Infant Behavior and Development, 15, 427-442. 
Matthews SG. Early programming of the hypothalamo-pituitary-adrenal axis. 
Trends Endocrinol Metab 2002 Nov;13(9):373-80 
Nachmias, M., Gunnar, M., Mangelsdorf, S., Parritz, R.H., & Buss, K. (1996). 
Behavioral inhibition and stress reactivity: The moderating role of 
attachment security. Child Development,67, 508-522. 
Norton R. Measuring marital quality: A critical look at the dependent 
variable. Journal of Marriage and the Family 1983; 45:141-151. 
O'Connor TG. Heron J. Glover V. The Alspac Study Team. Antenatal anxiety 
predicts child behavioral/emotional problems independently of postnatal 
depression. Journal of the American Academy of Child & Adolescent 
Psychiatry. 2000 41:1470-7, 

 
34
Offord DR, Boyle MH, Racine YA, Fleming JE, Cadman DT, Blum HM, Byrne 
C, Links PS, Lipman EL, MacMillan HL, et al. Outcome, prognosis, and 
risk in a longitudinal follow-up study. J Am Acad Child Adolesc Psychiatry 
1992 Sep;31(5):916-23 
Owens MJ, Vargas MA, Knight DL, Nemeroff CB. 1991. The effects of 
alprazoplam on corticotropin-releasing factor neurons in the rat brain: 
acute time course, chronic treatment and abrupt withdrawal. J. 
Pharmacol. &  Exptl. Therap.  258:349-56. 
Parker B, McFarlane J, Soeken K, Torres S, Campbell D. Physical and 
emotional abuse in pregnancy: A comparison of adult and teenage 
women. Nursing Research 1993; 42: 173-178. 
Parker G, and Lipscombe P. The relevance of early parental experiences to 
adult dependency, hypochondrias and utilization of primary physicians. 
British Journal of Medical Psychology 1980; 53, 355-363. 
Parker G, Tupling H, and Brown LB. A parental bonding instrument. British 
Journal of Medical Psychology 1979; 52, 1-10. 
Pearlin LI, Schooler C. The structure of coping.  Journal of Health and Social 
Behavior 1978; 19:2-21. 
Pederson, D.R., Gleason, K.E., Moran, G., & Bento. S. (1998). Maternal 
attachment representations, maternal sensitivity, and the infant-mother 
attachment relationship. Developmental Psychology, 34, 925-933. 
Pederson, D. R. & Moran, G. (1995). A categorical description of infant-
mother relationships in the home and its relation to Q-sort measures of 
infant-mother interaction. Monographs of the Society for Research in 
Child Development, 60(2-3), 111-132. 
Pederson, D.R., Moran, G., Sitko, C., Campbell, K., Ghesquire, K., & Acton, 
H. (1990). Maternal sensitivity and the security of infant-mother 
attachment: Q-sort study. Child Development, 61, 1974-1983.  
Pedhazur, E.J., Pedhazur Schmelkin, L.P. Measurement, Design, and 
Analysis:  An Integrated Approach.  Hillsdale, NJ:  Lawrence Erlbaum 
Associates Inc., 1991; 819 p. (Chapters 23 and 24) 
Pharoah POD, Stevenson CJ, Cooke RWI, Stevenson RC. Prevalence of 
behaviour disorders in low birthweight infants. Arch Dis Child 
1994;70:271–74. 
Radloff LS. The CES-D Scale: A self-report depression scale for research in 
the general population. Applied Psychological Measurement 1997; 1:385-
401. 
Renken, B, Egeland, B, Marvinney, D, Mangelsdorf, S, & Sroufe, LA (1989) 
Early childhood antecedents of aggression and passive-withdrawal in 
early elementary school Journal of Personality, 57, 591-615. 
Rosenberg M. Society and adolescent self image. Princeton, NJ: Princeton 
University Press, 1965. 
Ruble, D.N., Brooks-Gunn, J., Fleming, A.S., Fitzmaurice, G., Stangor, C., & 
Deutsch, F. (1990).  Transition to motherhood and the self: 

 
35
Measurement, stability and change. Journal of Personality and Social 
Psychology, 58, 450-463. 
Scheier MF, Carver CS. Optimism, coping, and health: Assessment and 
implications of generalized outcome expectancies. Health Psychology 
1985; 4:219-247. 
Seckl JR, Nyirenda MJ, Walker BR, Chapman KE. 1999. Glucocorticoids and 
fetal programming. Biochem. Soc. Trans. 27:74-78. 
Sergeant JA, Leung P, Zhang YP, Sadeh A, Chen C, Whalen CK, Babb KA, 
Moyzis R, Posner MI. (2000). Attention deficit/hyperactivity disorder 
children with a 7-repeat allele of the dopamine receptor D4 gene have 
extreme behavior but normal performance on critical neuropsychological 
tests of attention. Proceedings of the National Academy of  Sciences, U S 
A, 97, 4754-4759. 
Spangler, G. & Grossmann, K.E. (1993). Biobehavioral organization in 
securely and insecurely attached infants. Child Development, 64, 1439-
1450. 
Swanson J, Oosterlaan J, Murias M, Schuck S, Flodman P, Spence MA, 
Wasdell M, Ding Y, Chi HC, Smith M, Mann M, Carlson C, Kennedy JL, 
Sykes DH, Hoy EA, Bill JM, McClure BG, Halliday HL, Reid MM. 
Behavioural adjustment in school of very low birth weight children. J 
Child Psychol Psychiatry 1997;38:315–25. 
Szatmari P, Saigal S, Rosenbaum P, Campbell D, King S. Psychiatric 
disorders at five years among children with birthweights <1000g: a 
regional perspective. Dev Med Child Neurol 1990;32:954–62. 
Thompson C, Syddall H, Rodin I, Osmond C, Barker DJP.  2001.  Birth weight 
and the risk of depressive disorder in later life. Br J Psychiatry 179:450-
455. 
Tinsley BJ, Holtgrave DR. Maternal health locus of control beliefs, utilization 
of childhood preventive health services, and infant health. Journal of 
Developmental and Behavioral Pediatrics 1989; 10:236-241. 
Trautman PD, Meyer-Bahlberg H, Postelnek J, New M. 1995.  Effects of 
prenatal dexamethasone on the cognitive and behavioral development of 
young childrem: results of a pilot study.  Psychoneuroendocrinology 
20:439-449. 
Uno H, Tarara R, Else G, Suleman MA, Sapolsky RM. 1989.  Hippocampal 
damage associated with prenatal glucocorticoid exposure.  Dev Brain Res.  
Valliéres EF, Vallerand RJ. Traduction et validation canadienne-française de 
l’Echelle de l’Estime de Soi de Rosenberg. International Journal of 
Psychology 1990; 25:305-316. 
Van der Reijden-Lakeman IEA, de Sonneville LMJ, Swaab-Barneveld HJT, 
Slipper F, Verhulst FC.  1997.  Evaluation of attention before and after 2 
years of growth hormone treatment in interuterine growth retarded 
children.  J Clin & Exptl Neuropsychology 19: 101-118. 

 
36
Zuckerman, M. & Lubin, B. (1985). Manual for the Multiple Affect Adjective 
Checklist.  San Diego, California: Educational and Industrial Testing 
Service.