We are the Association for Child and Adolescent Mental Health or ACAMH for short. And this is ACAMH Learn. Welcome to Mind the Kids podcast. What does it mean for children when trauma ripples through generations? And how can social support create hope for better outcomes? This episode is called Breaking the Cycle-- Prenatal Substance Use. Prenatal exposure to substances such as alcohol, tobacco, and cocaine might not sound like the cheeriest of topics, but today's guest frames her research featured in JCPP in a powerful and uplifting way, offering real hope to those affected. I'm Mark Tebbs. I'm your host for today. I've kind of spent my whole career working in mental health and frontline service delivery as Director of Mental Health Commissioning. I'm currently a chief executive of a charity. I'm a trustee for another mental health organisation. I'm a career coach, and I'm delighted to be hosting these podcasts because we get to speak to clinicians and academics at the forefront of children and young people's mental health. Today, I'm joined by Dr. Meeyoung Min, Associate Professor at the University of Utah. Meeyoung has spent her career unravelling how a child's own childhood maltreatment and prenatal substance misuse, especially cocaine during the 1990s epidemic, shaped child development over time. Maternal trauma fuels psychological distress and harsher parenting, rippling into the child's own emotional and acting out behaviours. While prenatal exposure independently rewires stress responses in the brain, heightening risks, but social support and early intervention offers real hope to break that cycle. So let's get started. Meeyoung, really lovely to be speaking to you today. Thank you. Thank you. Great. Let's start with some introductions. So it'd be great if you could introduce yourself, maybe say a little bit about your research interests. And if there's anybody that you collaborate with on the paper, you'd like to give a name check to, then here's your opportunity. Great. I'm Dr. Meeyoung O. Min. I'm an Associate Professor and Belle S. Spafford Endowed Chair of College of Social Work at the University of Utah in Salt Lake City in the US. My research area is substance using mothers and their children. And my wonderful longtime colleagues, both doctors Lynn Singer and Sonia Muniz, are professors from Case Western Reserve University in Cleveland, Ohio. And two other people who collaborated on this work is Dr. Joonyoung Kim, who is Assistant Professor at the University of North Dakota, and [INAUDIBLE] Kim is a fourth year doctoral student at the University of Utah working with me. Let's start at the beginning. So I'd be really interested to hear what kind of drew you to this area of research. Why were you particularly interested in mother's own childhood experience and what impact that had on child development? I'm very interested in various biological and interpersonal and ecological factors shaping human development, especially for children and adolescents. So after spending some years studying and documenting the pervasive and very negative impact of childhood maltreatment across multiple, multiple domains of mental and physical health, it was just so natural for me to ask, what happens to the next generation? I kept wondering, how do these experience echoes through families? That question really drove me to extend the scope of the investigation to the next generation. So many listeners will be familiar with the impact of childhood or maternal trauma on childhood development. Before, it'd be really useful just to give a little bit of a background in terms of before this study, what was known about that kind of intergenerational transmission of trauma? So most study really focused on maternal psychological functioning, such as psychological distress and parenting behaviour as a main mechanism connecting mother's childhood trauma and their own child behaviour problem, which makes sense given that importance of mother's influence on children. What we found some are missing is that few studies examined intergenerational impact of maternal childhood maltreatment in the context of prenatal substance use, because we know and multiple studies also showing that there is a strong relationship between childhood maltreatment and subsequent substance use. So we really want to connect these dots. Our study, because of very relatively large sample size with developmentally appropriate measures across, in this case 12 years of study, it provides a very rare ability to look into complex intergenerational effects. OK, so were you seeing whether substance abuse was the kind of mediating factor between trauma and then childhood outcomes? So I think that was our original hypothesis. And that was our original motivation. But in our study, no, it was not. The prenatal substance exposure is related to child behaviour symptoms, especially externalising behaviour, but not through mother's trauma or mother's attitude measurement. So it is independent risk process. OK, right, yeah. OK. So let's get into more detail then. So it was a longitudinal study. You followed families for a decade. So could you describe how you went about the kind of methodology? So I was lucky to involve with a really very well-established team focusing on mothers during pregnancy and how that impact child development over time. So these children are recruited, actually recruited due to mum. So this study sample, we have about 400. But for this particular study, about 300 both mother and child diet. And as I said, it recruited mothers from hospital when they come to hospital to deliver. And it is Midwest USA and also urban teaching hospital. So they were recruited originally for a study to look at the developmental effects of prenatal cocaine exposure. At the time in the US, cocaine was a really big issue. It's like opioid endemic. So