Smoking During Pregnancy Linked to Mental Health Challenges in Children, ECHO Study Finds

Authors: Kristine Marceau, et al.

Who sponsored this study?

The Environmental influences on Child Health Outcomes (ECHO) Program, Office of the Director, National Institutes of Health supported this research.

Why was this study needed?

Previous research has shown that children whose mothers smoked during pregnancy are more likely to develop behavior problems, particularly difficulties with acting out or following rules. However, it has been less clear whether prenatal smoking also increases the risk of mental health problems generally, or if it’s a specific risk for difficulties with acting out or following rules alone. Researchers from this study wanted to understand whether prenatal smoking contributes to co-occurring emotional and behavioral symptoms or specifically behavioral symptoms, and whether its effects differ by age or sex. This study helps address these gaps by examining which developmental periods may be especially sensitive to prenatal smoking effects and whether boys or girls are more vulnerable.

What were the study results?

Children exposed to smoking before birth were more likely experience multiple co‑occurring emotional and behavioral symptoms, and also to show more externalizing problems—such as attention problems, aggressive behavior, and rule‑breaking. These associations were observed across nearly all age groups and remained even after accounting for family history, background, and other exposures.

The strongest effects on mental health symptoms were seen in early childhood (under age 7) and early puberty (ages 9 to 12). There were very few differences between boys and girls. Only at ages 13-14 did boys seem to have more co‑occurring emotional and behavioral symptoms and externalizing-specific problems than girls. In general, both boys and girls were affected in similar ways.

What was the study's impact?

These results suggest that prenatal exposure to nicotine may increase the risk of mental health and behavioral problems. Because this study included a large number of children from different backgrounds, it helps clarify past research and contributes new insight about when certain problems tend to appear and how different symptoms may occur together.

Who was involved?

The study included 16,335 children and adolescents ages 1 to 18 from 55 U.S. ECHO Cohort Study Sites. All participants completed Child Behavior Checklist (CBCL) and Strengths and Difficulties Questionnaire (SDQ) behavioral assessments.

What happened during the study?

Researchers gathered standardized information about children’s behavior and created a simple score to show how many symptoms a child had and whether those symptoms were more emotional (such as sadness, anxiety) or behavioral (such as acting out, rule breaking). They then looked at these patterns across different age groups, while taking into account important factors such as the mother’s age and education, family mental health history, and exposure to smoke or other substances during and after pregnancy.

Footnote: Results reported here are for a single study. Other or future studies may provide new information or different results. You should not make changes to your health without first consulting your healthcare professional.

What happens next?

Future work could help researchers understand how timing, dose, and frequency of smoking during pregnancy correlates with child mental health. Future research could also use methods to separate the effects of family background from the effects of smoking itself and look more closely at how nicotine and other chemicals in smoke might affect children’s development.

Where can I learn more?

Access the full journal article, titled “Prenatal Smoking and Child Psychopathology Associations by Age and Sex in the ECHO Cohort,” in Development and Psychopathology.

The content is the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Published April 6, 2026

Read the associated news release.

Download this summary

Smoking During Pregnancy Linked to Mental Health Challenges in Children, ECHO Study Finds

Prenatal Smoking Associated with Higher Risk of Mental Health Challenges in Children

Posted on April 6, 2026April 6, 2026 by Jodi Snare

Mother and toddler laughing Children exposed to maternal smoking before birth are more likely to experience behavioral and mental health challenges, according to a large study funded by the National Institutes of Health’s Environmental influences on Child Health Outcomes (ECHO) Program.

While previous research had linked prenatal smoking to acting out or rule-breaking, it was less clear whether smoking during pregnancy also affects broader mental health outcomes and whether effects differ by sex. The new study sheds light on these questions, examining thousands of children across the U.S. and identifying periods when exposure may be most impactful.

“These findings show that prenatal nicotine exposure can affect more than just acting-out types of behavior problems—it can influence children’s overall mental health and experiences of both emotional and behavioral problems at the same time,” said Kristine Marceau, PhD, of Purdue University. “Understanding when kids are most vulnerable can help families and healthcare providers provide support at the right time.”

