ORIGINAL ARTICLE

Maternal Alcohol Use during Pregnancy, Birth Weight and Early Behavioral Outcomes
Jen-Hao Chen
*
University of Chicago, 1155 East 60th Street, Chicago, IL 60637, USA
*Corresponding author: Tel: +1-773-834-7829; E-mail: jenhao@uchicago.edu
(Received 29 February 2012; first review notified 12 April 2012; in revised form 28 June 2012; accepted 11 July 2012)
Abstract Aims: To examine the effect of maternal alcohol use during pregnancy on infant behavioral outcomes and birth weight,
and to investigate the differential susceptibility of infant behavioral outcomes and birth weight to prenatal alcohol exposure.
Methods: Data on children born to women taking part in the United States National Longitudinal Survey of Youth (NLSY)
(n = 1618) were analyzed using the sibling fixed-effects model, which helps adjust for maternal, genetic and social confounders
when examining effects of pre-natal exposure to possible toxins such as alcohol. Mothers were classified as non-drinkers, light-to-
moderate drinkers and heavy drinkers according to their frequency of alcohol use during pregnancy. Infants behavioral outcomes
were assessed using the modified Rothbart Infant Behavior Questionnaire in the NLSY, which measures three dimensions of behav-
ioral outcomes: positive mood, fearfulness and difficultness. Results: Estimates from the model indicated that drinking during preg-
nancy was positively associated with infant difficultness, but not with positive mood or fearfulness. Further analysis by frequency of
alcohol use suggested that both light-to-moderate and heavy drinking were associated with an increase in infant difficultness.
Additionally, while low-to-moderate drinking during pregnancy was associated with infant difficultness, drinking at this level was
not associated with low birth weight. Conclusion: The findings suggest that maternal alcohol use during pregnancy is a risk factor
for infant behavioral outcomes, after taking into account many confounding factors. Infant behavioral outcomes appear to be more
vulnerable to light-to-moderate levels of alcohol use during pregnancy than birth weight is.
Drinking during pregnancy represents a major public health
problem and generates much public attention in many coun-
tries (OLeary et al., 2007). In the USA, the Centers for
Disease Control and Prevention (CDC) showed that in 2005
approximately one in every eight pregnant women reported
that they had consumed alcohol during their pregnancy.
Furthermore, this high rate of alcohol use during pregnancy
has remained relatively unchanged in the USA since the
1990s (Centers for Disease Control and Prevention, 2009).
Accordingly, approximately half a million infants are
exposed prenatally to alcohol each year. Understanding the
consequences of prenatal alcohol exposure on children is not
only of academic interest, but is also important for those de-
termining policy.
Prenatal alcohol exposure has been associated with
various behavioral problems in children, including conduct
problems (DOnofrio et al., 2007), attention problems
(Streissguth et al., 1984; Knopik et al., 2005) and criminal
and delinquent behaviors (Streissguth et al., 1999; Fast and
Conry, 2004). While these studies provide the best evidence,
more methodologically rigorous studies are definitely needed
in order to develop a comprehensive understanding of the
impact of prenatal alcohol exposure on childrens behavioral
development, particularly the developmental consequences
associated with low-to-moderate levels of alcohol exposure
(Jacobson and Jacobson, 1999; Huizink and Mulder, 2005).
Results from animal experiments show that light-to-moderate
alcohol consumption during pregnancy may cause mental
health and behavioral problems in offspring (Schneider et al.,
1997; Kraemer et al., 2007; Cuzon et al., 2008).
Additionally, experimental evidence further suggests that
prenatal alcohol use has a greater influence on the behavioral
outcomes of offspring than it does on infant birth weight. In
two randomized experiments on rhesus monkeys, Schneider
et al. (1997, 2001) found that moderate alcohol consumption
throughout pregnancy was associated with irritability, atten-
tion problems and poor neurological functioning in offspring,
in spite of the fact that the baby monkeys born during the
study showed no significant difference in birth weight
between the control and the experiment groups (Schneider
et al., 1997). Animal experiments thus suggest a differential
susceptibility hypothesis, in which infant behavioral out-
comes are more vulnerable to prenatal alcohol exposure than
physical growth is.
Extant findings from observational studies of the conse-
quences of low-to-moderate levels of alcohol consumption
during pregnancy, however, remain somewhat contradictory.
Several studies found that low-to-moderate levels of alcohol
exposure were positively associated with childrens problem
behaviors (Streissguth, 1980, 1999; Olson et al., 1997; Sood
et al., 2001). In contrast, two recent analyses showed that
low-to-moderate drinking was not independently associated
with an increased risk of either attention deficit hyperactivity
disorder or behavioral problems in children (Knopik et al.,
2006; Kelly et al., 2009). The mixed results of these studies
may be due to the problem of identifying the causal effect of
prenatal alcohol exposure (Linnet et al., 2003; Testa et al.,
2003; Huizink and Mulder, 2005). In particular, many prior
evaluations did not adequately control for confounders, such
as family processes and maternal characteristics, which may
correlate with both child behavioral outcomes and maternal
alcohol use. The causal inference problem is further compli-
cated by study design and the type of data collected. Many
studies have relied on small, selective, clinical samples
where measures of family processes and parental characteris-
tics were often unavailable. Consequently, many prior
studies involve a risk of confounding resulting from simple
comparisons between children born to drinking mothers and
children born to non-drinking mothers without controlling
for unobserved differences between the subjects.
Quasi-experimental designs are useful alternatives to
account for potential confounders, including factors that are
not measured (Duncan et al., 2004; DOnofrio et al., 2007).
For studies where randomized trials are not feasible,
Alcohol and Alcoholism Vol. 47, No. 6, pp. 649656, 2012 doi: 10.1093/alcalc/ags089
Advance Access Publication 14 August 2012
The Author 2012. Medical Council on Alcohol and Oxford University Press. All rights reserved