a lot of people are nervous about, what is their outcome? So that is the kind part of historical motivation at the time. And this study sample are primarily Black and very poor, getting public assistance. And about 40% of mothers didn't finish high school. And the issue is that the incidence of child maltreatment tended to be higher in substance using women. So this is a very good sample to test, to study intergenerational transmission of maternal childhood maltreatment and the potential role, possible role of prenatal substance exposure to extend our understanding about child psychopathology. And did you just kind of-- was it mainly focused around cocaine use or were there other kind of drug usage that you were studying? Well, that's a great question. No. Usually that when women use cocaine, they use other drugs too, like alcohol, marijuana, tobacco. So a lot of times, most times cocaine users are polydrug users. So we collected data on alcohol, marijuana, tobacco too. And also we collected like months prior to pregnancy. And each trimester, first, second, third trimester and ask about their amount and frequency of use and even the money they spend. And then also for cocaine, we used meconium, which is baby's first stool, to detect mother's cocaine use. So I mentioned it was a longitudinal study, and you kind of followed the families over a long period of time. So could you describe the kind of sequence of the research? Oh, yes. So we recruited women, the mothers when they come to our hospital to deliver. And there we kind of collected the mother's urine and infant urine and meconium. And then about a month later, we invite them to come to University-based lab. So that's about-- the child became about a month old. So at the time, we collected the mother's drug use like alcohol, marijuana, and tobacco use. And then around four years, we asked mothers about their own childhood management experience. So sexual abuse, physical abuse, emotional abuse, and physical neglect, and emotional neglect. And when the child become around 10 years old, the mothers also reported their psychological distress. So mental health symptoms and also their parenting practise which more are involving some kind of mind treating practise like shouting, hitting, that kind of. And then when child control, which is really only beginning of adolescence, we asked both mothers and child about the child behavioural symptoms. So when we say that period symptoms, we can say that there are two types of symptoms. One is internalising, which can refer to depressive symptoms, anxiety, and psychosomatic symptoms. And externalising behaviour is more like aggressive behaviour, acting out behaviour. So we ask those things to both mothers and child because that provides a more complete picture of understanding child behaviour. OK, brilliant. Really super clear. And were the families receiving any intervention during this time? Were they receiving any kind of therapeutic support or was it a mixture? So that we didn't really provide any kind of treatment or therapy. However, we provide some resources if the family like to do that. And then also we have on site psychologist. So if there is any kind of incident requiring some attention from professionals we have instead. So yeah. And then also for this family, you can see that there's very extensive study. So they usually comes around 9: 00 AM and we provide some light breakfast and then they stay for lunch. So we provide also lunch. Then usually, it ends like 2:00 or 3:00 PM. And then in the beginning, I teach mothers. So they are putting infant. And also sometimes they have siblings. So we have some playroom and lots of fun animation movies for small children. And then also we fed the children too. So it was quite kind of family outing event. And for those women who cannot drive themselves because they don't have car or it's not easy to use public transportation, then we have contract with taxi driver. We hire and that taxi driver went to the mothers, the family's house and then bring them. And then when the assessment is done, then that taxi driver drove back. So we provide really good support to really make this study successful and not to lose women. Very good, high-level of retention rate. What did you find? What were the key findings from the work? This is quite complex because we have-- so you can think about that. Those to mother's childhood maltreatment, they recollected. But historically, that occur first. And then mother's drug use during pregnancy. And then we have the mothers report at age 10 when their child was 10, like their mental health symptoms, psychological distress. And there's a parenting behaviour which is self-report. And then at age 12, mother reported internalising symptoms about their child-- the depressive symptoms and anxiety and psychosomatic symptoms. So externalising behaviour, like acting out behaviour, aggressive disruptive behaviour. And then also the child's own reported internalising and externalising. So we have four outcome variables here. You can see the mother's childhood management disciplines, drug use during pregnancy, and mental health symptoms parenting. So we have what? Like seven key variables. And also we control for other factors like child gender. And then also the mother's kind of home or caregiving home environment and then also some kind of socioeconomic status proxy variables. So we control for those things. So what we found is that the mothers, the higher level of maltreatment exposure is related to mother's higher mental health symptoms. And that is related to mother-reported child internalising/externalising behaviours. And also, then how about those adolescence, the child-reported internalising and externalising behaviour? That was directly related to from mother's childhood treatment. So what that means is that regardless