Depression in mothers the effects on their children

As childbearing women go through bio-psycho-social changes, they experience social morbidity and depressive symptoms, which are often unidentified and untreated. Maternal depression and mood disorders during postpartum phase are common. Postnatal psychiatric disorders categorised into three main divisions: postpartum blues, postpartum psychosis and postpartum depression. Postpartum blues is a comparatively a mild emotional disturbance with anxiety, confusion, crying and low mood which most mothers experience and wane away after few hours to few days and it is common as in 85% of women. At the other end of the severe scale, postpartum psychosis disorder in one and two women per 1000 who have given birth, and can occur two to three weeks of postpartum within three month period including, hallucinations, delusions, suicidal thoughts and impairment in functioning. Unlike baby blues, postpartum depression can occur within the first year after giving birth it is common in 10-15% of deliveries. Postpartum depression and its core features include anxiety, irritability, tearfulness, sleep disturbances, dysphoric mood, fatigue, weight loss, diminished concentration, indecisiveness, reduced libido, excessive guilt and frequent thoughts of death and suicide (RCPSYCH, 2006). If these symptoms persist for more than a month and effects in the woman’s functioning, it’s diagnosed as post natal depression. The Diagnostic and Statistic Manual of Mental Disorders (DSM-IV) diagnostic criteria of a postpartum-onset specify depressed patients for ‘onset within four weeks’ of delivery and necessitate at least five of the symptoms mentioned above ( APA, 1994). Maternal depression compromises mother’s emotions and interfere with communication of emotions between mother- infant interactions. Therefore, early maternal influences are crucial in the development of children according to animal and human research shown over the years. Postpartum depression attributes to quality of maternal care and, it is thought to be a major risk factor for the disruption in children’s later cognitive, socio emotional, behavioural and physical development (Ramachandani et al, 2005). The effects of postpartum depression on children are not limited to infancy, but can also extend into influencing development at toddlerhood, pre-school age, school age, teenage age and even adulthood. The relationship between maternal depression and their behaviours show complex association with child outcomes, as not all studies have suggested a positive correlation between maternal depression, bad parenting and poor child behaviour (Ramachandani et al, 2005, O’Hara, 1997). The researchers have incorporated fathers into the equation. What is so fascinating about fathers? The existences of fathers have been as long there have been children. The concepts of fathers’ wellbeing, just like the mothers, have an effect on their babies. Paternal depression can have an astounding impact on infants and extend to adulthood development and it is an important area to explore just like the effects of maternal depression on children (Ramachandani et al, 2005).

This review focuses on early interaction of parenting, evidence based literature on the consequence of maternal and paternal depression on the development of newborns, infants, children and adults, safety practices and psychological interventions.

Epidemiology and Aetiology

Postpartum depression is a moderately common disorder and its prevalence is13% of women in the first three months after birth(O’Hara & Swain, 1996).Women who have encountered post natal depression have a 50-62% chance of developing depression again. Is postpartum depression genetic? Family and twin studies have shown to have link between genetics and major depression. First degree relatives are two to three times more prevalent in major depression, and identical twins have 50% more chance of inheriting major depression with much lower 20% in non identical twin (Moore et al, 2004). According to Serge et al, 2006, ethnicity/race is an important contributory factor to postpartum depression. Of the women he studied, 15.7% were diagnosed as depressed, and 25.2% of that was African American women, even after adjusting all other confounding factors such as sex, age, marital status, education, income and baby’s health. The next affected groups were American Indian (22.9%), white (15.5%), Hispanic (15.3%), and Asians (11.5%) respectively. Although the idea of hormonal changes inclined to cause postpartum depression, there is no significant consistent evidence correlating change in hormonal levels with variation in postpartum depression (O’Hara, 1995). Further, in line of reasoning, do fathers who suffer from postpartum depression undergo any profound hormonal changes? Therefore, it is arguable if all mothers go through hormonal changes, then what could be the potential rationale for only 10-15% of post natal women to endure mood disorders (Goodman, 2004). This does not mean hormonal has no impact on depression. It is possible; women who are vulnerable to hormonal changes would be triggered to postnatal depression than non vulnerable women to hormones (Beck, 2001). According to Kumar & Robson, 1984, childbearing stage of woman’s life has deleterious consequences on mental health due to bio-psycho-social changes in her life. Sometimes, a pre-existing mental health conditions can bring about postpartum depression. Frank et al, 1987, agrees that women who have been depressed postnataly were considerably younger at the onset of illness, and in later in life found to be more unstable emotionally and significantly more depressed. Further, it is widely known that families with a history of mental health conditions such as bipolar, schizophrenia, autism, and alcohol addiction can increase the likelihood of postpartum depression. A study conducted by Ross et al, 2007, indicated lesbian and bisexual mothers shown to have a significantly higher Edinburgh postnatal depression scale (EDPS) scores in comparison to sample of heterosexual women. His reasons were lesbian and bisexual mothers get less social support, particularly in terms of family support and homophobic discrimination, which is not surprising as a study done by midwife claimed that family support is the most important factor in the establishment of maternal well being (Ball, 1987). There are other contributory factors such as maternal self confidence, anxiety, formula feeding instead of breastfeeding, poor marital relationship, single parent, infant temperamental behaviour, unwanted and pregnancy and life stress can increase the chance of postnatal depression in mothers(O’Hara, 1997)