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quasi-experimental designs rely on natural experiments that
pull apart processes that are typically confounded and
provide better evidence for causal inference. One class of
quasi-experimental designs draws inferences from siblings or
children-of-twins comparisons (often referred to as a
fixed-effects model in the social science literature) and is
particularly useful for studies in human development. By
contrasting children exposed to prenatal alcohol with their
siblings or cousins who were exposed to less, this approach
controls for the mothers characteristics, including genetic li-
abilities that are shared by mothers and offspring. However,
only a few recent studies have adopted such a design in
examining the behavioral consequences of prenatal alcohol
consumption (for example, Knopik et al., 2006; DOnofrio
et al., 2007; Knopik et al., 2009). Results from these studies
suggest that while many of the prior associations may be
spurious, maternal alcohol use during pregnancy may remain
a risk factor for certain behavioral problems. More import-
antly, these studies demonstrate the potential of the sibling
approach in studying the impact of low-to-moderate alcohol
use while pregnant. Furthermore, the differential susceptibil-
ity hypothesis suggested by the animal model has not been
adequately examined with observational data in humans.
According to this hypothesis, it would be expected that
low-to-moderate alcohol use would have a stronger negative
effect on child behavioral outcomes than on infant birth
weight. An empirical test of this hypothesis might also
inform theories about the neurological development and
physical growth of the fetus.
The present study was designed to address the methodo-
logical limitations and research gaps in the literature.
Specifically, this study investigated the association between
maternal drinking during pregnancy and infant behavioral
outcomes as related to the level of alcohol use. The study
employed a sibling fixed-effects model to account for unob-
served heterogeneity among the mothers of the children in
the sample. In addition, the study tested the differential sus-
ceptibility hypothesis with observational data. Finally, add-
itional analyses were performed to check the fixed-effects
identification assumption and to investigate whether the asso-
ciations between prenatal drinking and infant behavioral out-
comes, if any, were moderated by social status. Given that
the majority of women who drink while pregnant are consid-
ered light or moderate drinkers (Centers for Disease Control
and Prevention, 2009), the findings from this study have sig-
nificant implications for public health campaigns and pre-
natal problem prevention efforts that promote healthy
pregnancies and child well-being.
The focus on infant behavioral outcomes is further driven
by two reasons. First, studying infant outcomes provides add-
itional opportunities to identify the causal effects of prenatal
alcohol exposure. As children grow up, they are increasingly
subjected to the influence of environmental forces (Shonkoff
and Philips, 2000). Studies that focus on child outcomes that
investigate children at older ages may not be able to isolate
the effects of prenatal alcohol use from the childs changing
environment. By examining behavioral outcomes during the
very first periods of life, the present study minimizes the in-
fluence of potential confounders from postpartum environ-
mental factors. Second, recent interdisciplinary evidence has
shown that early behavioral outcomes, which have often been
referred to as non-cognitive skills in economic and socio-
logical literature (e.g. Farkas, 2003; Cunha et al., 2010), are
strong predictors of later psychological well-being (Caspi
et al., 2003), problem behaviors (Caspi et al., 1995) and labor
market success (Caspi et al., 1998). At the same time, re-
search suggests that the investments made in interventions
later in life appear to be less efficient than earlier investments
(Carneiro and Heckman, 2003; Coneus et al., 2012). In order
to safeguard childrens development, policies should empha-
size early intervention, and, if possible, beginning during
pregnancy (Doyle et al., 2009). Inferences about the relation-
ship between alcohol use while pregnant and the behavioral
development of offspring in early life may thus shed light on
the origins of social inequality and future policy solutions for
reducing social inequality.
METHODS
Sample
The current study investigated children born to women who
participated in the National Longitudinal Survey of Youth
(NLSY). The NLSY is a nationally representative sample of
12,686 participants, who were between 14 and 21-year-old at
the start of the survey in 1979. Since 1986, the NLSY has
biennially interviewed and gathered information on the chil-
dren of the women in the original NLSY sample. However,
the NLSY stopped collecting information on infant behavior-
al outcomes for children born after 2000. The following stat-
istical analyses were thus restricted to children born between
1986 and 2000. The NLSY data include extensive informa-
tion on maternal behaviors during pregnancy for every birth
since 1986. Moreover, further data on the mothers can be
obtained from the NLSY master files and linked to the corre-
sponding child records on a year-by-year basis.
In the NLSY data, there were ~6700 children born to the
participating women between 1986 and 2000. The final ana-
lytical sample included only children aged 23 months to 4
years who had at least one sibling born between 1986 and
2000, thereby eliminating very young infants, whose beha-
viors are more difficult to assess (Rothbart, 1981; Shonkoff
and Philips, 2000). This left 2132 children. Cases with
missing values for infant behavioral outcomes and prenatal
alcohol use (n = 371) and time-varying covariates were
excluded (n = 143), producing a sample of 1618 children.
Most of the sibling groups in the sample included only two
children; however, sibling groups that included three or four
children were not uncommon. The maximum number of chil-
dren in a sibling group was five.
Outcome measures
The measures of the infant behavioral outcomes were
derived from the NLSY child temperament instruments,
which were a modified version of the Rothbart Infant
Behavior Questionnaire (Center for Human Resources
Research, 2006). Children of different ages received different
sets of temperament items. The present study used 11 items
administered to all of the children under 23 months to con-
struct infant behavioral scales. In addition to these common
items, six other items were administered to children under
650 Chen