Researchers analyzed data from 16,335 children ages 1 to 18 from 55 ECHO Cohort Study Sites. Behavioral assessments measured emotional and behavioral symptoms using standardized questionnaires.

Key Findings

Widespread Impact: Children exposed to prenatal smoking were more likely to have multiple mental health or behavioral symptoms at the same time.
Critical Windows: The strongest effects appeared in early childhood (under age 7) and early puberty (ages 9–12).
Similar Effects for Boys and Girls: Both sexes were affected in comparable ways, with slightly higher symptom levels in boys only at ages 13–14.
Independent of Family Background: Associations persisted even after considering family history and other environmental factors, such as maternal age, education, and additional substance exposures.

Future studies could take a closer look at the timing, amount, and frequency of smoking during pregnancy. Researchers could also work to better understand which effects are due to smoking itself—rather than other family factors—and how nicotine and other chemicals in smoke may affect how children grow and develop.

This collaborative research, titled “Prenatal Smoking and Child Psychopathology Associations by Age and Sex in the ECHO Cohort,” is published in Development and Psychopathology.

Media Contacts

For information or to request an interview, contact Rebekah Yeager, rebekah.yeager@nih.gov.

If you are not a member of the media, but have a general inquiry, please contact NIHKidsandEnvironment@od.nih.gov.

Connect With Us

Check out the recent issues of our bi-monthly newsletter, the ECHO Connector, for program news and the latest research findings.

To receive the ECHO Connector through email, subscribe here.

Follow the ECHO Program on LinkedIn and X for the latest updates.

Family Lifestyle and Behavior Changes During COVID-19 Pandemic Associated with Youth Mental Health

Posted on February 11, 2026February 11, 2026 by Jodi Snare

Children and teens who experienced significant changes in their lifestyle and health behaviors during the COVID-19 pandemic may be more likely to experience symptoms of pandemic-related post-traumatic stress (PTS), according to a recent ECHO Cohort study led by Amy Margolis, PhD of The Ohio State University.

The United States is facing a growing youth mental health crisis with a significant increase in mental or behavioral health conditions, partly linked to changes during the COVID-19 pandemic. To understand how changes in family hardships, behaviors, and coping strategies during the COVID-19 pandemic influenced youth PTS symptoms, researchers collected information from 7,786 children and 1,353 teens and young adults and their parents or caregivers across the United States between April 2020 and August 2021.

Key Takeaways include:

Two groups of families were identified based on their experiences of hardships, changes in daily behaviors, and coping strategies during COVID-19. The first group had minimal changes in their lifestyle and behaviors, while the second group had significant changes. The low change group included a higher proportion of Black families, single-parent households, and lower income and education levels.
Children and teens in the group with significant changes had higher Pandemic-related Traumatic Stress Scale (PTSS) scores compared to the group with minimal changes.
Some aspects of parent or caregiver experiences, including their ability to isolate during the pandemic, were associated with lower PTSS scores in children. Youth whose parents or caregivers reported no change in their own behaviors were more likely to report lower PTSS scores.
Changes in youth health behaviors (like eating, physical activity, and media use) and access to healthcare were important factors associated with PTSS scores. Stability in these areas was linked to lower PTSS scores.
The use of coping strategies by children and teens did not significantly reduce PTSS scores. Some coping strategies, like increased media use and substance use, were linked to higher PTSS scores.

This study provides valuable insight that could help improve youth mental health now and in the wake of future public health emergencies. It demonstrates the importance of stability in health behaviors, access to healthcare, and the ability for parents to isolate safely as key factors in reducing youth PTS symptoms.

This collaborative research, titled “Changes to Family Life, Youth COVID-19 Pandemic-Related Traumatic Stress, and the Youth Mental Health Crisis,” is published in the Journal of Clinical Child & Adolescent Psychology.

Read the research summary.

Early Childhood Weight Patterns May Signal Future Obesity Risk, NIH Study Finds

Posted on May 22, 2025August 27, 2025 by Jodi Snare

Researchers identified growth patterns and early-life factors linked to higher obesity risk at age 9.

Not all children grow the same way. A new study from the Environmental influences on Child Health Outcomes (ECHO) Program suggests that body weight changes in early childhood may be associated with later obesity risk.