of who is providing the information about child behaviour problems, there was a relationship between mother's childhood maltreatment experience and the child, their own child offspring behaviour problem at age 12. So that's the one finding. The other finding, what our study was very interested in is that whether the mother who have childhood maltreatment experience is related to prenatal drug use. The relation was somewhat weak, what we call marginal relationship. Statistically, it's more than 0.5 value. But there is some link there, but it was not significant. But those, the mother's drug use during pregnancy is related to child-reported externalising, acting out behaviour, not internalising or not mother-reported internalising or externalising behaviour. So what this is telling us. So it looks like the mother's childhood maltreatment experience, that effect going through mother's functioning, obviously, tend to affect child behaviour problem regardless who is really talking about their behaviour. However, prenatal substance exposure, the mother's substance use during pregnancy, we know that, that i somehow change the brain development in utero. So it change training and also structure of the brain. And maybe it more likely to dispose the child brain to be more sensitive to stress. And that is showing at age 12 in our study. OK, right. So that was a great explanation. So can we take those two separate findings and unpack them a little bit. So the first finding, could you give an example to bring it alive for the listeners around what that would look like from a kind of lived experience perspective? So we know that the mother's kind of mental health status is so critical for child development. That's why we really also trying to provide some support to the mothers, especially young children. So one example might be that you can think about if the mother, if you don't have good ability to regulate your own emotion, it's very difficult to help your child to regulate their own emotion. And also when you have a lot of stress, whether it's coming from, I mean, our study is really about childhood maltreatment history. But when you don't have really good way to regulate and you're still dealing with some aftermath effects of childhood maltreatment experience, you may not be able to available emotionally to your child. And also because of that, you tend to use more coercive disciplinary parenting practise. And also you are less likely to monitor your child where they are and who they are talking to. So that is the really some issues. And then also mother and child, try to learn from mothers. Usually, mother how to process and interpret the stressful event. And the child, the mother cannot really help child to deal with that because they don't have their own ability to do so. So it is very-- I know, we don't want to blame mothers. But given the proximity, it's really important that mother can really showing that how to regulate some emotional kind of situation, especially during stressful time. Yeah. And was that consistent across like boys and girls? That's a very good question. That's one of the areas I was very interested in that. Kind of can be. I think it is. I mean, there is a really mixed findings. So sometimes mother tended to associate kind of cultural differences. I'm from South Korea. The mother may treat that boy and girl somewhat differently. And also there may be some innate differences for boys and girls. But I think it is kind of similar, but it's very mixed. So one kind of interesting one is that one time, our team studied how the parental monitoring. So we also ask that parenting monitoring to mother and also children. So the mother answered that it is kind of question that how I think I monitor to my children. For children, how they think that my mother monitor, is that successful or not? So when you look at that goes it's the same question, but it's different instrument again about their parents monitoring. And the correlation is around 0.2. So it's not that strong. But there is some correlation. But when you divide it into boys and girls, it's very different. So for boys, the mother's assessment about how I monitor to my son and how that boys think that their mother monitor me, no correlation, no correlation. However, girls, the correlation is around 0.3-ish, I think slightly above 0.3. And that's why we have half boys, half girls, it combined is around 0.2. So I have two children. I have daughter and son at the time they are like 10 and 11. And I thought, oh, my God, what I think I do to my son, it's nothing what my son thinks I'm doing. So, well, guys, that's one thing. So when you have son, you may need to be extra careful. So that was kind of interesting. So yes, there is, boy and girl, some differences. However, I think the studies are-- some are mixed and complex. You can think of it that there is kind of biological hormone differences and then also the society treat boys and girls differently. You expect more to boys. You expect boys to be more risk-taking. Go out there try. But for girls, you are protective. That's why I think that the correlation relation between mothers and girls, daughters, correlation is higher because the parents provide more monitoring, high levels of monitoring. And you worry more about your daughters than son. So there are differences in multiple levels. Parents and teachers, whether it's good or bad. And because of that, girls are more shy from taking risk and boys are encouraged to take. So when you think about that accumulation over lifetime, the lifetime maybe 10 years, 12 years or 15 years, what can be done. And also maybe there might be some conflict between either side, what you want versus what parents or teachers or society expect from you. So it is kind of-- yeah, it's not easy. You think that it can be very simple, but it's