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Fathers who are depressed during early stages of children’s lives have received very little attention. Depression is a major global health issue as it is the fourth biggest cause of disability and it will probably be second to cardiovascular disease by 2020 (Murray and Lopez, 1997). It is known that one in 25 men experience postnatal depression (MIND 2008). Further, a study done in 2010 at United stated claims that as many as one in 10 men suffers from post natal depression. 10.4% pre and post natally depressed fathers, with highest prevalence rate between three and six months after birth were noted in fathers (Paulson & Bazemore 2010). Although, pregnancy is a stressful period for fathers, the chronocity of the problem is reported was where half the men depressed before the pregnancy were also depressed eight weeks afterwards (Ramachandani, 2008). Holopainen, 2004, postulated the importance of fathers role as a supportive person is a key if the mother is depressed as 70% of new mothers turn to their partners for emotional support compared to 47% in the 1960s (GMTV survey, 2009).

There are many factors involved with father’s depression. There is 24-50% chance of the father experiencing depression if the partner was detected with depression (Goodman, 2004). Other risk factors of paternal post natal depression including Infant related problems (Dudley et al, 2001), neuroticism and substance dependence (Huang & Warner, 2005), relationship difficulties with the mother (Paulson & Basemore, 2010), fathers own previous history of depression (Ramachandani, 2008), unemployment, low income, housing difficulties, alcohol, (Anderson et al, 2005) and marital status (Huang & Warner, 2005). Rates of paternal depression in married men was 6.6% compared to considerable 19.9% depression in fathers that were ‘not involved’ with mothers in any way

The association between maternal depression and maternal behaviour on child development is complex and post natal depression does not necessarily leads to poor parenting. The differences in outcome in children could also be potentiated by financial stresses, low social support, family adversity and variations in the type of maternal depression (severity, chronicity and timing). In the absence of maternal depression, stress factors can be responsible for adverse child outcomes (Ramachandani, 2008).

Infant- mother early interactions of parenting

As previously mentioned, long-term maternal depression have attributed to disturbed early infant interactions. The consequences on the child of a mother or father with post natal depression not only affects at infancy, but can extend into later stages, such as toddlerhood, preschool age, school age and even as an adult. Maternal or paternal depression that occurs later in life influences the school age child and adolescent development.

A meta-analysis study done by Lovejoy et al, 2000, looked at women who were depressed across their infants’ first 3 months of life and were noted to be more irascible, hostile, less engaged, which demonstrated less warmth, emotion and less play with their 3 month old infants.

Through research, its established for primary form of play for infants is between 3 and 6 months, therefore, most studies have focused around that age. One of the most interesting differences between non depressed and depressed mothers are their level of face to face interaction play behaviour with features of vocalising, imitation, smiling and game playing, known as “playing field”, which in turn for the infants to learn communication skills by ‘turn taking’ with the mother (Field, Diego, & Hernandez-Reif, 2006). Depressed mothers lack some of these behaviours that might lead to contributing interaction disturbances with their infants (Field et al, 2006). Further, these interaction disturbances appear to be universal across different socioeconomic groups and cultures. Righetti- Veltema et al, 2002, claimed that depressed mothers in Switzerland lacked vocal and visual communication and less smiling with their infants. Similarly, Murray et al, 1996 suggested, depressed mother in England are less sensitively attuned to their infants.