Funded by the National Institutes of Health (NIH), the study tracked children’s body mass index (BMI) from infancy through age 9 and found two distinct growth patterns. Most children followed a typical curve, with BMI decreasing in early childhood before gradually rising again. But a smaller group followed a trajectory marked by a sharp rise in BMI, which put them at higher risk of developing obesity by age 9.

Key takeaways:

Researchers found two main BMI growth patterns in children. Most children (89.4%) had a typical pattern where their BMI declined from ages 1 to 6, then rose slowly. A smaller group (10.6%) had an atypical pattern where their BMI stayed the same from ages 1 to 3.5, then increased rapidly from ages 3.5 to 9.
By age 9, children in the atypical group were more likely to develop obesity, with an average BMI higher than the 99th percentile.
Several early-life factors were associated with the child’s risk of developing obesity, including high birthweight, maternal smoking during pregnancy, high maternal BMI before pregnancy, and excessive maternal weight gain during pregnancy.

Childhood obesity—defined as having a BMI at or above the 95th percentile for a child’s age and sex—is often the result of excess body fat. Without support or intervention, children with higher BMI patterns in early life are more likely to carry that weight into adolescence and adulthood, increasing their chances of developing serious health conditions like diabetes and heart disease.

“The fact that we can identify unusual BMI patterns as early as age 3.5 shows how critical early childhood is for preventing obesity,” said ECHO researcher Chang Liu, PhD, of Washington State University.

The study included 9,483 children across the United States who are part of the ECHO Cohort. Researchers looked at weight and height data collected over time from medical records, caregiver reports, and in-person or at-home measurements. They tracked how children's BMI changed as they grew and looked for patterns related to experiences early in life.

“Our findings suggest there are important opportunities to reduce childhood obesity, such as helping pregnant women quit smoking and manage healthy weight gain, as well as closely monitoring children who show early signs of rapid weight gain,” said Liu.

This collaborative research is published in JAMA Network Open.

Liu, Chang, M., et al. (2025) Early-Life Factors and Body Mass Index Trajectories Among U.S. Children in the ECHO Cohort. JAMA Network Open. DOI: 10.1001/jamanetworkopen.2025.11835

About ECHO
The ECHO Cohort Consortium is a research program supported by the National Institutes of Health (NIH) with the mission to enhance the health of children for generations to come. ECHO Cohort investigators study the effects of a broad range of early environmental influences on child health and development. For more information, visit echochildren.org.

Media Contacts

For information or to request an interview, contact Rebekah Yeager, rebekah.yeager@nih.gov.

If you are not a member of the media, but have a general inquiry, please contact NIHKidsandEnvironment@od.nih.gov.

Connect With Us

Check out the recent issues of our bi-monthly newsletter, the ECHO Connector, for program news and the latest research findings.

To receive the ECHO Connector through email, subscribe here.

Follow @ECHOChildHealth for the latest ECHO Program updates on X.

Stronger Executive Functioning Skills in Children May Support Healthier Behaviors and Lower Chronic Disease Risk, Study Finds

Posted on March 7, 2025March 7, 2025 by Jodi Snare

Children with stronger executive functioning skills may be better equipped to develop health-promoting behaviors that reduce their risk of chronic disease, according to a new study funded by the Environmental influences on Child Health Outcomes (ECHO) Program at the National Institutes of Health.

Key takeaways include:

Across all pediatric life stages, children with higher working memory consumed fewer sugary drinks and saturated fats.
In middle childhood, greater cognitive flexibility and behavioral inhibition were linked to eating more fruits and vegetables. These skills were also associated with increased physical activity.
In adolescence, higher scores in all executive functioning domains were linked to greater physical activity.

“The results of this study allow us to get more specific in how and when we intervene,” said ECHO Cohort investigator Nichole Kelly, PhD of the University of Oregon. “For example, targeting working memory as a specific domain of executive functions may be most fruitful in improving children’s dietary behaviors, particularly through early intervention, as the link between working memory and diet was evident in early childhood.”

The findings suggest that early interventions targeting executive functioning, particularly working memory, could improve dietary habits throughout childhood. However, the effects of executive functioning on health behaviors were small, indicating that additional strategies may be necessary to support families in fostering healthier lifestyles. Additionally, because this study looked at this association at only one point in time for each child, it isn’t clear whether executive functioning influences health behaviors or vice versa.

