Page Last Updated: October 10, 2025
APA Level 1 / Level 2🔗
pex_bm_apaConsideration of Mental Health Symptoms Experienced During Pregnancy
The co-occurrence of psychiatric symptoms and substance use during pregnancy is well-documented (Massey et al., 2011, Massey et al., 2012). Phenotypic risk in birthing parents may affect offspring neurodevelopment through both prenatal and postnatal mechanisms, beyond direct exposure alone (Estabrook et al., 2016, Massey et al., 2016, Massey et al., 2018). These factors may confound associations between exposures and neuroimaging or neurodevelopmental outcomes, but they also represent malleable targets for prevention and early intervention. When possible, incorporating parental mental health symptoms as covariates offers a robust strategy to account for these confounding influences.
Administration & Quality Control🔗
| Child Specific | No |
| Respondent | Pregnant Participant, Birth Parent, or Primary Caregiver |
| Administration | Self-administered in-person or remote |
| Visits | V01, V02, V03 |
| Completion Time | 5 min |
| Quality Control |
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Instrument Details🔗
The HBCD mental health screening instrument is a highly sensitive screening tool for use in community samples. It has two levels, adapted from DSM-5 Self-Rated Level 1 and Level 2 Cross-Cutting Symptom Measures:
Level 1 includes 1 - 2 questions for each of 11 mental health domains Depression, Anger, Mania, Anxiety, Somatic Symptoms, Suicidal Ideation, Psychosis, Sleep Disturbance, Memory, Repetitive Behaviors, Dissociation. This excludes Personality Functioning and Substance Use present in the original measure (SU is captured by a separate set of instruments for HBCD - see measures listed here). When symptoms were reported for Level 1, participants were subsequently administered corresponding Level 2 measures, which asked about additional symptoms Anger, Anxiety, Depression, Somatic Symptoms, Mania, Repetitive Thoughts, Sleep Problems associated with the following 8 mental health domains: Anxiety, Anger, Depression, Mania, Personality, Repetitive Behavior, Sleep, and Somatic symptoms. For HBCD, Level 2 symptom measures for Depression and Sleep Disturbance were replaced with the PROMIS Short Forms v1.0 Depression 8a questionnaire and Sleep Disturbance 8a. Level 2 additionally includes the Personality Inventory for DSM-5 Brief, which assesses 5 personality trait domains Negative Affect, Detachment, Antagonism, Disinhibition, Psychoticism.
Gating Modifications
Gating was adapted for the HBCD study population so that participants proceeded automatically to the Level 2 measure for Personality Inventory. In addition, all participants answered the Level 1 questions for Depression and Somatic Symptoms, but proceeded to Level 2 questions irrespective of answers. Future publications should be sure to acknowledge the removal of Level 1 and 2 Substance Use and the gating mechanisms for Personality Inventory, Depression, and Somatic Symptoms.
Clinical Alerts
This measure was modified to alert HBCD study staff if responses to the Level 1 APA self-harm question ('Thoughts of actually hurting yourself?') or Level 2 APA Depression questionnaire (items from 'I felt worthless' to 'I felt that nothing could cheer me up') exceed thresholds of 0 and 32, respectively.
Response Option Changes
For HBCD, the response option ‘Decline to answer’ was added to all questions. The response option ‘Don’t know’ was also included at the beginning of data collection, but was subsequently removed. Questions answered with ‘Decline to answer’ or ‘Don’t know’ are marked as missing.
Depression and Sleep
For Depression and Sleep, when any item responses are marked missing, the sum score is marked as missing.
Personality Inventory
For the Personality Inventory measure, the total sum and average scores are only calculated for the full scale; individual subscale scores are not provided. Data users interested in subscale scores should refer to Personality Inventory scoring procedures for instructions on calculating subscale scores.
Remaining Level 2 Measures
For the remaining Level 2 measures, sum scores are prorated when up to 25% of item responses are marked missing. If more than 25% of items are missing, the sum score is marked as missing. The following formula is used to generated a prorated score, with the answer rounded to the nearest whole number:
\[ \text{Prorated Score} = \left( \frac{\text{Sum of answered items}}{\text{Number of items answered}} \right) \times \text{Total number of items} \]
References🔗
Doss, R. A., & Lowmaster, S. E. (2022). Validation of the DSM-5 Level 1 Cross-Cutting Symptom Measure in a Community Sample. Psychiatry Research, 318, 114935. https://doi.org/10.1016/j.psychres.2022.114935
Estabrook, R., Massey, S. H., Clark, C. A. C., Burns, J. L., Mustanski, B. S., Cook, E. H., O’Brien, T. C., Makowski, B., Espy, K. A., & Wakschlag, L. S. (2016). Separating family-level and direct exposure effects of smoking during pregnancy on offspring externalizing symptoms: Bridging the behavior genetic and behavior teratologic divide. Behavior Genetics, 46(3), 389–402. https://doi.org/10.1007/s10519-015-9762-2
Massey, S. H., Lieberman, D. Z., Reiss, D., Leve, L. D., Shaw, D. S., & Neiderhiser, J. M. (2011). Association of clinical characteristics and cessation of tobacco, alcohol, and illicit drug use during pregnancy. The American Journal on Addictions. https://doi.org/10.1111/j.1521-0391.2010.00110.x
Massey, S. H., Mroczek, D. K., Burns, J. L., Clark, C. A. C., Espy, K. A., & Wakschlag, L. S. (2018). Positive parenting behaviors in women who spontaneously quit smoking during pregnancy: Clues to putative targets for preventive interventions. Neurotoxicology and Teratology, 67, 18–24.https://doi.org/10.1016/j.ntt.2018.02.003
Massey, S. H., Neiderhiser, J. M., Shaw, D. S., Leve, L. D., Ganiban, J. M., & Reiss, D. (2012). Maternal self concept as a provider and cessation of substance use during pregnancy. Addictive Behaviors, 37(8), 956–961. https://doi.org/10.1016/j.addbeh.2012.04.002
Massey, S. H., Reiss, D., Neiderhiser, J. M., Leve, L. D., Shaw, D. S., & Ganiban, J. M. (2016). Maternal personality traits associated with patterns of prenatal smoking and exposure: Implications for etiologic and prevention research. Neurotoxicology and Teratology, 53, 48–54. https://doi.org/10.1016/j.ntt.2015.11.010
Roche, M. J., Pincus, A. L., & Cole, P. E. (2019). Linking dimensions and dynamics in psychopathology research: An example using DSM-5 instruments. Journal of Research in Personality, 82, 103852. https://doi.org/https://doi.org/10.1016/j.jrp.2019.103852