According to research, depressed mothers appear to have two different styles of communication with their infants, including an intrusive, controlling and over stimulating style and withdrawn, disengaged, under stimulating style, where each form had a different impact on the infant (Malphurs et al, 1996, Tronick,1989 and Cohn et al, 1986). Postnatally depressed mothers are less affectionate, touch the infants less frequently and much more negatively compared to non depressed mothers (Fergus et al, 1996). Infants of post natally depressed mothers tend to spend more time touching their own skin, which might be a compensatory action for receiving less positive touch from their mothers (Herrera, Reissland, & Shepherd, 2004). “Intrusive” mothers associated in rough pulling, tickling, poking, actively interfering with infants activities, spoke in angry tone of voice, including using longer utterances, less repetition, fewer explanations, questions, and suggestions (Herrara, et al, 2004, Cohn et al, 1986).By contrast, withdrawn mothers, were affectively flat and unresponsive and supported very little with infants activities.

The authors Zlochower & Cohn, 1996, explained that depression could reduce synchrony in depressed mothers’ and infants’ interaction impinging on coordination of mothers’ vocalisation with infants’ vocalisations and non verbal behaviour. Therefore, it is not surprising, later in life, the infants of depressed mothers less expressive language and perform poorly on cognitive-linguistic functioning (NICHD Early Child Care Research Network, 1999). There is strikingly difference in behaviours of infants of these two groups of mothers. Infants of intrusive mothers often look at objects as most of the time they avoid looking at their mothers. In contrast, infants of withdrawn mothers were distressed, sad and more likely to protest, suggesting disengaged behaviour of mothers seem to be aversive to infants. Here, the researchers describe infants as “detectors” of emotional meaning to chronic exposure to interactive interference influence on affective state of infant’s behaviour. Withdrawn mothers lack of affective responsiveness which leads to failing social connectedness that ultimately hinders mother-infant interaction. Without any external regulatory scaffolding, the infant will try to self regulate. As they cannot cope on their own in chronic situations, they become dysregulated, cry and fuss as this failure of self emotional regulation compels them to devote much of their coping strategies to control infants own affective organisation than utilising in regulating homeostatic states such as temperature and hunger. Infants of withdrawn mothers

looks depressed as they have developed a sad, withdrawn, disengaged self and they turn away from the world as the mother has shown to be ineffective, helpless, unresponsive and untrustworthy( Cohn et al, 1986).

The infants of intrusive mothers behave differently to the infants of withdrawn mothers. The infants of intrusive mothers initially express anger, turn away from their mothers, drive them away and conceal them out because the mothers consistently disrupt the infants’ activities by preventing the interaction with the infant. To an extent this may be a positive mechanism to limit intrusiveness by mother. Nonetheless, the infants eventually begin to internalise anger, a defensive coping mechanism and the infants will generate outbursts of anger when interacting with their mothers, and others, as well as acting on objects.

Cohn et al, 1986, quoted,

“These differences in infant reaction to maternal withdrawal and intrusiveness suggest an interpretation of differential effects associated with parental neglect and abuse”

(Cohn et al, 1986)

infants who suffer from withdrawal is so extreme that they fail to grow as seen in orphanages, where they constantly have to self regulate without assistance from a mother compromises the infants communication with the environment and even their drive to connect with the world. By contrast, in the intrusive situation, parental mistreatment leads to chronic physical defensiveness and irritation, and heightened fear and alertness (Tronick, 1989).

A sample of 5089 of depressed fathers and mothers, mothers who were depressed were less engaged in activities such as playing peek-a-boo and telling stories in comparison to depressed fathers, who were less like to be singing songs and play with the infants. However, Lyons-Ruth, 2002, opposes by indicating paternal depression did not affect fathers interaction with the infant in any frequency.