not. [INAUDIBLE]. I just wondered whether the study opens the door to interventions, whether they're the work that you're doing, and particularly that finding kind of like opens the door to opportunities to work with mothers around their own psychological well-being as a kind of an opportunity to impact on offspring's outcomes. About how we can help these families. So for me, the social support, I know it sounds very, of course, right? But that's the really key. I really think that because that providing support and, of course, the support can be so many different things. But the social support, if we provide the mothers. So if mother thinks that I have some social support, think about that. It's something that backup or some safety. You can go back there to ask help. And I'll be OK, kind of social support. So that will really help mother to be a mother they want to be. They can be more calm with their child. They can be more engaged with their child. And they can also take care of themselves. So I think that kind of social support and having good network of people who are really willing to help provide. And even if it's not realised, just the mother think that I do have that support. In emergency, these are the people I can rely on and I'll be OK and my kid will be OK because of these people. So that core group of people providing social support will be the really key. And having that. And also the other thing is that if mother has a good social support and good social network, providing people to mothers, and that also, I think directly impact benefit to the child because the child will participate that network through mothers. I'm thinking of that also I'm Christian, I go to church every Sunday. The children, my child, they are also taken care of, my college-- not college, my church colleagues. And then they make friends through that organisation. So that relieves some kind of pressure from parents. And also the child really participate that extended group of people, and that each people may provide some kind of opportunities to model the child and also connected with other resources and opportunities. It really is not just mother, but also providing that kind of very socially enriched environment, not only to mother, but also child. Yeah, the power of the community. That's community, yes. And then I'd like us all to just touch base on the kind of that second finding. So you kind of mentioned about the impact of drug usage on brain development. So could you tell us a little bit more about that? There is a whole field of studying that area. And it's a hard area to study because you cannot really test with humans. So a lot of study is done with animals like red and even some fly. But what we found is that it change some brain structure and functioning, especially in relation to stress response. So my study group is more focusing on cocaine. And you can see that this study is kind of secondary data analysis using the dataset that collected for the developmental outcome for prenatal cocaine exposure. So what we found that it may not showing in the beginning, but there is some really quite good evidence that the prenatal cocaine exposure tended to restrict brain development, meaning that is really affecting some cognitive development, which can have multiple, multiple implications for human development. But also it really affects some brain functioning that deal with stress response. So what that means, though, is that when you have, in life, there are full of stresses. Whether it's small or big or whether you can deal with or you cannot. But the thing is that your threshold to deal with those stress, your ability, your capability to process and cope with that stress is low. And so that's why it increases vulnerability to psychopathology, exposed to either I call or other types of drug can-- it's like that. I'm not really talking about very specifically, but because that's such a huge work out there. But what we found in general, it really related to our compromised ability to deal with stress response. So because of that, they are more prone to. Everything equal, even if you are exposed to the same level of stress. If somebody is exposed to a prenatal substance and their ability to deal with stress will be lower. So it increases the vulnerability to mental health problems down the road. And of course, it's not deterministic. I want to emphasise that it's not done there. No, it is like you have your life. We are talking about what happened when you are in mother's womb. So if you have really good enriched environment, that relationship will be weak. But, I mean, think about that. If the woman used cocaine or other drugs during pregnancy, that means that the woman has a problem, substance use problem. How she got there, we don't know. maybe the childhood neglect, abuse, maybe one of the big contributor. And also they tend to-- some poor background. So their life opportunity may be limited. So they didn't have a chance to really explore and get. But anyhow, that prenatal exposure to substance predispose some vulnerability to those affected child being in terms of psychopathology. And was that seen in both kind of internalising and externalising kind of behaviour? That's a good question, excellent question. In our study, it is more related to externalising behaviour, although it's really depending on also what kind of substance. So I think what we found there is cocaine is more related to externalising behaviour. Alcohol is, I think it can be both internalising and externalising behaviour. And then for my previous study, we found that tobacco smoking is related to internalising behaviour. And of course, you need to really think about it is also depending on the dosage. So how frequently and how much the woman used that dose drug dependency and also when. So it's like during 10 months period