The relationships among MAOA, COMT Val158Met, and 5‐HTTLPR polymorphisms, newborn stress reactivity, and infant temperament

Abstract Introduction Variance in hypothalamic–pituitary–adrenal (HPA) axis reactivity is considered to be one of the sources of differences in infant temperament. The cortisol enters into interactions with dopamine and serotonin, so it is expected that polymorphisms in genes coding monoamine metabolism influence both HPA axis reactivity and temperament. Methods We therefore explore the relationship among 5‐HTTLPR S/L, MAOA H/L, and COMT Val158Met polymorphisms, the stress reaction of newborn infants after a heel stick blood draw (measured by determining salivary cortisol at three time points), and temperament assessed at the age of 3 months using Rothbart's Infant Behavior Questionnaire—Revised (IBQ‐R) with a sample of 84 infants. Results The decrease in the salivary cortisol correlated with nine primary scales and all three secondary scales of IBQ‐R. Children with a greater cortisol decrease were assessed as less susceptible to negative emotions, more extraverted, and more regulated. The polymorphisms that were observed were related both to the course of the stress reaction and to temperament. The 5‐HTTLPR S allele was connected to higher scores for Negative Emotionality and lower scores for Orienting/Regulatory Capacity. The presence of the MAOA L allele predisposed its carriers to higher scores for Negative Emotionality, lower scores for Orienting/Regulatory Capacity, and a lower decrease in cortisol. The Met allele of COMT Val158Met polymorphism was connected to a higher Positive Affectivity/Surgency and Orienting/Regulatory Capacity and a greater cortisol decrease. Conclusions Contrary to previous studies referring mainly basal cortisol and its increase, the results of our study emphasize the importance of cortisol elimination in infant temperament. Another interesting finding was a higher cortisol increase, higher Distress to Limitations, Negative Emotionality, and Approach in MAOA LL homozygotes which are traditionally understood as more vulnerable toward early stress in developing later externalizing behavior.