This collaborative research, titled “Children’s executive functioning and health behaviors across pediatric life stages and ecological contexts,” was published in the Journal of Behavioral Medicine.

Executive Functioning May Be Connected to Child Health Behaviors, ECHO Cohort Study Suggests

<< Back to Research Summaries

Executive Functioning May Be Connected to Child Health Behaviors, ECHO Cohort Study Suggests

Author(s): Nichole Kelly, Derek Kosty, Leslie Leve et al.

Who sponsored this study?

The Environmental influences on Child Health Outcomes (ECHO) Program, National Institutes of Health supported this research.

Why was this study needed?

Executive functioning refers to the cognitive processes that relate to a person’s ability to shift attention (cognitive flexibility), control impulsive actions (behavioral inhibition), and remember multiple pieces of information while solving a problem (working memory). Studies with adults suggest that lower executive functioning is related to less engagement in health-promoting behaviors, which increases risk for chronic disease. This study aimed to understand how these three domains of executive functioning relate to health behaviors in different age groups (early childhood, middle childhood, and adolescence). The goal was to inform more specific and developmentally tailored intervention strategies that target executive functioning to improve health behaviors and ultimately reduce chronic disease risk in children.

What were the study results?

Across all age groups, children with higher working memory also had more health-promoting eating behaviors, such as less frequent intake of sugary drinks and saturated fats. In middle childhood, children who showed more cognitive flexibility and behavioral inhibition also ate more fruits and vegetables and engaged in more physical activity. In adolescence, children with higher scores in all three executive function domains reported more engagement in physical activity. Researchers did not find significant connection between child sleep and executive functioning in this study.

What was the study's impact?

The results of this study can help researchers and clinicians plan better interventions that target children’s executive functioning to improve their health behaviors and, ultimately, their risk for chronic disease. For example, the results of this study suggest that early intervention targeting children’s working memory may help improve their dietary behaviors throughout childhood. However, associations with executive functioning observed in this study were small, so other interventions may be needed to support families in developing health-promoting behaviors. Additionally, because this study looked at this association at only one point in time for each child, it isn’t clear whether executive functioning influences health behaviors or vice versa.

Who was involved?

The study included children and their parents/caregivers from 38 ECHO Cohort Study Sites across 78 locations in the U.S. and Puerto Rico. Children from three life stages participated in the study: 2,074 in early childhood (age 5–8 years), 3,230 in middle childhood (age 8–12 years), and 1,416 in adolescence (age 12–18 years).

What happened during the study?

During the study, participating children completed computer tasks to measure their executive functioning. Participants also shared details about their diet, physical activity, and sleep through parent- and/or child-reported questionnaires. Additionally, information on income, positive parenting, neighborhood crime, and greenspace was collected.

What happens next?

To continue identifying the best health intervention strategies, researchers could continue to explore how executive functioning relates to health behaviors by collecting data on how these effects change over time.

Where can I learn more?

Access the full journal article, titled “Children’s executive functioning and health behaviors across pediatric life stages and ecological contexts,” in the Journal of Behavioral Medicine.

The content is the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Published January 9, 2025

Read the related research alert.

Download this summary

Executive Functioning May Be Connected to Child Health Behaviors, ECHO Cohort Study Suggests

NIH Study Suggests Measurement Bias in Common Child Behavior Assessment Tool

Posted on September 29, 2023August 27, 2025 by Jodi Snare

FOR IMMEDIATE RELEASE

Researchers identify less biased questions that could reliably capture childhood behavior problems

Scores from a commonly used measure of behavior problems in young children may be skewed depending on the primary language, education, and sex of the caregiver who fills out the survey, as well as the child’s age and race, according to new research from the NIH’s Environmental influences on Child Health Outcomes (ECHO) Program.

ECHO Cohort researchers analyzed data from caregivers who filled out the widely used Child Behavior Checklist (CBCL) 1.5–5 on behalf of 9,087 young children ages 18 to 71 months from 26 ECHO research sites across the United States. The caregiver-reported survey evaluates a range of behavior problems in young children.