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11 months. These items were excluded from the scale con-
struction, because they focused more on measuring very
young childrens activity levels and behavioral routines (i.e.
sleepy and hungry at the same time), which are not the
primary interest of this study and were administered only to
part of the age range of the children in the sample.
For each of the 11 items, the mothers rated their infants
behavior using a 5-point scale, where a higher value indi-
cated a higher frequency of occurrence (i.e. 1, almost never,
2, less than the time, 3, about of the time, and so on).
To construct the infant behavioral scales, this study followed
the procedures described in previous studies and the guide-
lines from the NLSY Users Guide (Center for Human
Resources Research, 2006; Lahey et al., 2008), which recom-
mend that researchers differentiate three dimensions of infant
behavioral outcomes: (a) positive mood (i.e. the childs fre-
quency of smiling or laughter in any situation); (b) fearful-
ness (i.e. the childs level of distress for novel people and
situations) and (c) difficultness (i.e. the childs level of fussi-
ness and ability to be comforted). A total score was obtained
by summing across all the items in each dimension. These
totals were then standardized to facilitate interpretation and
comparison across different behavioral ratings.
Maternal drinking during pregnancy
The NLSY asked every woman to report her drinking behav-
ior during each pregnancy between 1986 and 2000 retro-
spectively. The mothers were first asked whether they had
consumed any alcohol in the 12 months before the birth of
the child. Next, if the answer was yes, they were asked to
report the frequency of alcohol consumption during the preg-
nancy: never (33.8%), less than once a month (32.0%),
about once a month (17.3%), 3 or 4 days a month (7.8%), 1
or 2 days a week (6.6%), 3 or 4 days a week (1.5%), nearly
every day (0.7%) and every day (<0.1%).
This information was coded in two ways. First, this study
created a dummy variable to indicate whether a mother
drank any alcohol during each pregnancy. Second, the fre-
quency of prenatal drinking was separated into three levels:
no drinking, light-to-moderate drinking (defined as less than
3 or 4 days a month) and heavy drinking (defined as more
than 1 or 2 days a week). These two variables were the key
explanatory variables in the following statistical analyses.
Control variables
In contrast to studies relying on clinical samples involving
the local recruitment of subjects, the NLSY database
includes rich information on maternal characteristics, demo-
graphic variables and family socioeconomic status.
Time-invariant control variables include race and ethnicity,
maternal education and grandmother and grandfathers edu-
cation. This study also controlled for several time-varying
variables that are known to be related to child outcomes, in-
cluding maternal characteristics, such as poverty, marital
status, age and the use of prenatal visits in the first trimester
of the pregnancy, as well as child characteristics, such as
gender, birth order and the childs age at the time of assess-
ment. Finally, with the availability of extensive measures of
maternal cognitive and behavioral skills in the NLSY, this
study also included the mothers Armed Force Qualification
Test (AFQT) test scores, locus of control (from the Rotter
Locus of Control Scale), self-esteem (from the Rosenberg
Self-Esteem Scale) and self-rated sociability as covariates.
Statistical analyses
To estimate the relationship between maternal alcohol use
and infant behavioral outcomes, this study first evaluated the
data using ordinary least squares (OLS) regressions, and con-
trolled for a wide range of maternal characteristics, including
measures of maternal cognitive and behavioral skills.
Nonetheless, the incidence of women who participated in
drinking during pregnancy was not randomly distributed in
the population of pregnant women. The impact of maternal
alcohol use during pregnancy on an infants behavioral out-
comes could reflect characteristics not often measured in
surveys. Traditional OLS regression, however, cannot account
for such unobserved variable bias; a sibling fixed-effects
model is a better alternative to deal with this unobserved vari-
able bias. A sibling fixed-effects model compares siblings with
the treatment of interest with siblings without the treatment
in the same family. This strategy allows anything that is shared
across births to be factored out. If, among otherwise similar
families, children who were exposed to prenatal drinking show
higher levels of behavioral problems than those with no expos-
ure to alcohol, a causal relationship between prenatal drinking
and behavioral outcomes is plausible. The rationale of sibling
fixed-effects can be expressed in the following equations:
Y
ij
bD
ij