| INTRODUC TI ON
Temperament is a highly inherited, biologically given, and relatively stable part of personality, and it manifests itself early in life (Goldsmith et al., 1987). Theoretists differ in what they include into the concept. While Thomas and Chess limit it to traits that determine formal characteristics of behavior, Goldsmith and Campos understand temperament as individual differences in the probability of experiencing, expressing and regulating the primary emotions (Goldsmith et al., 1987). Rothbart provides perhaps the most comprehensive and influential theory: It comprises of both the formal characteristics of behavior and predispositions not only to primary emotions but also to other particular responses (orienting and motor reactions). Apart from differences in behavior, she also includes differences in phenomenological experience and psychophysiological functioning into her definition. In Rothbart's words, temperament is defined as "relatively stable, primarily biologically based individual differences in reactivity and self-regulation" (Rothbart & Derryberry, 1981, p. 40). Rothbart's first instrument for measuring temperament (Infant Behavior Questionnaire) was originally derived from nine temperamental traits resulting from the New York Longitudinal Study, to whom she added unipolar scales for fear, frustration, and positive affect. Subsequent factor analyses yielded three secondary factors of surgency, negative affect, and self-regulation.
From a Rothbart's broad point of view, variations in threshold, latency, intensity, rise time, and the recovery of physiological responses to stress are part of the temperamental reactivity which is further modulated by self-regulatory processes such as attention, approach, avoidance, and inhibition (Rothbart & Derryberry, 1981).
While the sympathetic-adrenomedullary (SAM) system is responsible for the quick reaction to environmental challenges (the fight or flight response), HPA axis is generally considered to be crucial to the later phases of coping with stress. Cortisol, the HPA's product, functions to increase the blood glucose level needed to supply the organism's heightened requirements while at the same time dampens the energetically demanding immune response. Cortisol is also a gene transcription factor, so it changes the expression of numerous genes that are essential to neural plasticity and therefore is considered as significant for the role of key player in the early development (Gunnar, Doom, & Esposito, 2015). Through its effects on the nervous system, cortisol changes the way the organism responds to similar stressors in the next encounter (Sapolsky, Romero, & Munck, 2000). Extreme forms of environmental challenges (loss of the parent, maltreatment) leads to a dysregulation of HPA axis function (in both direction of hypo and hyper functioning; Morris, Compas, & Garber, 2012;Tyrka et al., 2008).
The differences in both basal and reactive cortisol levels are regarded as one of the sources of temperamental variability. With regard to temperament, three higher order factors are supposed to be differently related with cortisol reactivity. In preschoolers, higher cortisol (both basal and reactive) is connected to a higher propensity to negative emotions, in particular fear (Kagan, Reznick, & Snidman, 1987;Smider et al., 2002;Talge, Donzella, & Gunnar, 2008).
However, Gunnar (1994) hypothesized that elevated cortisol levels occur because surgent, exuberant children are much more likely to enter stressful encounters with peers and adults. Regarding effortful control in relation to basal or reactive cortisol levels, negative associations were generally found (Turner-Cobb, Rixon, & Jessop, 2008). Even though thoroughly studied and satisfactorily explained in the preschool period, there is more ambiguity in these results of studies regarding the relationship between cortisol stress response and early temperament below three years of age. It is not clear whether a more intense cortisol reactivity is related to higher (Blair et al., 2008;Van Bakel & Riksen-Walraven, 2004) or lower (Beijers, Riksen-Walraven, & Weerth, 2012;Gunnar, Porter, Wolf, Rigatuso, & Larson, 1995) propensity for negative emotions or whether these variables are unrelated to each other (White, Gunnar, Larson, Donzella, & Barr, 2000).
On one hand, HPA axis reactivity is a genetically determined part of temperament, and on the other hand, HPA axis itself is largely shaped by early experiences with stress and concurrent social support (Gunnar et al., 2015), resulting in the relatively stable patterns of coping. Because of its initial setup through environmental influences, it is considered in a role of mediator between genetic predispositions, early experiences, and developmental outcomes (Gottlieb & Halpern, 2002;Pariante & Lightman, 2008). For example, in an extensive review (Bornstein, Schuppenies, Wong, & Licinio, 2006), HPA axis reactivity was placed into the role of a mediator between genetic and environmental influences and the consequent development of depression and obesity.
Besides HPA axis variability, differences in the metabolism of dopamine and serotonin are other important factors in the biological underpinnings of temperament. Nevertheless, dopamine and serotonin enter in bidirectional relations with the physiology of the HPA axis as well, so we may expect polymorphisms in genes coding monoamine metabolism to influence both temperament and HPA axis.
