Maternal depression and child development

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Maternal depression and child development

• Pediatric Child Health

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Content

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

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Objectives

• To review the present knowledge on the
  consequences of maternal depression on the
  development of children at various ages
• To review the evidence-based literature on the
  treatment of maternal depression and its impact
  on newborns, infants and children and
• To review the role of the childs physician in
  the detection of symptoms of maternal depression,
  and the coordination of appropriate support and
  management.

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Introduction

• Postpartum blues is a relatively common emotional
  disturbance
• with crying,
• confusion,
• Mood lability, anxiety and depressed mood.
• The symptoms appear during the first week
  postpartum, last for a few hours to a few days
  and have few negative sequelae

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Introduction
Postpartum Blues

• 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 intervention
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Definitions

• Postpartum psychosis refers to a severe disorder
  beginning within four weeks postpartum, with
  delusions, hallucinations and gross impairment in
  functioning.

• Postpartum depression begins in or extends into
  the postpartum period and core features include
  dysphoric mood, fatigue, anorexia, sleep
  disturbances, anxiety, excessive guilt and
  suicidal thoughts.

• The diagnosis requires that symptoms be present
  for at least one month and result in some
  impairment in the womans functioning

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Postpartum Depression-PPD

• Major depression
• Psychosis, infanticide, homicide
• 60 women experience their 1st major depression
  PP
• Idealization of birth motherhood
• Feeling inadequate, lack of social support,
  primipgt30 (Beck, 2001 Fergerson, 2002)
• Hormones, thyroid, cholesterol, anemia, stress

(Eberhard-Gran et al. 2002Oates, 2003) Depression Psychosis
General 10-15 0.1-0.2
Teens 26
High-risk gt35 8 suicidal
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Postpartum Depression-PPD
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Risk Factors

• A history of mood disorders,
• Depression symptoms during the pregnancy,
• And a family history of psychiatric disorders.

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• Depression in pregnancy does
• not
• predict Postpartum depression
• in individual women
• but
• Up to 66 of women depressed in pregnancy go on
  to have PPD
• and
• Is a disease unto itself

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• Fetus
• Cortisol the stress hormone
• Fetal and maternal endocrine levels are
  correlated
• Hypercortisolaemia affects gluccocorticoid
  receptors in fetal brain
• ? CHR, ACTH
• FHR 35 wks
• ? variability ? rate / contradicted in one study
• Habituation and dishabituation decreased, delayed
  in depressed
• Uterine irritability
• ?resistance in blood vessels to the uterus
• ? blood flow to the baby- IUGR
• ? pre-term delivery
• (Austin, 2005 Okeane,
  2005Teixeira,1999 Zuckerman, 1990)

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• Hypothalamic-pituitary-adrenal (HPA) axis
• Chronic dysregulation affects neural function
• Estrogen/HPA are intertwined
• ?depression ?fertility
• HPA-placental neuroendocrine axis
• Maternal stress affects fetal development
• Sustained HPA dysregulation and stress reaction
• Neuronal death abnormal development of fetal
  brain
• Altered performance on neuromotor tests, ability
  to cope
• monkeys, rats no reason to expect different in
  humans (Austin, 2005 Okeane Scott, 2005
  Glover et al, 2002)

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TABLE 1 Consequences of maternal
depression Prenatal Inadequate prenatal care,
poor nutrition, higher preterm birth, low birth
weight,pre-eclampsia and spontaneous
abortion Infant Behavioural Anger and protective
style of coping, passivity, withdrawal,
self-regulatory behaviour, and dysregulated
attention and arousal Cognitive Lower cognitive
performance Toddler Behavioral Passive
noncompliance, less mature expression of
autonomy, internalizing and externalizing
problems, and lower interaction Cognitive Less
creative play and lower cognitive
performance School age Behavioral Impaired
adaptive functioning, internalizing and
externalizing problems, affective disorders,
anxiety disorders and conduct disorders Academic
Attention deficit/hyperactivity disorder and
lower IQ scores Adolescent Behavioral Affective
disorders (depression), anxiety disorders,
phobias, panic disorders, conduct disorders,
substance abuse and alcohol dependence Academic
Attention deficit/hyperactivity disorder
and learning disorders
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INFANT DEVELOPMENT

• Mother-infant interaction
• Regulation of interaction
• Withdrawal. (disengaged, unresponsive,
  affectively flat and do little to support the
  infants activity.)
• Intrusiveness.( hostile affect, and disrupt the
  infants activity.)

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Effects on Newborn

• ? risk of preterm delivery
• ?NICU admission
• Effects of depression and/or antidepressants
• Lower Apgar scores
• Lower birth weight/IUGR
• ? weight gain
• ? NBAS
• Less breastfeeding
• PPDSG
• ? Failure to thrive
• Smaller head circumference (Chung, 2001 Murray,
  2003)

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Effects on babies

• Less developed motor tone
• ? activity levels
• More withdrawn
• Cry excessively, irritable, less consolable
• ? expressivity and imitative behavior
• Negative expression
• ? SIDS
• Effects of lifestyle
• alcohol ?FASD, smoking, poor diet etc.
  (Murray, 2003 Zuckerman, 1989)

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INFANT DEVELOPMENT

• Cognitive development
• patterns of dysregulated attention and arousal.
• Two factor
• Depressed mothers are less likely to offer
  contingent stimulation to their infants.
• negative affect shown by infants of depressed
  mothers, even when they are interacting with non
  depressed adults.

