Maternal depression and child Maternal depression and child developmentdevelopment

Pediatric Child HealthPediatric Child Health

ContentContent

Objective.Objective. Introduction.Introduction. Definitions.Definitions. Effects on Development.Effects on Development. Treatment Recommendations.Treatment Recommendations.

ObjectivesObjectives To review the present knowledge on the To review the present knowledge on the

consequences of maternal depression on consequences of maternal depression on the development of children at various the development of children at various ages;ages;

To review the evidence-based literature on To review the evidence-based literature on the treatment of maternal depression and the treatment of maternal depression and its impact on newborns, infants and its impact on newborns, infants and children; andchildren; and

To review the role of the child’s physician in To review the role of the child’s physician in the detection of symptoms of maternal the detection of symptoms of maternal depression, and the coordination of depression, and the coordination of appropriate support and management.appropriate support and management.

IntroductionIntroduction Postpartum blues is a relatively Postpartum blues is a relatively

common emotional disturbance common emotional disturbance with crying, with crying, confusion, confusion, Mood lability, anxiety and depressed mood.Mood lability, anxiety and depressed mood.

The symptoms appear during the first The symptoms appear during the first week postpartum, last for a few hours week postpartum, last for a few hours to a few days and have few negative to a few days and have few negative sequelaesequelae

IntroductionIntroduction

““Normal” transient, emotional response – up to 85% of women, peak day 3-5

Depressed in the 1st week after delivery– 20-40% major depression in the 1st year pp– Significant increase risk for PPD at 4-8weeks (Teissèdre

&Chabral, 2004)

• Present in father (day 1-2)– co-morbidity in parents

• Impaired bonding – associated with “blues”– I feel trapped, my baby cries too much, I wish my baby would

somehow go away, I feel happy when my baby smiles and laughs, my baby irritates me, I resent my baby, my baby is the most beautiful baby in the world (Edborg, 2005)

awareness, early identification & interventionawareness, early identification & intervention

Postpartum BluesPostpartum Blues

DefinitionsDefinitions

Postpartum psychosis refers to a severe disorder Postpartum psychosis refers to a severe disorder beginning within four weeks postpartum, with beginning within four weeks postpartum, with delusions, hallucinations and gross impairment in delusions, hallucinations and gross impairment in functioning.functioning.Postpartum depression begins in or extends into the Postpartum depression begins in or extends into the postpartum period and core features include dysphoric postpartum period and core features include dysphoric mood, fatigue, anorexia, sleep disturbances, anxiety, mood, fatigue, anorexia, sleep disturbances, anxiety, excessive guilt and suicidal thoughts.excessive guilt and suicidal thoughts.The diagnosis requires that symptoms be present The diagnosis requires that symptoms be present for at least one month and result in some impairment for at least one month and result in some impairment in the woman’s functioningin the woman’s functioning

Postpartum Depression-PPDPostpartum Depression-PPD

• Major depression Major depression – Psychosis, infanticide, homicidePsychosis, infanticide, homicide

• 60% women experience their 160% women experience their 1stst major depression major depression PPPP

• Idealization of birth & motherhoodIdealization of birth & motherhood• Feeling inadequate, lack of social support, Feeling inadequate, lack of social support,

primip>30 primip>30 (Beck, 2001; Fergerson, 2002)(Beck, 2001; Fergerson, 2002)

• Hormones, thyroid, cholesterol, anemia, stressHormones, thyroid, cholesterol, anemia, stress

(Eberhard-Gran et (Eberhard-Gran et al. 2002;Oates, al. 2002;Oates,

2003)2003)DepressionDepression PsychosisPsychosis

GeneralGeneral 10-15%10-15% 0.1-0.2%0.1-0.2%

TeensTeens 26%26%

High-riskHigh-risk >35%>35% 8% suicidal8% suicidal

Postpartum Depression-PPDPostpartum Depression-PPD

Risk FactorsRisk Factors

A history of mood disorders,A history of mood disorders, Depression symptoms during the Depression symptoms during the

pregnancy, pregnancy, And a family history of psychiatric And a family history of psychiatric

disorders. disorders.