5-HTTLPR insertion/deletion polymorphism in a regulatory sequence of the serotonin transporter gene gives a short and long version of the gene. The short version of the gene is connected with a lowered expression of the serotonin transporter and a lowered reuptake of serotonin into the presynaptic neuron (Greenberg et al., 1999) presumably resulting in heightened HPA-axis reactivity (Miller, Wankerl, Stalder, Kirschbaum, & Alexander, 2013), anxiety (Sen, Burmeister, & Ghosh, 2004), and depression (Caspi et al., 2003) in S K E Y W O R D S 5-HTTLPR, COMT, gene polymorphisms, HPA axis reactivity, infant temperament, MAOA carriers. In infants, there has been only one study of genetic underpinning of the HPA stress reaction; it indicates that newborns with the 5-HTTLPR SS genotype showed a significantly higher endocrine response after a heel prick when compared with newborns with the LL or SL genotype (Mueller, Brocke, Fries, Lesch, & Kirschbaum, 2010). With regard to the relationship between 5-HTTLPR polymorphism and infant temperament, S allele has been given into connection to negative emotions proneness (Auerbach et al., 1999), sensitivity to maternal anxiety during pregnancy (Pluess et al. (2011), and lower positive affect (Grossmann et al., 2011).
The main role of monoamine oxidase A (MAO-A) is thought to be in degrading serotonin following its re-uptake by the serotonin transporter from the synaptic cleft, although it is also capable of degrading both norepinephrine and dopamine. It is encoded by the MAOA gene, and the common VNTR polymorphism in a promoter region results in higher or lower enzyme activity (Sabol, Hu, & Hamer, 1998). A more active form of the MAOA gene has been given into connection to depression (e.g., Younger et al., 2005), and the low-activity allele is considered in relation to a higher level of aggression (McDermott, Tingley, Cowden, Frazzetto, & Johnson, 2009) and antisocial behavior in men with a history of early maltreatment (Caspi et al., 2002). In infants, a less active form of the gene in the interaction with aversive events during prenatal development predicted higher levels of negative emotionality (Hill et al., 2013), and a more active genotype was connected to higher self-regulation in girls (Zhang et al., 2011).
Catechol-O-methyltransferase (COMT) is one of several enzymes that degrade catecholamines (such as dopamine, epinephrine, and norepinephrine). A common functional polymorphism in the COMT gene which is the result of G to A mutation that translates into valine (val) to methionine (met) substitution at codon 158 has been shown to account for a fourfold decrease in enzyme activity (Lachman et al., 1996). COMT plays an important role in the degradation of dopamine in the prefrontal cortex, and thus, Val158Met polymorphism is believed to influence executive functions in favor of met carriers (Barnett, Jones, Robbins, & Müller, 2007;Bruder et al., 2005; with the possible implications for self-regulatory capacity).
Somewhat contradictory, the met allele has been given into relation to the ability to experience reward in the flow of daily life (Wichers et al., 2008) but at the same time also to a more intensive reaction to an aversive stimulus (Jensen, Lonsdorf, Schalling, Kosek, & Ingvar, 2009;Smolka et al., 2007) and to a lesser capacity to regulate this response (Bishop, Cohen, Fossella, Casey, & Farah, 2006). Data on infant populations showed a greater sensitivity to fear expression but at the same time an easier recovery from negative emotions in met carriers (Grossmann et al., 2011). Sheese, Voelker, Posner, and Rothbart (2009) found a higher level of positive emotions in 6-month-old val/met heterozygotes compared to both homozygote groups.
Differences in infant temperament fundamentally influence parental adjustment, parenting, and developmental outcomes (Kiff, Lengua, & Zalewski, 2011). To gain an understanding of early temperamental display, it is critical to pay attention to its biological and genetic underpinnings. The aim of our study was to explore the relationships between the genetic polymorphisms 5-HTTLPR ins/ del, MAOA H/L, and COMT Val158Met, the reaction of a newborn to a heelstick blood draw measured by the determination of salivary cortisol, and temperament at three months as rated by mothers in IBQ-R.
The first partial aim of our study is to show whether newborn stress reactivity is related to the later temperament of an infant. A heelstick blood draw three days after delivery provides a unique chance to measure the reaction to a highly aversive stimulus very shortly after birth. Even though studies on this topic have already been carried out, they are just a few in number and their results are contradictory.
The second partial aim of our study is to explore the genetic dispositions of the reaction to stress in neonates as well as infant temperament. To our knowledge, there is only one study of the genetic underpinnings of newborn reaction to stress, and thus, our results are genuinely new in this respect. There are more studies of the genetic background of temperament, but they are certainly not abundant.
The third partial aim of the study was to show whether the genetic influence on temperament is mediated by newborn stress reactivity. To the best of our knowledge, our study is the first one to explore all three variables in an infant sample and thus enables us to test the hypotheses of mediation.