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TODDLERS AND PRESCHOOLERS

• Behavioral development.
• less attentiveness and responsiveness to their
  childrens needs.
• Poor models for negative mood regulation and
  problem solving.
• depressed mothers were less likely to set limits
  on their children and to follow through if they
  did set limits.

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TODDLERS AND PRESCHOOLERS

• Children response
• More passively noncompliant, with less mature
  expressions of age-appropriate autonomy.
• More vulnerable, and having more internalizing
  (depressed) and externalizing problems
  (aggressive and destructive), which are
  associated with lower interaction ratings
• More likely to respond negatively to friendly
  approaches, more likely to engage in low-level
  physical play and less likely to engage in
  individual creative play than control children

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TODDLERS AND PRESCHOOLERS

• Cognitive development
• Early experience with insensitive maternal
  interactions (as in maternal postpartum
  depression) appears to be predictive of poorer
  cognitive functioning.
• Boys may be more sensitive than girls to the
  effects of the mothers illness.
• decrease on standardized tests of intellectual
  attainment, and the draw-a child task.
• cognitive-linguistic functioning, have also been
  shown to be negatively affected, and there were
  also deficits on the perceptual and performance
  scale.

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SCHOOL-AGE CHILDREN

• Behavioral development
• School-age children of depressed mothers display
  impaired adaptive functioning, including
  internalizing and externalizing problems.
• Children of depressed parents are also at higher
  risk of psychopathology, including affective
  (mainly depression), anxiety and conduct
  disorders.

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Behavioral development

• Academic development
• lower IQ scores, attentional problems,
  difficulties in mathematical reasoning and
  special educational needs were significantly more
  frequent in children whose mothers were depressed
  at three months postpartum than in controls.
• boys were more affected than girls.

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ADOLESCENTS

• Behavioral development.
• Adolescence is a vulnerable period for affective
  illness and major depressive disorder, which are
  observed twice as often in girls than in boys.
• Higher rates of major depression and other
  psychopathology (anxiety disorders, conduct
  disorders and substance abuse disorders) in
  adolescents with an affectively ill parent than
  in control families with similar demographic
  characteristics.
• children/adolescents with mothers suffering from
  unipolar depression had higher rates of affective
  disorders, with frequent multiple diagnoses,
  while the disorders in children/adolescents with
  mothers suffering from bipolar depression were
  less severe.

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ADOLESCENTS

• Academic development
• Problems encountered in school-age children,
  mainly ADHD and learning disabilities, persist
  into adolescence.

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RISK FACTORS, VULNERABILITYAND RESILIENCE

• Contextual factors
• Marital conflict,
• Stressful life events,
• Limited social support, poverty,
• Lower social class and lower maternal education

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RISK FACTORS, VULNERABILITYAND RESILIENCE

• Role of Fathers.
• infants of depressed mothers interacted better
  with their non depressed fathers who could
  buffer the effects of the mothers depression on
  infant interaction behavior.
• Characteristics of the child
• Boys being more vulnerable and distressed by
  maternal depression than girls.
• Depressed mothers make more negative appraisals
  of their childs behaviors, feel less confident
  in their parental efficacy and use maladaptive
  parenting techniques more often

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TREATMENT OPTIONS

• Pharmacotherapy
• Safety Consideration.
• Effects of depression
• Inadequate prenatal care, poor nutrition,
• Higher preterm birth, low birth weight,
  pre-eclampsia,
• Spontaneous abortion, substance abuse and
  dangerous risk taking behavior.
• The substantial morbidity of untreated depression
  during pregnancy must be weighed against the risk
  of medication
• In the neonatal period, it seems that behavioral
  and heart rate responses to pain are reduced in
  newborn infants exposed to SSRIs in utero.

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TREATMENT OPTIONS

• Tricyclic antidepressants and Fluoxetine had no
  adverse effects on the global IQ, language
  development or behavior of children between 15
  and 71 months of age.
• For Breast Feeding Mothers
• Information about risk and benefits about
  treatment.
• If the antidepressant medication is discontinued
  in the postnatal period, there is a risk of
  relapse, with negative consequences on the
  emotional and behavioral development of the
  infant.
• On the other hand, all antidepressants are
  excreted in breast milk.

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• Antidepressants
• Neonatal toxicity
• transient
• Heart malformations
• PPHN
• 0.01 (10 fatal)
• UNKNOWNS
• No known long term effects to IQ or developmental
  milestones SSRIs on market for 25yrs now

• Untreated Depression
• Operative deliveries
• Preterm birth
• IUGR
• Failure to thrive
• SIDS
• Poorer prenatal care
• Developmental delays
• Social, behavioral, psychological difficulties
• UNKNOWNS

From what we know at this timeeveryday new
information
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TREATMENT OPTIONS

• Social support and psychoeducational
  interventions during infancy
• Interventions have focused on altering the
  mothers mood state, increasing her sensitivity
  to or awareness of the infants cues and
  diminishing the negative perceptions about the
  infants 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

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TREATMENT OPTIONS

• Family therapy
• School-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.

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TREATMENT OPTIONS

• Psychotherapy
• Psychodynamic treatment focuses on the mothers
  representation of her infant and her relationship
  with the infant, and explores aspects of the
  mothers own childhood and early attachment
  history.
• the interaction guidance therapy seeks to
  identify positive caregiving behaviours and to
  suggest alternative interpretations of an
  infants behavior.

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Thank You