of pregnancy that sensitive time might be different. And then also even if [LAUGHS] the kind of-- even if the child, two children may be exposed to the same amount of, let's just say alcohol or cocaine, maybe it's different how that child body process that drug will be different, and also how the mother's body process the drug and then also go to the child, it will be different. So there's some kind of degree of variability and how it's really showing up. But we know that from multiple, multiple studies that there's no safe level for drinking or for drug use because you don't know how your body and how your child body respond. Yeah, OK. It's such a complex area. I just kind of wonder, how do you control for so many kind of variables? Right. Such a great question. Yes. We're struggling. I think everyone, every researcher's struggling. As long as you're working with the human population, unlike rats or mice, you can really control. But for human you cannot do that. So what we do, you collect the data that the data that's related to substance use as much as possible. So all those socioeconomic variables and also life events include that childhood maltreatment history. And also the child-mother relationship and also neighbourhood characteristics and mother's IQ, vocabulary abilities, and that neighbourhood, how the neighbourhood provide, we call those ecological asset. And how your peer and your school, you name it. We have so many variables. And it is really challenging. I don't want to undermine that amount of challenge and the amount of effort to try to control and document. So we can really say with some confidence, yes, this is what we found. And it's more likely this is what we think. But that's what. And it's not just our code. There's kind of multiple study groups trying to struggle with that question. And we try to teasing out those confounded and nested, correlated, co-influencing factors. I'm just wondering, did the study uncover any kind of protective factors? Were there any things that stood out in the research that were kind of protective for better offspring outcomes? That's very good question. And I think that the field is really heading to that direction. So we have, in our study, in our particular study, we collected information about what we call developmental asset. So that developmental asset has two kind of groups. You get two buckets, two categories. One is internal asset. Now you can see that a lot of internal-- it's internal asset. And the other one is external asset. So internal asset is more like the child own strengths, the self-esteem. This is children. So commitment to learning, positive value, honesty, the positive identity, the future orientation. So that's the internal asset. So it's like own individual's intrinsic strength. External asset is the ecological asset. So that is related to how my neighbourhood or my neighbour think about me. If I am in trouble today, intervene to help me, that kind of thing. And also my teachers, my school, and my peer, whether my peer is more proactive and pro-social, meaning that they don't drug or they don't drink. And also my parents, whether my parents spend enough time with me, whether we have dinner together every night, or any couple of nights per week, that kind of thing. So we have those asset variables. And then how that kind of relates to all these kind of bad outcomes, meaning bigger problems. And also we have substance use variables. Yeah, that is. And then also we collected the mother's social sutures support. I mentioned those mother's support. And also a lot of times, those protective factors are also supportive of the vulnerability. So whether the monitoring, whether you have the parents monitor you in higher level compared to lower level. So those are things that are there. But it's given because of the nature of the research question to start with, which is mother's drug use during pregnancy. It was really focused on that some kind of problems. So yeah. And so did you get a sense of there being key moments where interventions could be most effective? Was there a sense on that kind of developmental period that you start-- were there are kind of points where there are lots more opportunities to intervene and change the course? That's really excellent if we can do. So I think I really like to focus on early times. So during pregnancy and also that postpartum early motherhood. That's the really golden time for us to intervene because that's the time that mothers really also highly motivated to get better for their baby. So that's the time that we can really intervene and to deal with some unfinished business like childhood trauma, the mother's, right? And then also substance use problems and also some psychological or psychiatric or psychological distress coming from those substance use and also trauma history. And also supporting the mother's parenting skill. Because think about that. It's pretty daunting to have a tiny human being with you. It is daunting for anyone, any woman. It was daunting for me. I'm highly educated with a PhD, but it's always daunting. So I think that's the really a time that we really need to invest. Of course, there's other time point. Everybody is ready for that time point. But I think that is the really, for me, a golden time because mothers are more motivated. And also we have-- there was a kind of foundational years for the child. And we already know that nurse visit programme for those early like first 30 days just visit to the new mum can be very beneficial and have great outcome. And I think that should be really strengthened. But also expanded, especially for these women who use drugs during pregnancy and having some challenges, psychosocial challenges. Yeah, brilliant. I'm just wondering whether you've got any further research in the pipeline or in these kind of questions