| Participants
One hundred physiological newborns and their mothers were recruited in the Department of Neonatology in the Ceske Budejovice Cortisol was analyzed by the second author of the publication.
The samples were assayed for cortisol using a commercially available EIA kit (expanded range high-sensitivity salivary cortisol EIA kit, Salimetrics LLC, PA, USA) without any modification to the manufacturer's protocol (Salimetrics, State College, PA). The test had average intra-and interassay coefficients with a variation of 3.5% and 4.2%, respectively.
Cortisol increase was defined as the difference between Peak and Basal (Peak minus Basal), while cortisol decrease was defined as the difference between Peak and Recovery (Peak minus Recovery).

| Infant temperament at three months
Rothbart's Infant Behaviour Questionnaire (IBQ-R; Gartstein & Rothbart, 2003) was translated into the Czech language and administered to mothers when their infants were three months old.
The IBQ-R represents a 191-item parent-report instrument derived from Rothbart's definition of temperament (Rothbart, 1981 see Huisman, 2000) and was generally similar to the alpha values reported by Gartstein and Rothbart (2003). Table 3 presents the descriptive statistics of the IBQ-R scales and salivary cortisol.

| Missing values
All the children whose mothers did not fill in IBQ-R (16 children) were excluded from further analysis. Neither those children nor their mothers differed from the rest of the group in their demographic characteristics. The final sample consisted of 84 newborns (56% boys, 44% girls). In 15 of these 84 children, cortisol data are missing because the amount of saliva needed for salivary cortisol analysis that was collected was insufficient. cortisol diurnal rhythm is not established at this early age (Santiago, Jorge, & Moreira, 1996), the time of the procedure was not considered as a variable. Before the first saliva collection, 72.6% of the children were sleeping and 27.4% were awake. These two groups did not differ statistically in any of the cortisol values (all p > .122). 11 infants (13%) were born by Caesarean section. They did not differ significantly from vaginally delivered babies in any of the cortisol measures (all p > .370).

| Statistical analyses
The gender of the child was not related to the course of stress reaction (all p > .133). Figure 1 shows means and standard deviations of salivary cortisol before, 20 min after, and 45 min after the heelstick blood draw.

| IBQ-R scales
None of the IBQ-R scales was related to a child's gender (all p > .087)  In our opinion, the aforementioned findings show the extent to which the inborn characteristics of the course of the HPA axis reaction (mainly the rapidity of cortisol elimination and the effectivity of the negative feedback loop) contribute to early behavioral differences in infants. We propose that the quick decrease of cortisol after its culmination after an aversive stimulus is the part of biological predisposition to extraversion and regulation, and conversely, the slower decrease of cortisol undergrids the propensity to negative emotions.

| The relationship among newborn stress reactivity and temperament at three months
Our assumption is rather in agreement with studies of preschool and school children in which the higher cortisol (both basal and reactive) is considered to be a symptom of HPA axis dysregulation and a source of negative emotionality and less effective self-regulation (Dettling, Gunnar, & Donzella, 1999;Gunnar et al., 1997;Kagan et al., 1987;Pérez-Edgar, Schmidt, Henderson, Schulkin, & Fox, 2008;Smider et al., 2002;Talge et al., 2008). In infant studies actually, the results of concurrent studies are far less clear-cut and sometimes in contradiction with the interpretation of our results. In the only study of the relation between the reaction of a newborn infant to the stress caused by a heelstick blood draw and temperament measured by IBQ-R (Gunnar et al., 1995), the peak correlated negatively with Distress to Limitations at six months. The authors deduced that the ability to react intensively to an aversive stimulus reflects better neurobehavioral organization. In a similar way, the results of study of Beijers et al. (2012) showed that a lower score for Negative Emotionality measured by IBQ-R at three and six months predicted a higher cortisol reactivity at one year of age. In agreement with our assumption, we can name the results of two studies carried out on toddlers; in Gunnar et al. study (Gunnar, Larson, Hertsgaard, Harris, & Brodersen, 1992), Distress to Limitations and the negative affect in nine-month-old infants observed in the laboratory correlated positively with a subsequent cortisol reaction to separation from the mother, while the observed positive affect correlated negatively. Another study in which higher cortisol reactivity was related to negative emotionality was conducted on infants and toddlers in F I G U R E 1 The course of HPA axis reaction; this figure illustrates means and standard deviations of salivary cortisol levels before (Basal), 20 min after (Peak), and 45 min after (Recovery) heelstick blood draw institutional care; shy children showed a higher increase in afternoon cortisol (Watamura, Donzella, Alwin, & Gunnar, 2003).
A comparison of our results is impeded by the fact that most of studies on infants, toddlers, and preschool children refer to basal cortisol or cortisol reactivity (peak and increase). As a consequence, we do not have that many results to support or contradict our hypotheses of cortisol recovery importance for temperament. Two studies referring cortisol decrease (Blair et al., 2008;Kagan et al., 1987) basically indicate that the propensity to negative emotions was related to a more pronounced HPA axis reaction (higher increase followed by higher decrease of salivary cortisol). Since we did not consider increase and decrease together in our study, it is again difficult to compare the results and interpret them in light of these two studies.
Even without the relevant literature to compare, our results regarding the importance of cortisol elimination are in agreement with the assumption derived from the HPA axis physiology-a quicker elimination of cortisol leads to a quicker recovery from stress. The capacity to regulate potentially harmful prolonged cortisol activation is key for extraversion and regulation, and accordingly, the lack of this capacity undergrids propensity to negative emotionality.