Toddlerhood and pre school age Behavioural

Depressed mothers display characteristics of inadequate attentiveness, responsiveness, poor at negative mood regulation and problem solving, which ultimately leads to detrimental behavioural and cognitive consequences on their children. It is been reported that children of depressed mothers had no set limits and even if they did, they weren’t followed through. These children show passively non compliant, less mature expression of autonomy, vulnerability and as a result of lack of interaction, they experience internalizing (depressed) and externalizing (destructive and aggressive) behavioural problems. The lower interaction is also associated with low levels of physical and creative play and low cognitive performance in children of depressed mothers compared to control children.

With large number of studies in consistent agreement on the negative impact of maternal postnatal depression on a child’s cognitive development, as the early experiences of infants with their insensitive postnatally depressed mothers are likely to show deficits in intellectual attainment, cognitive linguistic functioning and low perceptual and performance. As Sharp et al, 1995 has shown, only boys showed a decrease in intellectual attainment suggesting boys may be more sensitive than girls to the effects of mothers illness.

School age children Behavioural development

Beardslee et al, 1983, have shown that school age children of depressed mothers exhibit internalizing and externalizing problems demonstrating impaired adaptive functioning. Further, Billings and Moss, 1983 found out that low support and family stress accounts for more disturb child than by having a depressed parent alone. However, Lee and Gotlib, 1989, disagrees by postulating other a child’s adjustments more strongly associated to the severity of maternal psychopathology than to diagnosis status. Children of depressed matters are also at risk of psychopathology, anxiety, depression and conduct disorder.

According to Hammen et al, 1987, where he compared children from four groups of mothers — mothers with unipolar, bipolar, chronic medical illness and normal mothers. Even after controlling chronic stress and standardising ethnicity, age, socioeconomic status and

educational level, there were still psychosocial outcome differences among groups, particularly, children of unipolar mothers.

In 1998, a study done by Wickramaratne and Weissman postulated an association between parents who suffer from depression before the age of 30 and the danger of their children developing depression in their childhood. Nevertheless, it is complex to demarcate which behavioural disorders are due to maternal depression, or genetic susceptibility or environmental factors.

Academic development

According to a cross sectional study done by Lesesne et al, 2003, it is suggested a link between maternal mental health and attention deficit/hyperactive disorder (ADHD) in children. A national health interview study done in 1998, recruiting 9529 mother-child dyads, after adjusting for the child’s age, sex, race, type of family and household income, indicating a significant correlation between mothers with anxiety, depression and emotional problems and ADHD in their children aged 4-17 years (Lesesne, et al, 2003). This study was supported by Hay et al, 2001, where 11 year old children of post natal depressed mothers had difficulty in mathematical reasoning, attention problems, and low IQ scores. Among these children, special education needs were significant compared to children of controlled mothers. Evidently, boys had more difficulties than girls. However, prospective IQ of depressed parents was not the basis of academic difficulties in children of depressed mothers.

Developmental outcomes of Adolescents

Adolescent phase is more impervious to depressive disorders, which girls are twice as more like to endure than boys. It is been consistently recognised in adults with major depression or psychopathology have an affectively ill parent with a similar condition than in control families. Beardslee et al, 1988, studied 153 children between the ages of 6 -19 years in 81 randomly selected families at an urban centre of health maintenance organisation. At the initial assessment, an astounding 30% of the adolescents with mentally ill parent had at least one episode of a mental illness in comparison with 2% in the control group. The rates of affective disorders after four years were changed to 26% and 10% respectively. Further, the children of parents with mental disorders had much earlier, longer periods and varied number of diagnosis ( Beardslee et al, 1993). This is also supported by Weissman et al, 1997, a 10 year follow up study with children aged between 6 — 23 years of 91 families. The offspring of depressed parents had panic disorders, phobias, alcohol dependence and major depression, particularly, in children of ages between 15 — 20 years, compared to children of non depressed parents.

It is not uncommon for problems such as ADHD and learning disabilities which experienced as a child to persist into adulthood by hindering the academic development ( Lesesne et al, 2003).