in your next projects. My next project, oh. I think really I mentioned a lot about support. And I think it is really key. And then I think it is key for every human being, but especially when each woman's, especially when they're taking care of our next collective next generation, we should help them. What I like to really do and also what other people, other researchers who are in this area like to do is that providing some more specification about support. What kind of support, what kind of nature of support? And when? To whom? So what kind of specific support, to what kind of types of families? And what time developmentally? So kind of honing, refining the data support and timing and also types of family. We have so many different types of family, ethnic differences, and also some families just mother only family. And some mothers have great networks. Some others they don't. So honing those specific things will really help us to prioritise what kind of intervention should be prioritised and what is the really optimal timing to implement such intervention. So I know it sounds very big and vague, but I think that's what we to do. We have been very good at documenting the negative effects of the childhood history of trauma. And also now we know that it's really going to generations. Hopefully, just can stop. But maybe who knows? They're go to second, third, fourth generation. We don't really provide intervention. And the thing is that child maltreatment, we can prevent, we can prevent. You are not born with that culprit. So we can prevent. So we should do. And I think having that kind of support in multiple, multiple levels like interpersonal and also school and educational, and neighbourhood and community and, of course, policy level in multiple layers to provide the support, I think we can do. Hopefully, we can do. So we can really reduce the number of maltreatment instance. Yeah, amazing. It's such an interesting area, such an important area. Is there a place where listeners could go to if they wanting to keep track of your work? Or is there a collective that are really, a kind of focal point for collecting data and research and influencing the policy area? That's a good question. I don't know. It's like I consider myself as a researcher who provide rationale and justification and the direction, but I think there is a really kind of multiple agencies and organisations to support to providing services. And then the thing is that there is kind of a support for the children who really have some verified evidence, but that can be very late. And then the mother's history of childhood maltreatment, it's not really obvious. You don't see that. You only see that some kind of, like the mother's behaviour parenting. And we don't know that certain types of parenting where it's coming from. And it may coming from so many different directions that her childhood history may be one of many sources. So it's how we can focus on, it's really providing parenting support for mothers who struggle. And then also-- and this group will be the women who are using substance because-- and there are a lot of women for that reason, they lose custody. And that is also then the child goes to foster care system. So all those things are connected. So when I think about those who support, maybe it's very difficult to identify the mothers with the childhood maltreatment history. So you need to really extend the net to provide support. So those humans can be part of the-- recipient of the services. Yeah. So we're coming to the end of the podcast. We can keep on talking for ages, I'm sure. I just wonder whether is there a final take home message that you'd like to share? So the last thing, I want to really emphasise is that if there is anyone know that their mothers used drug during pregnancy, and I really want to say that, that's not deterministic. It can change. Yes, it's not fair. You can overcome. And also mothers who feel sorry about their child because of their lack of ability, it's not helpful. Somehow society could help you, but you can also change yourself. So hopefully, that my talk is not really providing some pessimistic negative outlook. Our study also showing that, as you can see, not every woman who experience childhood trauma used drug during pregnancy. And everyone, any woman, not every woman we use drug during pregnancy, their child having problem. So there is some good things in life that make you turn around. So just trust that force. Sorry that we don't really pinpoint what it was. However, what we suspected is that, that will be the social support. So that I think I want to really flip our story, although we were trying to see that the relationship with the child behaviour problem, it's not guaranteed. And there is power of not guaranteed. So stick to that piece of the story and hopefully that this tool provided that kind of different kind of reframing to understand the story. Thank you for sharing such a heartfelt final reflection. It's been a really great conversation. It's been lovely speaking to you. Thank you so much for this opportunity. I'm so grateful that my studies have additional outlet to public. Thank you. Thank you so much. What an incredible all closing message from Meeyoung. It was really touching and inspiring. So I do hope you take a closer look at the paper and her work. It's been a real honour to talk to her today. As always, please leave a comment, a review, a suggestion. Please share these podcasts with your friends and colleagues and also sign up for the ACAMH Learn account. You can get this at www.acamhlearn.org. And you'll be able to get a free CPD CME certificate for listening to any of the podcasts. Next week, we're off to Michigan to speak to Professor Adrian Beltz about the Adolescent Brain Cognitive Development study known as ABCD, its use and misuse. [MUSIC PLAYING]