| Genetic disposition to stress reaction and temperament
The Kruskal-Wallis test with two degrees of freedom was used for testing the relationships between genetic polymorphism, salivary cortisol, and the IBQ-R scales. Tables  prolonged activation of neural pathways predisposes them for negative emotions propensity and lessened regulation. Surprisingly, we did not find any relation between 5-HTTLPR polymorphism and the course of stress reaction, contrary to the conclusions of meta-analyses of studies on adult populations (Miller et al., 2013) and the only study of newborns (Mueller et al., 2010), which both show more intensive cortisol reactivity in SS homozygotes. The missing link between 5′-HTTLPR polymorphism and the course of stress reaction in our results also contradicts the assumption following from the role of serotonin in HPA axis activation (Cassano, & D'mello, 2001) and negative feedback control (Lowry, 2002 (Hill et al., 2013;Zhang et al., 2011). But to the best of our knowledge, no existing study showed higher surgency in HH homozygotes seen in our study (even though the size effects were relatively smaller compared to the two other remaining secondary scales). Nonetheless, MAOA is involved in dopamine metabolism, and thus, its connection to variability in surgency may be assumed.
HH homozygotes had a statistically lower increase in cortisol than LL homozygotes and a statistically higher decrease in cortisol compared to HL carriers. Given the above-reported role of cortisol decrease in temperament, we may assume that lower negative emotions, higher self-regulation, and surgency in HH carriers are at least partly the result of their greater ability to downregulate cortisol after culmination of HPA stress response. In previous research, the L allele carriers were found to be more predisposed to impulsivity and aggressiveness (Manuck, Flory, Ferrell, Mann, & Muldoon, 2000), and at the same time, more vulnerable toward aversive environmental influences in subsequent development of impulsive and aggressive behavior (Caspi et al., 2002;Eisenberger, Way, Taylor, Welch, & Lieberman, 2007;Frazzetto et al., 2007;Kim-Cohen et al., 2006). Thus, it is of interest that in our study, LL genotype connected both higher sensitivity to aversive stimulus (higher increase of cortisol compared with HH homozygotes) and temperamental precursors of potential externalizing problems (the highest Distress to Limitations and Negative Emotionality and the higher Approach significantly compared to HL). Taken into account that very plastic HPA axis is molded by early experiences and mediates their influence on consequent development, we accordingly suggest that the HPA axis Capacity and, more robustly, to cortisol decrease. Met/met carriers got higher scores for Approach, High Intensity Pleasure, and Positive Affectivity/Surgency in comparison with val/val carriers.

F I G U R E 3
Post hoc analysis of Kruskal-Wallis test; direction of > signs denotes the direction of inequality between groups, their number denotes statistical significance of p after Bonferroni correction: ">"p < .05; ">>"p < .01; ">>>"p < .001; ">>>>"p < .0001. Important relationships are highlighted by colored rectangles Besides hypothetical suppositions resulting from the role of dopamine in temperament, most of our findings summed up above concur with those of existing studies of the child population. The connection between met allele and Falling Reactivity has been found in Grossmann et al. (2011) study of seven-month-old infants.
The relationship between COMT polymorphism and positive emotionality reported above was previously shown in a study of infants (Sheese et al., 2009). Nevertheless, in this study, six-month-old met/val heterozygotes had the highest positive emotionality, while in our study, met/met homozygotes had higher scores compared to val/val homozygotes. Our finding that the met allele was related to Duration of Orienting and Orienting/Regulatory Capacity in favor of met carriers is also in agreement with the existing literature. A longer attention span and lower distractibility of met carriers were shown in a study of nine-month-old infants (Holmboe et al., 2010).
In a different study (Markant, Cicchetti, Hetzel, & Thomas, 2014), seven-month-old met carriers got higher scores for Duration of Orienting and higher behavioral regulation.
Our findings of a positive relationship between the met allele and Approach are in contradiction to the only study referring to significant relationships between these variables at an early age. In their already-cited study, Markant et al. (2014) showed that seven-monthold val carriers reached for a new toy more quickly and had a higher Approach. In children, adolescents, and adults, results concerning this connection are mixed; in a minority of studies, the val allele indicated a predisposition to impulsivity (Eisenberg et al., 1999;Wagner et al., 2010), while in a majority, it was the met allele (Bellgrove et al., 2005;Kreek, Nielsen, Butelman, & LaForge, 2005;Paloyelis, Asherson, Mehta, Faraone, & Kuntsi, 2010). It is also possible that the ambiguity of the findings results from the intervening variable of self-regulation. If-in compliance with our results-the met allele was a predisposition for both impulsivity and self-regulation, the relationship between the met allele and the resulting behavior would not be direct, since the degree of control of behavior is influenced by both impulsivity and control capacity.