X
n
k1
g
k
X
kij
m
j
1
ij
1
Y
ij
Y
ij
bD
ji
D
ij

X
n
k1
g
k
X
kij
X
kij
1
ij
1
ij
2
Here, the subscript i refers to a child and subscript j refers to
the family (mother) of the child. Y is the outcome of interest.
D represents maternal drinking while pregnant. X
k
is the vector
of n covariates, which serve as control variables. In addition,
refers to the family-level, time-invariant unobserved factors. If
these unobservable factors are simultaneously correlated with
infant behavioral outcomes and prenatal drinking, traditional
OLS estimates (as presented in the first equation) would yield
a biased estimate of . The sibling fixed-effects estimator
removes bias from the time-invariant maternal and family com-
ponents of by subtracting the average for all siblings in a
given family from each childs value (represented in the
second equation) and provides better estimates of the effects of
maternal alcohol use during pregnancy on infant behavioral
outcomes.
RESULTS
Descriptive statistics
Descriptive statistics are presented in Table 1. These statistics
are reported at the maternal and child levels, because each
mother in the sample had multiple children. Less than half of
Maternal alcohol use during pregnancy 651

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the sample was non-drinking mothers, while mothers who
drank during all of their pregnancies and mothers who drank
during at least one pregnancy constituted 17% and 29% of
the sample, respectively. The mean age of the mothers in
1986 was 24.5 years, and, on average, each had two children.
Mothers who drank during their pregnancies were more
likely to be white and better educated, and they were less
likely to be poor. In contrast, mothers who did not drink at
all or who drank only during some of their pregnancies
tended to be African-American and Hispanic, with lower
levels of education. Furthermore, drinking mothers showed
higher levels of marital stability, but were more likely to
smoke while pregnant. Mothers who changed their drinking
behavior were less likely to live in a stable environment and
were more likely to have experienced short-term poverty, and
24% had a change in marital status between pregnancies.
The bottom half of Table 1 shows selected characteristics
of the children. Infant behavioral outcomes varied with ma-
ternal drinking behavior during pregnancy. Mothers who
drank while pregnant tended to have children with slightly
lower levels of positive mood and higher levels of difficult-
ness. Children born to non-drinking mothers showed higher
levels of fearfulness compared with children born to mothers
who drank while pregnant.
Effects of maternal alcohol use on infant behavioral
outcomes
Estimates of the effects of alcohol use on infant behaviors
are reported in Table 2. Table 2 shows the estimates of the
overall effects of maternal drinking during pregnancy, re-
gardless of the level of alcohol used. In the basic OLS
model (Model 1), drinking while pregnant was associated
with a lower level of positive mood of 0.25 standard devia-
tions (P < 0.001). Children whose mothers drank while preg-
nant scored 0.20 standard deviations higher (P < 0.001) on
the difficultness rating. Prenatal drinking appeared to have
no effect on childrens fearfulness. None of the maternal
demographic variables significantly correlated with any
infant behavioral outcomes examined. However, some mater-
nal cognitive and behavioral skills were strong predictors of
infant behavioral outcomes. For example, maternal self-
esteem had a significant positive effect on the childrens dif-
ficultness. An additional unit increase in the maternal self-
esteem rating was associated with an increase of 0.02
Table 1. Weighted descriptive statistics for samples of children of the NLSY born between 1986 and 2000
Total sample
mean or %
By maternal alcohol use status across pregnancies
Drinkers
mean or %
Non-drinkers
mean or %
Change behavior
mean or %
Selected maternal characteristics
Demographic characteristics
Hispanic 6.0 2.0 8.4 7.1
African-American 11.3 7.8 11.8 10.1
Mother less than high school 7.3 6.5 8.5 7.4
Mother high school 38.9 34.3 38.0 44.6
Mother some college 20.4 19.8 18.0 22.2
Mother college 21.8 24.1 21.9 20.2
Mother more than college 11.6 15.3 13.7 5.7
Mothers age at baseline (1986) 24.5 24.9 24.2 24.5
Number of children 2.4 2.3 2.4 2.4
Maternal cognitive and behavioral skills
Mothers AFQT Score
(Percentile)
53.6 64.0 51.7 51.6
Mothers self-esteem (1040) 32.5 33.3 32.6 31.7
Mothers Locus of Control (416) 8.6 8.1 8.7 8.7
Mothers sociability (14) 2.9 3.1 2.8 2.9
Prenatal smoking
Smoking for all births 17.5 17.0 11.9 26.9
Non-smoking for all births 72.9 75.1 80.0 60.0
Change behavior 9.6 7.9 8.1 13.1
Marital status
No change of marital status 82.2 90.4 82.5 76.3
Get married 12.2 8.0 11.9 15.4
Divorced 5.6 1.6 5.6 8.3
Poverty status
Poor for all births 6.0 6.5 6.7 4.3
Non-poor for all births 81.4 89.2 80.5 77.8
Change poverty status 12.6 4.3 12.8 17.9
Child characteristics
Infant behavioral outcomes
Positive mood
a
13.5 13.1 13.6 13.5
Fearfulness
b
10.6 10.3 10.9 10.4
Difficultness
c
5.8 6.1 5.8 5.7
First born 30.1 39.2 28.6 29.4
Sample size 1618 265 856 497
Sample size (fixed-effects) 725 124 389 212
a
Positive mood score ranges from 3 to 15.
b
Fearfulness score ranges from 5 to 25.
c
Difficultness score ranges from 3 to 15.
652 Chen