Depression in pregnancy does Depression in pregnancy does notnot

predict Postpartum depressionpredict Postpartum depressionin individual women in individual women

butbut Up to 66% of women depressed Up to 66% of women depressed in pregnancy go on to have PPDin pregnancy go on to have PPD

andand Is a disease unto itselfIs a disease unto itself

FetusFetusCortisol Cortisol “the stress hormone”“the stress hormone” • Fetal and maternal endocrine levels are Fetal and maternal endocrine levels are

correlatedcorrelated– Hypercortisolaemia affects gluccocorticoid receptors Hypercortisolaemia affects gluccocorticoid receptors

in fetal brain in fetal brain CHR, ACTHCHR, ACTH

• FHR FHR 35 wks+35 wks+

variability variability rate / contradicted in one study rate / contradicted in one study– Habituation and dishabituation decreased, delayed in Habituation and dishabituation decreased, delayed in

depressed depressed

• Uterine irritabilityUterine irritability resistance in blood vessels to the uterus resistance in blood vessels to the uterus blood flow to the baby- IUGRblood flow to the baby- IUGR pre-term deliverypre-term delivery

(Austin, 2005; O’keane, (Austin, 2005; O’keane, 2005;Teixeira,1999; Zuckerman, 1990)2005;Teixeira,1999; Zuckerman, 1990)

Stress

Hypothalamic-pituitary-adrenal (HPA) Hypothalamic-pituitary-adrenal (HPA) axisaxis

• Chronic dysregulation affects neural functionChronic dysregulation affects neural function• Estrogen/HPA are intertwinedEstrogen/HPA are intertwined

– ↑↑depression ↓fertilitydepression ↓fertility

HPA-placental neuroendocrine axisHPA-placental neuroendocrine axis• Maternal stress affects fetal developmentMaternal stress affects fetal development• Sustained HPA dysregulation and stress Sustained HPA dysregulation and stress

reactionreaction• Neuronal death & abnormal development of Neuronal death & abnormal development of

fetal brainfetal brain• Altered performance on neuromotor tests, Altered performance on neuromotor tests,

ability to copeability to copemonkeys, rats: no reason to expect different in monkeys, rats: no reason to expect different in

humanshumans (Austin, 2005; O’keane & Scott, 2005; Glover et al, 2002)(Austin, 2005; O’keane & Scott, 2005; Glover et al, 2002)

TABLE 1Consequences of maternal depression

Prenatal Inadequate prenatal care, poor nutrition, higher preterm birth, low birth weight,pre-eclampsia and spontaneous abortion

InfantBehavioural: Anger and protective style of coping, passivity, withdrawal, self-regulatory behaviour, and dysregulated attention and arousal Cognitive: Lower cognitive performance

ToddlerBehavioral: Passive noncompliance, less mature expression of autonomy, internalizing and externalizing problems, and lower interactionCognitive: Less creative play and lower cognitive performance

School ageBehavioral: Impaired adaptive functioning, internalizing and externalizing problems, affective disorders, anxiety disorders and conduct disordersAcademic: Attention deficit/hyperactivity disorder and lower IQ scores

AdolescentBehavioral: Affective disorders (depression), anxiety disorders, phobias, panic disorders, conduct disorders, substance abuse and alcohol dependenceAcademic: Attention deficit/hyperactivity disorder andlearning disorders

INFANT DEVELOPMENTINFANT DEVELOPMENT

Mother-infant interactionMother-infant interaction Regulation of interactionRegulation of interaction

Withdrawal. (disengaged, Withdrawal. (disengaged, unresponsive, affectively flat and do unresponsive, affectively flat and do little to support the infant’s activity.)little to support the infant’s activity.)

Intrusiveness.( hostile affect, and Intrusiveness.( hostile affect, and disrupt the infant’s activity.)disrupt the infant’s activity.)

Effects on NewbornEffects on Newborn– ↑ ↑ risk of prrisk of preterm deliveryeterm delivery– ↑↑NICU admissionNICU admission

Effects of depression and/or Effects of depression and/or antidepressantsantidepressants

– Lower Apgar scoresLower Apgar scores– Lower birth weight/IUGRLower birth weight/IUGR

↓ ↓ weight gainweight gain– ↓ ↓ NBASNBAS– Less breastfeedingLess breastfeeding

PPDSGPPDSG– ↑↑ Failure to thriveFailure to thrive– Smaller head circumferenceSmaller head circumference (Chung, 2001; Murray,

2003)

Effects on babies…Effects on babies…

• Less developed motor tone Less developed motor tone – ↓↓ activity levelsactivity levels

• More withdrawnMore withdrawn• Cry excessively, irritable, less Cry excessively, irritable, less

consolableconsolable• ↓ ↓ expressivity and imitative behavior expressivity and imitative behavior

– Negative expressionNegative expression• ↑↑ SIDSSIDS• Effects of lifestyle Effects of lifestyle

– alcohol ?FASD, smoking, poor diet alcohol ?FASD, smoking, poor diet etc.etc. (Murray, 2003; Zuckerman, 1989)(Murray, 2003; Zuckerman, 1989)

INFANT DEVELOPMENTINFANT DEVELOPMENT

Cognitive developmentCognitive developmentpatterns of dysregulated attention and patterns of dysregulated attention and

arousal.arousal. Two factor:Two factor:

Depressed mothers are less likely to offer Depressed mothers are less likely to offer contingent stimulation to their infants.contingent stimulation to their infants.

negative affect shown by infants of negative affect shown by infants of depressed mothers, even when they are depressed mothers, even when they are interacting with non depressed adults.interacting with non depressed adults.