Depressed Fathers compared to a depressed mother

Maternal depression is possibly one of the most researched areas in developmental psychopathology and very little research has been done on fathers. Few researchers have included fathers into the equation. Only a small percentage of fathers report about their illness after the birth of the child, suggesting the importance of depression in post natal period. Symptoms of depression such as irritability, feelings of hopelessness and low mood are likely to interfere in providing sensitive and responsive parenting in first year of child like, which is the stage that has the greatest impact on development. (O’Conner et al, 2003). Governmental policies such as National Services Framework for Children, young people, and Maternity Services in England encourages parents to get more involved in the upbringing of their children, especially, fathers ( Department of Health, 2004).

Interestingly, maternal depression effects on child cognitive and behaviour problems can be exacerbated by post natal paternal depression, where the father spends considerable amount of time caring for the infant (Mezulis, Hyde & Clark, 2004). As unexpected, being exposed to a non depressed father did not compensated the effects of a depressed mother, even if the father is the primary care giver out of two caring for the infant.

A Longitudinal cohort study done by Ramachandani et al, 2005 on mothers and fathers at regular points during and after pregnancy. Strikingly, boys of age 3.5 years are more vulnerable with behavioural problems than girls when their fathers are post natally depressed compared to their mothers. Perhaps, boys are more sensitive to the fathers parenting responsive role of the differential association with their sons compared to the role of mothers. Alternatively, boys are simply more affected by adverse parental influences, such as paternal depression. Although, Sharp et al, 1995 reported that preponderance of problems in boys might be an explanation for this. However, the study also claims, an association between depression in mothers and increase rate of behavioural and emotional problems with their children. Nevertheless, this association is different with depressed fathers in two ways; first, there was an emotional and behavioural effect across children, and, second, no significant difference in the magnitude of effects seen in boys or girls. These findings confirm three possible explanations. First, depressed fathers might have a direct effect on the way fathers interact with their children, similarly to post natally depressed mothers, where it is not surprising given the persistent effects of depression in social and psychological functioning. Interference in early interaction which might leads to increase adverse development in children. There is also an indirect effect in children’s development due to marital conflict and a possible genetic link and environmentally mediated factors (Ramachandani et al, 2005). There is also a suggestion from Sethna et al (2009), higher percentage of infants negativity is due to the way depressed fathers talk to their infants.

Importantly, Paulson et al, 2006 quoted;

“Depressed fathers are less likely to read, sing songs and tell stories to their babies than other fathers – and than depressed mothers, which may explain why fathers’ depression has a more powerful negative impact than mothers’ depression on their infants’ language development in the first year”

Further, depressed fathers interact with their infant with flatter tone of voice which is associated with cognitive delay in their infants (Wanless et al, 2008). There are also other negative behavioural factors such as lack of sensitivity and responsiveness, diminished positive emotions, increased negative emotions, disengagement, intrusion and hostility( Wilson & Durbin, 2010). Paulson et al, 2008, suggested that when both parents are depressed, they are likely to follow good care giving practices, such as breastfeeding, putting the baby to sleep on their back and not to give them a bottle while trying to get them to sleep. To the contrary, Field et a1,1999, disagrees with this and claims, there was no difference in depressed fathers and non depressed fathers in the way they interacted with their infants. Interestingly, McElwain & Valley (1999) states that depressed fathers are less intrusive compared to non depressed fathers with their 12 months old babies. However, Wilson & Durbin, 2010, counteracts by stating it is a “symptomatic disengagement”, instead of less intrusive parenting.

In the past the influence of fathers in early childhood development might have been underestimated. It’s important to appreciate to actively consider the depression in fathers as well mothers. Depression could compromise ability of the fathers and mothers responsive care roles for their children and to relinquish other roles in the family.

Gender Differences in two regulatory methods

Inadequate care giving practices

There are fundamental care giving practices of parenting in early stages of developing infants’ life such as breastfeeding, sleep routines, vaccination and child visits. These are severely compromised by the postnatal depression of mothers and fathers and have given less interest than the effects of post natal depression on mother-infant relationship.