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standard deviations (P < 0.001) in childrens positive mood
and with a decrease of 0.03 standard deviations (P < 0.001)
in child difficultness. The mothers sociability was also nega-
tively correlated with fearfulness among children.
Model 2 in Table 2 employed the sibling fixed-effects
model. Compared with the estimates obtained from Model 1,
the negative effect on positive mood disappeared. This sug-
gests that the previously identified negative relationship
between prenatal drinking and childrens positive mood
might be spurious (i.e. the result of other unobserved vari-
ables). With respect to difficultness, the negative effect
remained sizable. The results showed that drinking while
pregnant is positively associated with an infants level of dif-
ficultness. Infants whose mothers drank while pregnant
scored 0.26 standard deviations higher (P < 0.001) on the dif-
ficultness rating compared with infants whose mothers did
not drink. In contrast, maternal alcohol use during pregnancy
appeared to have no effect on the positive mood or fearful-
ness of the infants.
Table 3 shows the sibling fixed-effects estimates by levels
of alcohol use. As Table 3 suggested, infants positive mood
and fearfulness were not affected by heavy drinking during
pregnancy. However, there were some interesting findings
regarding infant difficultness. Estimates suggested that the
negative effects of prenatal drinking on infant difficultness
were not limited to women who drank heavily during preg-
nancy. Although infants whose mothers drank heavily while
pregnant scored 0.36 standard deviations higher (P < 0.05)
on the difficultness rating than infants of non-drinkers,
light-to-moderate drinking also increased infants difficult-
ness ratings by 0.20 standard deviations (P < 0.01). Thus, it
appears that the adverse behavioral consequences of
light-to-moderate drinking are not trivial. In addition, the
estimates from Table 3 provided suggestive evidence that the
negative impact of prenatal drinking increased linearly with
the amount of alcohol consumed. Further explorative analysis
by using the original categories of frequency of alcohol use
found partial support for the hypothesis. However, the data
do not allow a closer examination of this linear relationship
among heavy drinkers, because the sample size in each
heavy drinking category was too small to render significant
results. Finally, the association between heavy drinking and
child fearfulness was sizable. Even though the association
was not statistically significant, the sizable effect suggested
that heavy drinking may be a risk factor for fearfulness as
well. More studies are definitely needed to investigate the re-
lationship between prenatal drinking and fearfulness.
To provide further evidence of the effect of alcohol and
infant difficultness and test the sensitivity of behavioral de-
velopment over physical growth as it relates to prenatal
drinking, the subsequent analysis expanded the previous
sibling fixed-effects model to include another important
outcome resulting from prenatal consumption of alcohol: low
birth weight. The fourth column of Table 3 shows these
results. The estimates showed no association between
light-to-moderate drinking and low birth weight, but mothers
who drank heavily during pregnancy had an increased
chance of 10% (P < 0.05) of giving birth to a child with a
low birth weight. Maternal smoking during pregnancy was
also associated with a higher chance of having a child with a
low birth weight. These findings are consistent with the con-
clusions of prior research: smoking is a strong risk factor for
Table 2. Effects of maternal alcohol use on infant behavioral outcomes (n = 1618)
a
Positive mood Fearfulness Difficultness
OLS
coefficient (SE)
Fixed-effects
coefficient (SE)
OLS
coefficient (SE)
Fixed-effects
coefficient (SE)
OLS
coefficient (SE)
Fixed-effects
coefficient (SE)
Prenatal behaviors and maternal demographic characteristics
Prenatal drinking 0.25*** (0.06) 0.07 (0.08) 0.02 (0.05) 0.10 (0.08) 0.20*** (0.05) 0.26*** (0.08)
Prenatal smoking 0.08 (0.08) 0.08 (0.14) 0.11 (0.08) 0.28* (0.13) 0.01 (0.08) 0.16 (0.13)
In poverty status 0.00 (0.09) 0.10 (0.11) 0.07 (0.08) 0.10 (0.11) 0.11 (0.08) 0.03 (0.11)
Non-married during pregnancy
(married omitted)
0.02 (0.09) 0.05 (0.15) 0.01 (0.08) 0.01 (0.14) 0.03 (0.08) 0.14 (0.14)
Divorced/separated during
pregnancy
0.07 (0.10) 0.04 (0.14) 0.01 (0.09) 0.07 (0.14) 0.03 (0.09) 0.00 (0.14)
Mother years of education 0.00 (0.02) 0.01 (0.01) 0.01 (0.01)
Grandmother years of education 0.00 (0.01) 0.01 (0.01) 0.01 (0.01)
Grandfather years of education 0.01 (0.01) 0.00 (0.00) 0.00 (0.03)
Prenatal care in first trimester 0.04 (0.07) 0.05 (0.08) 0.01 (0.07) 0.01 (0.08) 0.01 (0.07) 0.03 (0.08)
Child characteristics
First born 0.02 (0.06) 0.03 (0.07) 0.24*** (0.06) 0.15* (0.07) 0.19** (0.06) 0.14* (0.07)
Male 0.00 (0.05) 0.04 (0.06) 0.10* (0.05) 0.09