TODDLERS AND TODDLERS AND PRESCHOOLERSPRESCHOOLERS

Behavioral development.Behavioral development.less attentiveness and less attentiveness and

responsiveness to their children’s responsiveness to their children’s needs.needs.

Poor models for negative mood Poor models for negative mood regulation and problem solving.regulation and problem solving.

depressed mothers were less likely to depressed mothers were less likely to set limits on their children and to set limits on their children and to follow through if they did set limits.follow through if they did set limits.

TODDLERS AND TODDLERS AND PRESCHOOLERSPRESCHOOLERS

Children response:Children response:More passively noncompliant, with less More passively noncompliant, with less

mature expressions of age-appropriate mature expressions of age-appropriate autonomy. autonomy.

More vulnerable, and having more More vulnerable, and having more internalizing (depressed) and externalizing internalizing (depressed) and externalizing problems (aggressive and destructive), which problems (aggressive and destructive), which are associated with lower interaction ratings are associated with lower interaction ratings

More likely to respond negatively to friendly More likely to respond negatively to friendly approaches, more likely to engage in low-level approaches, more likely to engage in low-level physical play and less likely to engage in physical play and less likely to engage in individual creative play than control childrenindividual creative play than control children

TODDLERS AND TODDLERS AND PRESCHOOLERSPRESCHOOLERS

Cognitive developmentCognitive developmentEarly experience with insensitive maternal Early experience with insensitive maternal

interactions (as in maternal postpartum interactions (as in maternal postpartum depression) appears to be predictive of depression) appears to be predictive of poorer cognitive functioning.poorer cognitive functioning.

Boys may be more sensitive than girls to Boys may be more sensitive than girls to the effects of the mother’s illness.the effects of the mother’s illness.

decrease on standardized tests of decrease on standardized tests of intellectual attainment, and the “draw-a intellectual attainment, and the “draw-a child” task.child” task.

cognitive-linguistic functioning, have also cognitive-linguistic functioning, have also been shown to be negatively affected, and been shown to be negatively affected, and there were also deficits on the perceptual there were also deficits on the perceptual and performance scale.and performance scale.

SCHOOL-AGE CHILDRENSCHOOL-AGE CHILDREN

Behavioral developmentBehavioral developmentSchool-age children of depressed School-age children of depressed

mothers display impaired adaptive mothers display impaired adaptive functioning, including internalizing functioning, including internalizing and externalizing problems.and externalizing problems.

Children of depressed parents are Children of depressed parents are also at higher risk of also at higher risk of psychopathology, including affective psychopathology, including affective (mainly depression), anxiety and (mainly depression), anxiety and conduct disorders.conduct disorders.

Behavioral developmentBehavioral development

Academic developmentAcademic developmentlower IQ scores, attentional problems, lower IQ scores, attentional problems,

difficulties in mathematical reasoning difficulties in mathematical reasoning and special educational needs were and special educational needs were significantly more frequent in children significantly more frequent in children whose mothers were depressed at whose mothers were depressed at three months postpartum than in three months postpartum than in controls.controls.

boys were more affected than girls.boys were more affected than girls.

ADOLESCENTSADOLESCENTS

Behavioral development.Behavioral development. Adolescence is a vulnerable period for affective Adolescence is a vulnerable period for affective

illness and major depressive disorder, which are illness and major depressive disorder, which are observed twice as often in girls than in boys.observed twice as often in girls than in boys.

Higher rates of major depression and other Higher rates of major depression and other psychopathology (anxiety disorders, conduct psychopathology (anxiety disorders, conduct disorders and substance abuse disorders) in disorders and substance abuse disorders) in adolescents with an affectively ill parent than in adolescents with an affectively ill parent than in control families with similar demographic control families with similar demographic characteristics.characteristics.

children/adolescents with mothers suffering from children/adolescents with mothers suffering from unipolar depression had higher rates of affective unipolar depression had higher rates of affective disorders, with frequent multiple diagnoses, while disorders, with frequent multiple diagnoses, while the disorders in children/adolescents with mothers the disorders in children/adolescents with mothers suffering from bipolar depression were less severe.suffering from bipolar depression were less severe.

ADOLESCENTSADOLESCENTS

Academic developmentAcademic developmentProblems encountered in school-age Problems encountered in school-age

children, mainly ADHD and learning children, mainly ADHD and learning disabilities, persist into adolescence.disabilities, persist into adolescence.