"Understanding children's behavior can help us identify potential issues in their development and mental health down the road,” said Shuting Zheng, PhD of the University of California, San Francisco. “To do this effectively, we need reliable ways to measure their behavior equivalently for children from diverse backgrounds."

The study found that how caregivers respond to the questions on the measure was biased the most by the language used to complete the survey, followed by factors such as the caregiver's education level and sex and the child's age and race. These biases persisted after accounting for mental health disparities between these groups. Researchers noted that some information could get lost in translation and people from different cultures could understand child behavior problems differently. The gender of the person answering the questions and their level of education also had an impact and researchers pointed to parents’ expectations about how children should develop as possible influences in how they answered the survey questions.

ECHO Cohort researchers were then able to identify some CBCL questions less affected by measurement biases introduced by sociodemographic factors but which still reliably captured childhood behavior problems. The subset of questions that showed little bias across survey-taker demographics still captures a wide range of behaviors across internalizing (e.g., emotionally reactive, withdrawn) and externalizing problems (aggressive behaviors and attention problems).

Going forward, ECHO Cohort researchers plan to apply these questions, evaluating their reliability in identifying children with clinically significant behavior problems.

“Finding questions with less measurement bias across socio-demographic groups helps researchers and clinicians measure behavior problems in different groups of kids of varying ages and family backgrounds more accurately,” Dr. Zheng said.

Dr. Zheng and Somer Bishop, PhD of the University of California, San Francisco, and Maxwell Mansolf, PhD of Northwestern University led this collaborative research that was published in the Journal of Child Psychology & Psychiatry Advances.

Zheng, S. et al. Measurement Bias in Caregiver-Report of Early Childhood Behavior Problems across Demographic Factors in an ECHO-wide Diverse Sample. Journal of Child Psychology & Psychiatry Advances. DOI: 10.1002/jcv2.12198.

###

About ECHO:

Launched in 2016, the Environmental influences on Child Health Outcomes (ECHO) Program is a research program in the Office of the Director at the NIH with the mission to enhance the health of children for generations to come. ECHO investigators study the effects of a broad range of early environmental influences on child health and development. For more information, visit echochildren.org.

About the NIH: NIH, the nation’s medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information, visit.

Media Contacts

For information or to request an interview, contact Rebekah Yeager, rebekah.yeager@nih.gov.

If you are not a member of the media, but have a general inquiry, please contact NIHKidsandEnvironment@od.nih.gov.

Connect With Us

Check out the recent issues of our bi-monthly newsletter, the ECHO Connector, for program news and the latest research findings.

To receive the ECHO Connector through email, subscribe here.

Follow @ECHOChildHealth for the latest ECHO Program updates on Twitter.

Caregiver-Reported Measures of Childhood Behavior May be Biased by the Demographic Traits of Caregivers and Children

<< Back to Research Summaries

Caregiver-Reported Measures of Childhood Behavior May be Biased by the Demographic Traits of Caregivers and Children

Authors: Shuting Zheng, Maxwell Mansolf, Somer Bishop, et al.

Who sponsored this study?

The Environmental influences on Child Health Outcomes (ECHO) Program, Office of the Director, National Institutes of Health supported this research.

Why was this study needed?

Behavior problems observed in a young child can provide information on that child’s risk for certain developmental conditions and later mental health issues. A valid and unbiased measure of childhood behavior is critical for helping researchers and clinicians answer questions about the development of behavior problems in children from different backgrounds.

What were the study results?

Scores from the Child Behavior Checklist (CBCL) 1.5–5—a commonly used, caregiver-reported measure of internalizing (e.g., anxious) and externalizing (e.g., aggressive) behavior problems in children ages 1.5 to 5 years—may be biased by demographic factors such as the child’s age or the caregiver’s sex, education level, and primary language. Researchers found that caregiver responses for a number of questions on the CBCL were affected by caregiver or child demographic factors. The language (English vs. Spanish) the caregiver used to complete the survey contributed most to measurement bias, followed by their education level and sex. The child’s age and race also influenced CBCL scores.

By determining the factors contributing to measurement bias, ECHO researchers identified a subset of questions on the CBCL that were less impacted by bias but still reliably captured childhood behavior problems.