(0.05) 0.09

(0.05) 0.01 (0.05)

Hispanic 0.03 (0.08) 0.08 (0.08) 0.04 (0.08)
African-American 0.01 (0.08) 0.28*** (0.08) 0.32*** (0.08)
Maternal cognitive and behavioral skills
Mothers AFQT score (tenth
percentile)
0.01 (0.01) 0.03** (0.01) 0.00 (0.01)
Mothers self-esteem 0.02*** (0.00) 0.00 (0.01) 0.03*** (0.01)
Mothers locus of control 0.00 (0.01) 0.02* (0.01) 0.02 (0.01)
Mothers sociability 0.03 (0.04) 0.11** (0.04) 0.05 (0.04)
a
All regressions also control for child age at the time of assessment, maternal age and a series of dummy variables of childs year of birth. Coefficients of
these variables are not reported for brevity.

P < 0.1; *P < 0.05; **P < 0.01; ***P < 0.001.
Maternal alcohol use during pregnancy 653

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low birth weight. Heavy drinking seems to reduce childrens
birth weights as well, whereas low-to-moderate levels of
alcohol use appear to show no effect on birth weight.
Results from these tests, therefore, offer a more compre-
hensive picture of the impact of prenatal drinking on child
development. These results suggest that light-to-moderate
drinking may convey little harm to an infant in terms of
birth weight. By contrast, light-to-moderate drinking while
pregnant has a substantial negative impact on a childs diffi-
cultness. These findings suggest that infant difficultness is
more susceptible to the influence of maternal alcohol con-
sumption during pregnancy. Results from Table 3 thus
provide partial support for the differential susceptibility hy-
pothesis that has been suggested in previous animal studies.
Finally, this study performed two additional sets of ana-
lyses in order to check the robustness of these findings. First,
this study estimated models that included interaction terms
for maternal alcohol use and gender, birth order, race and
maternal education. This was done in order to examine
whether the negative consequences of alcohol use on infant
difficultness differed by child and/or maternal characteristics.
The results are presented in Table 4. Interestingly, none of these
interaction terms was statistically significant. Therefore, there
was no strong evidence that the impact of prenatal drinking
on infant mental health differs across gender, birth order,
race or maternal education status. Second, this study exam-
ined whether the results were altered by the use of different
selection criteria in sampling. The sibling fixed-effects
model relies on the assumption that unobserved characteris-
tics are time invariant. Intuitively, however, it seems that the
longer the time between births, the more likely it is that this
assumption may fail. To deal with this issue, the new ana-
lysis excluded children who were born >60 months apart.
Results are presented in Table 5. Although the magnitudes
of the estimated coefficients did change slightly, the patterns
were quite similar to those in the previous analyses. Prenatal
drinking remained positively correlated with the infants dif-
ficultness, and the harmful effects of light-to-moderate
alcohol consumption remained sizable and statistically sig-
nificant. Thus, the results held, regardless of the potential
problems implicit in the assumptions of fixed-effects
modeling.
DISCUSSION