RISK FACTORS, VULNERABILITYRISK FACTORS, VULNERABILITYAND RESILIENCEAND RESILIENCE

Contextual factorsContextual factorsMarital conflict, Marital conflict, Stressful life events,Stressful life events,Limited social support, poverty,Limited social support, poverty,Lower social class and lower Lower social class and lower

maternal educationmaternal education

Role of Fathers.Role of Fathers.infants of depressed mothers interacted infants of depressed mothers interacted

better with their non depressed fathers who better with their non depressed fathers who could buffer’ the effects of the mother’s could buffer’ the effects of the mother’s depression on infant interaction behavior.depression on infant interaction behavior.

Characteristics of the childCharacteristics of the childBoys being more vulnerable and distressed Boys being more vulnerable and distressed

by maternal depression than girls.by maternal depression than girls.Depressed mothers make more negative Depressed mothers make more negative

appraisals of their child’s behaviors, feel less appraisals of their child’s behaviors, feel less confident in their parental efficacy and use confident in their parental efficacy and use maladaptive parenting techniques more oftenmaladaptive parenting techniques more often

RISK FACTORS, VULNERABILITYRISK FACTORS, VULNERABILITYAND RESILIENCEAND RESILIENCE

TREATMENT OPTIONSTREATMENT OPTIONS

Pharmacotherapy:Pharmacotherapy:Safety Consideration.Safety Consideration.Effects of depression:Effects of depression:

Inadequate prenatal care, poor nutrition,Inadequate prenatal care, poor nutrition, Higher preterm birth, low birth weight, pre-Higher preterm birth, low birth weight, pre-

eclampsia,eclampsia, Spontaneous abortion, substance abuse and Spontaneous abortion, substance abuse and

dangerous risk taking behavior.dangerous risk taking behavior. The substantial morbidity of untreated depression The substantial morbidity of untreated depression

during pregnancy must be weighed against the during pregnancy must be weighed against the risk of medicationrisk of medication

In the neonatal period, it seems that behavioral In the neonatal period, it seems that behavioral and heart rate responses to pain are reduced in and heart rate responses to pain are reduced in newborn infants exposed to SSRIs in utero.newborn infants exposed to SSRIs in utero.

TREATMENT OPTIONSTREATMENT OPTIONS

Tricyclic antidepressants and Fluoxetine Tricyclic antidepressants and Fluoxetine had no adverse effects on the global IQ, had no adverse effects on the global IQ, language development or behavior of language development or behavior of children between 15 and 71 months of age.children between 15 and 71 months of age.

For Breast Feeding Mothers: For Breast Feeding Mothers: Information about risk and benefits about Information about risk and benefits about

treatment. treatment. If the antidepressant medication is discontinued If the antidepressant medication is discontinued

in the postnatal period, there is a risk of relapse, in the postnatal period, there is a risk of relapse, with negative consequences on the emotional with negative consequences on the emotional and behavioral development of the infant. and behavioral development of the infant.

On the other hand, all antidepressants are On the other hand, all antidepressants are excreted in breast milk.excreted in breast milk.

AntidepressantsAntidepressants• Neonatal toxicityNeonatal toxicity

• transienttransient• Heart malformationsHeart malformations• PPHNPPHN

• 0.01% (10% fatal)0.01% (10% fatal)• UNKNOWNSUNKNOWNS• No known long term No known long term

effects to IQ or effects to IQ or developmental developmental milestones – milestones – SSRIs on SSRIs on market for 25yrs nowmarket for 25yrs now

Untreated DepressionUntreated Depression• Operative deliveriesOperative deliveries• Preterm birthPreterm birth• IUGRIUGR• Failure to thriveFailure to thrive• SIDSSIDS• Poorer prenatal carePoorer prenatal care• Developmental delaysDevelopmental delays• Social, behavioral, Social, behavioral,

psychological psychological difficultiesdifficulties

• UNKNOWNSUNKNOWNSFrom what we know at this time…everyday new informationFrom what we know at this time…everyday new information

TREATMENT OPTIONSTREATMENT OPTIONS

Social support and psychoeducational interventions during infancyInterventions have focused on altering the

mother’s mood state, increasing her sensitivity to or awareness of the infant’s cues and diminishing the negative perceptions about the infant’s behaviors.

Interaction coaching techniques-instructing overstimulating intrusive mothers to imitate their infants or byshowing withdrawn mothers how to attract and maintain their infants’ attention.

Social support and home visiting interventions

TREATMENT OPTIONSTREATMENT OPTIONS

Family therapySchool-age children and adolescents

from families with a depressed parent may benefit from a family-centered intervention, focusing on communication about the illness within the family and on the development of resiliency in the child.

Clinician-facilitated psychoeducational intervention.

TREATMENT OPTIONSTREATMENT OPTIONS

PsychotherapyPsychodynamic treatment focuses on

the mother’s representation of her infant and her relationship with the infant, and explores aspects of the mother’s own childhood and early attachment history.

the interaction guidance therapy seeks to identify positive caregiving behaviours and to suggest alternative interpretations of an infant’s behavior.

Thank You