Footnote: Results reported here are for a single study. Other or future studies may provide new information or different results. You should not make changes to your health without first consulting your healthcare professional.

What was the study's impact?

The results of this study highlight the need to carefully consider possible sources of bias when using caregiver-reported measures. This study was the first to use a large, diverse sample of families to examine how demographic factors influence the answers given for individual survey questions in the widely used CBCL. Developing surveys with less bias can help researchers and clinicians better measure and compare behavior problems across groups of children who differ in age and family background.

Who was involved?

The study included caregivers of 9,087 young children (ages 18 to 71 months) from 26 ECHO research sites across the United States.

What happened during the study?

The researchers used data from 26 ECHO research sites to evaluate how caregiver responses to the CBCL varied based on the characteristics (age, sex, race, bilingual status, and neurodevelopmental disorders) of the child and the characteristics (sex, education level, household income level, and depression diagnosis) of the caregiver. Researchers then selected the CBCL questions that showed the least amount of bias and compared how well this subset of questions worked for evaluating childhood behavior problems when compared to the full CBCL survey. Additionally, the researchers mapped the scores from the less biased question sets to the scores provided by the full item sets, allowing them to derive comparable scores to the original CBCL scale.

What happens next?

ECHO researchers plan to apply the newly identified subset of less biased CBCL survey questions, evaluating its reliability in identifying children with clinically significant behavior problems. The identification of question sets with little bias offers researchers and clinicians better alternatives for measuring and comparing behavior problems across groups of children who differ in age and family background.

Where can I learn more?

Access the full journal article, titled “Measurement Bias in Caregiver-Report of Early Childhood Behavior Problems across Demographic Factors in an ECHO-wide Diverse Sample,” in the Journal of Child Psychology & Psychiatry Advances.

The content is the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Published September 29, 2023

Access the associated article.

Download this summary

Caregiver-Reported Measures of Childhood Behavior May be Biased by the Demographic Traits of Caregivers and Children

New ECHO Cohort Suggests Bias in Child Behavior Assessment Tool

Posted on September 29, 2023October 9, 2023 by Jodi Snare

Collaborative ECHO Cohort research led by Shuting Zheng, PhD, of the University of California, San Francisco, Maxwell Mansolf, PhD, of Northwestern University, and Somer Bishop, PhD, of the University of California, San Francisco suggests that scores from a commonly used measure of behavior problems in young children may be skewed depending on the primary language, education, and sex of the caregiver who fills out the survey. This research, titled “Measurement Bias in Caregiver-Report of Early Childhood Behavior Problems across Demographic Factors in an ECHO-wide Diverse Sample,” is published in the Journal of Child Psychology & Psychiatry Advances.

Behavior problems observed in a young child can provide information on that child’s risk for certain developmental conditions and later mental health issues. A valid and unbiased measure of childhood behavior can help researchers and clinicians answer questions about the development of behavior problems in children from different backgrounds.

The Child Behavior Checklist 1.5-5 (CBCL) is a commonly used, caregiver-reported measure of internalizing (e.g., anxious) and externalizing (e.g., aggressive) behavior problems in children ages 1.5 to 5 years. Researchers wanted to find out if scores from this test could be affected by demographic factors such as the child’s age or the caregiver’s sex, education level, and primary language, even after accounting for mental health disparities between these groups. The research team’s goal for this study was to identify factors contributing to measurement bias and identify a subset of questions on the CBCL that were less impacted by bias but still reliably captured childhood behavior problems.

The study included caregivers of over 9,000 children between the ages of 18 to 71 months from 26 ECHO study sites across the United States. The data collected was used to evaluate how the characteristics of the child and the caregiver influence the caregiver responses to the CBCL questions. Researchers found that caregiver or child demographic factors affected caregiver responses to many questions on the CBCL. The language (English vs. Spanish) the caregiver used to complete the survey contributed most to measurement bias, followed by their education level and sex. The child’s age and race also influenced caregiver responses to many CBCL questions.

Researchers then selected the CBCL questions that showed the least amount of bias and compared how well they worked to evaluate childhood behavior problems when compared to the full CBCL survey. The researchers also mapped the scores from the less biased question sets to the scores provided by the full item sets, allowing users to derive comparable scores to the original CBCL scale.

Read the research summary.