The present study provides additional evidence for the
impact of prenatal alcohol exposure on early developmental
outcomes using data from the NLSY. The results show a
negative effect of maternal alcohol use on infant difficult-
ness, even for light-to-moderate drinking. By contrast, there
is no significant association between prenatal alcohol expos-
ure and positive mood and fearfulness in children.
Furthermore, this study suggests that prenatal alcohol expos-
ure has a greater effect on infant difficultness than it does on
Table 4. Effects of maternal alcohol use on infant behavioral outcomes by
subgroup (n = 1618)
a
Positive mood
coefficient (SE)
Fearfulness
coefficient (SE)
Difficultness
coefficient (SE)
Panel A: By gender
Male 0.08 (0.13) 0.10 (0.14) 0.31* (0.14)
Female 0.04 (0.11) 0.11 (0.10) 0.24* (0.10)
P (Male = female) 0.69 0.88 0.53
Panel B: By birth order
First-born 0.06 (0.14) 0.05 (0.15) 0.39** (0.15)
Non-first-born 0.07 (0.09) 0.12 (0.09) 0.23** (0.09)
P (first-born =
non-first-born)
0.92 0.55 0.16
Panel C: By race
Black 0.18 (0.17) 0.12 (0.16) 0.33* (0.16)
Hispanic 0.33 (0.18) 0.26 (0.17) 0.30

(0.17)
White 0.07 (0.11) 0.03 (0.10) 0.26* (0.10)
P (Black = white) 0.20 0.62 0.72
P (Hispanic =
white)
0.20 0.22 0.84
Panel D: By maternal education
Less than high
school
0.12 (0.20) 0.08 (0.18) 0.39* (0.19)
High school or
more
0.06 (0.09) 0.10 (0.08) 0.26** (0.08)
P (Less than high
school = high
school or more)
0.77 0.92 0.47
a
All results are reported using the specification including sibling fixed-
effects, and, all pre-treatment covariates. Subgroup estimates are obtained by
interacting the prenatal drinking effect with a full set of dummy variables for
each subgroup. Standard errors are in parentheses.

P < 0.1; *P < 0.05; **P < 0.01; ***P < 0.001.
Table 3. Effects of maternal alcohol use on infant behavioral outcomes and birth weight by levels of alcohol use using sibling fixed-effects model (n = 1618)
a
Positive mood
coefficient (SE)
Fearfulness
coefficient (SE)
Difficultness
coefficient (SE)
Low birth weight
b
marginal effect (SE)
No drinking (omitted category)
Light-to-moderate drinking 0.09 (0.09) 0.08 (0.08) 0.20** (0.06) 0.02 (0.02)
Heavy drinking 0.05 (0.18) 0.27 (0.16) 0.36* (0.18) 0.10* (0.05)
Prenatal smoking 0.08 (0.14) 0.28* (0.13) 0.15 (0.14) 0.08* (0.04)
In poverty status 0.10 (0.11) 0.10 (0.11) 0.03 (0.11) 0.04 (0.03)
Non-married during pregnancy (married omitted) 0.05 (0.15) 0.02 (0.14) 0.13 (0.14) 0.01 (0.04)
Divorced/separated during pregnancy 0.03 (0.14) 0.06 (0.13) 0.00 (0.14) 0.04 (0.04)
Prenatal care in first trimester 0.05 (0.08) 0.01 (0.08) 0.04 (0.08) 0.01 (0.02)
Child characteristics
First born 0.03 (0.07) 0.16* (0.07) 0.14* (0.07) 0.01 (0.02)
Male 0.04 (0.06) 0.09

(0.05) 0.01 (0.05) 0.01 (0.02)

a
All regressions also control for child age at the time of assessment, maternal age and a series of dummy variables of childs year of birth. Coefficients of
these variables are not reported for brevity.
b
Results were estimated by using the linear probability model (LPM) in the fixed-effects context. Results using fixed-effects logistic regressions show similar
patterns. For ease of comparison and interpretations, I report results from the linear probability model.