| HPA axis reactivity as a mediating variable of the influence of genetic polymorphism on early temperament
In COMT and MAOA polymorphisms, all three variables (gene polymorphisms, newborn stress reactivity, and temperament at three months) were related to each other, and thus, we tested the mediating role of stress reactivity in the relationship between gene polymorphisms and temperament. We tested the assumption that the influence of COMT and MAOA polymorphism on infants' temperament at three months is mediated by their inborn stress reactivity.
We used a series of regression analysis to test this assumption according to the procedure of Baron and Kenny (1986).
The number of alleles of the polymorphisms that were examined was considered as a predictor. The decrease in cortisol was a media-  (Chen et al., 2004); it results in a higher release of prefrontal dopamine and its slower degrading (Yavich, Forsberg, Karayiorgou, Gogos, & Männistö, 2007), while a higher amount of prefrontal dopamine leads to the more effective termination of a stress reaction (Sullivan & Dufresne, 2006), which is a basis for extraversion (Blair, Peters, & Granger, 2004;Kontoangelos et al., 2015).

| S TRENG TH S AND LIMITATI ON S
A strong point of our study is the fact that it was carried out at a very early infant period and thus enabled us to follow the variables that are significantly less influenced by later developed self-regulating capacities that could complicate the relationship between genetic disposition to temperamental reactivity and its phenotypic display. Although there are studies that survey the relationship between genetic polymorphism and temperament and between salivary cortisol and temperament, there is no other study that measured all three variables at once. This allowed us to test the mediation hypotheses.
The vigor of the results presented here is limited by the self-selection sampling strategy. Particularly in IBQ-R data, we can expect that it could be different in those mothers who agreed to take part in the study and in those mothers who refused. However, during the statistical control of demographic variables, the relationships that were found were rather marginal.
Another limiting factor could be that the IBQ-R questionnaire was administered at three months, when the infant's emotional displays are not fully differentiated and the lack of locomotion reduces the amount of behavior from which temperament could be inferred. For instance, we cannot yet observe fear of strangers at three months; it could have contributed to the fact that we did not find significant relationships between any variable and Fear, which is otherwise largely biologically and genetically determined, with very well observable and measurable displays.
The statistical operations with cortisol were limited because of missing data; in samples of fifteen children, we did not collect enough saliva to run the following analyses. Nevertheless, this problem is quite typical in infant salivary cortisol research (Kirschbaum & Hellhammer, 1994).

| CON CLUS I ON AND FURTHER DIREC TIONS
In our study, we were mapping a part of the genetic and biological underpinning of early temperament. Extraversion was connected to a greater cortisol decrease and to the presence of met COMT and the high-activity MAOA allele; negative emotionality was linked to a lower decrease in cortisol and to the occurrence of S 5-HTTLPR and L MAOA and regulation was associated with a greater cortisol decrease and the presence of met COMT, H MAOA, and the L 5-HTTLPR allele. We were also able to follow the genetic foundation of the stress reaction in newborn children and since there is only one other study concerning this topic our findings are promising with regard to further research. For instance, the statistically highest increase in MAOA LL homozygotes is interesting, taking into account the fact that childhood trauma (potentially leading to HPA dysregulation) has the worst impact (quantified by the amount of antisocial behavior) in male LL carriers (Caspi et al., 2002). The connection of the met allele with a higher cortisol decrease is again relatively pioneering considering the role of dopamine in HPA negative feedback and this hypothesis deserves scientific verification.
And, last but not least, it would be interesting to follow the logic of testing the hypotheses of HPA axis reactivity as a mediator between genetic polymorphisms and temperament.

CO N FLI C T O F I NTE R E S T
None declared.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.