P < 0.1; *P < 0.05; **P < 0.01; ***P < 0.001.
654 Chen

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infant birth weight. Although occasional drinking during
pregnancy does not have an adverse effect on birth weight,
infrequent alcohol consumption produces a statistically sig-
nificant positive association with infant difficultness.
The present study has several limitations. First, by restrict-
ing the study subjects to children born between 1986 and
2000, the sample consists of infants born to relatively older
mothers. Women that have more education and come from
relatively higher socioeconomic strata tend to give birth at
older ages (Rindfuss and John, 1983). As a result, this sam-
pling strategy may provide a more conservative estimate of
the impact of maternal drinking during pregnancy than many
epidemiological surveys that sampled high-risk populations.
Second, results from the sibling-based analyses may not gen-
eralize to children without siblings. However, families with a
single child may not be the contemporary norm in the USA.
The total fertility rate per woman in the USA is approximate-
ly two and the predominant ideal family size in the USA is
made up of two to three children (Hagewen and Morgan,
2005). Results from sibling comparison are therefore still
relevant with regard to a large portion of the US population.
Third, the results from these analyses may not generalize to
different countries and societies. Fourth, the assessment of
maternal alcohol use during pregnancy in the NLSY was
based on frequency, which did not include information on
the amount of alcohol consumed on each occasion.
However, the magnitude of the association and the results
are consistent with previous research. Furthermore, explora-
tive analysis of the NLSY substance use data measured
during the non-pregnant period suggested a strong positive
association between frequency of alcohol use and amount of
alcohol consumption on each occasion. In fact, binge drin-
kers are among the most frequent drinkers. Prior episodes of
binge drinking also strongly relate to frequent alcohol con-
sumption while pregnant. Therefore, frequency of alcohol
use remains a meaningful indicator of the levels of maternal
alcohol use during pregnancy. Finally, maternal ratings of
infant behaviors are subjective, and thus may vary from
mother to mother. However, the sibling fixed-effects model
compared siblings behaviors that were rated by the same
mother, and therefore eliminated (or at least minimized) the
problem of different evaluative standards. Furthermore, some
child psychologists argue that maternal reports generally
provide valid and reliable measures of infant behaviors in
everyday life, and this may capture the infants behaviors
better than lab assessments that measure only a snapshot of
the childs behaviors in a contrived environment (Fox and
Henderson, 2000).
Limitations notwithstanding, this study makes several sig-
nificant contributions to the literature. Most importantly, the
sibling fixed-effects modeling technique removed potential
biases due to unmeasured time-invariant family-specific
characteristics. While the sibling model cannot fully account
for all unobserved heterogeneities, it provided better esti-
mates on the relationship between prenatal alcohol exposure
and temperamental outcomes than the traditional OLS
model. In addition, this study examined infant behavioral
outcomes. Longitudinal evidence has demonstrated a strong
link between difficultness and childhood problem behaviors,
which suggests a continuity of early problem behaviors. For
example, using data from a prospective longitudinal study,
Guerin et al. (1997) found that infants who scored high on
difficultness when they were 1.5 years old had higher ratings
of aggressive behaviors during school age, as rated by
parents and teachers. Another study by Keenan et al. (1998)
also found that a high level of difficultness measured
between 1 and 2 years of age was significantly associated
with boys internalizing problem behaviors and externalizing
problem behaviors by age 3. Thus, infant difficultness is a
strong predictor of behavioral problems in childhood, and
recent reviews of the literature show that infant difficultness
is an indicator of early behavioral problems, which can be
used to identify children at high risk for problem behaviors
(Bates et al., 1985; Frick and Morris, 2004). Findings from
this study thus broaden the scope of those obtained from
prior studies, and provide further evidence of a link between
prenatal drinking and offspring behavioral problems in early
periods of life. Moreover, this study investigated the differen-
tial susceptibility of prenatal drinking in infant behavioral
outcomes and birth weight. Results provide the very first evi-
dence, and partial support, of the relative sensitivity of infant
behavioral outcomes over birth weight using observational
data involving humans. Finally, this studys findings are
more generalizable than those obtained in prior clinical
studies, because the present results are based on a sample of
the offspring of women in a large national study, including
women from diverse social and economic backgrounds. In
terms of public health practices, the present study also pro-
vides information that may have significant implications for
public policy. Findings imply that interventions that aim to
reduce maternal drinking while pregnant may generate
improvements on childrens behavioral well-being. In add-
ition, given that a substantial proportion of Americans do not
consider light drinking during pregnancy to be hazardous
(MacKinnon et al., 1995), these findings also send an im-
portant message to the general public. Nevertheless, add-
itional studies are definitely needed to inform theories about
the etiology of child behavioral problems and provide neces-
sary information for public health campaigns.
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