Most research on parenting care giving practices have noted that post natally depressed mothers are less keen to breastfeed. There are studies suggesting mother with high post natal depression scores significantly likely to discontinue breastfeeding at 4-16 weeks and have substituted breastfeeding to juice, water and cereal within that time (Mc Learn et al, 2006a, 2006b, Paulson et al, 2006). In addition, Righetti-Veltema et al, 2002 not only supported this claim, but he also suggested, the undesirable feeding practices by depressed parents could in

turn, lead to feeding difficulties arisen in these infants. Further, a study done by Hatton et al (2005), an inverse relationship was noted between mothers with high Edinburgh depression scores, women with depressive symptoms and breastfeeding at 6 weeks post natal, although, this inverse relationship discontinued beyond 12 weeks. However, McCarter-Spaulding &

Horowitz (2007), opposed the idea indicating that there is no significant relationship between depression and breastfeeding, which I find eccentric to oppose such claim completely, given that depressed mothers show withdrawal style of parenting and not keen in interacting with the infant at early stages of development.

McLearn et al (2006a, 2006b), also researched on sleep practices linked to maternal depression and its rather distressing to find out that depressed mothers lay their infants in the prone position instead of placing the infant in recommended supine position. What more, infants are more like to sleep in the parents bed, take longer time to fall asleep and wake up more often, and being nursed to sleep are some of the sleep problems faced by the infants

(Hiscock & Wake, 2001). Another study done by Dennis & Ross (2000), stated mothers with depressive symptoms at 4-8weeks reported waking up more than 3 times between 10p.m. – 6a.m. and had less than 6 hours of sleep in a day and complained of being tired because their infants cry more often. Other potential causes of sleep disturbances include, infant sleeping in the parents’ room, dispute between parents regarding infants sleeping patterns, infant being nursed to sleep by the mother, and infant waking up 7 nights per week and mothers themselves having poor mental and physical health problems (Hatton et al, 2005).

It’s not surprising that children were affected in receiving health care during infancy by their depressed mothers. A prospective cohort study on mothers with depressive symptoms between 2-4 months claimed these mothers use acute care, including emergency department in late infancy stage, fewer preventative services such as child visits at 12 months, and up to date vaccinations at 24 months (Minkovitz et al, 2005).

Safety Practices

Maternal depression symptoms can affect the provision of safety practices associated with infants, including lowering hot water temperature, having cabinet safety latches, using infant car seats and having electric outlet covers (McLearn et al, 2006a, 2006b). Once again, mothers who had depressive symptoms between 2-4 months was less likely using seat belts and lowering temperature compared to mothers with coexistent depression had less odds of remembering to use safety latches and electric outlet covers (McLearn et al, 2006a, 2006b). In contrast, Mulvaney & Kendrick (2006) stated that there is no significant difference between mothers with depressive symptoms and safety practices, including the use of smoke alarms, storing medication and sharp objects safely.

It has brought to our attention that 41% depressed mothers have thoughts of harming infants compared to 7% of control mothers acknowledging to thoughts of harming their infants (Jennings et al, 1999). Moreover, depressed mothers finding hard to cope with their infants, fear of being in alone with the infant and thoughts of harming and using harsh punishment on infants.

Behavioural Interventions

The two most focused interventional programmes for depressed mothers are pharmaceuticals and psychotherapy. Psycho educational interventions applies in altering the mood state of the mothers, by enhancing her sensitivity to be more aware of the infants cues and revise the negative perceptions about the infant’s behaviour (Field, 1992). The reviews on antidepressants are mixed; it is recommended that antidepressants should not be used at least used during breastfeeding. To the contrary, psychotherapy studies had a positive impact on depressed mothers (Field T.,2008). However, according to Dennis & Creedy, 2004, women who received psychosocial intervention and standard care had no significant difference in developing post natal depression Nevertheless, the intensive post natal support by midwives and public health nurses seem to be promising. As a preventative measure, identifying mothers at risk of developing postnatal depression and providing interventions benefited, although, astonishingly, interventions on postnatal women emerged to have benefited more than interventions used on prenatal women. Further, it was noted group based interventions were less effective compared to individual based interventions, and, surprisingly, women who received single contact intervention were equally like to develop post natal depression compared to women who received multiple contact interventions ( Dennis & Creedy, 2004).

A psychotherapy study done by Foreman et al, 2007 on depressed and non depressed mothers’ and their interactions with infants found , that mothers who are 6 months depressed were encountered more parenting stress, a notion of negative attitude towards infants and were less responsive to their infant than non depressed mothers. The psychotherapy treatment had some effect to an extent by reducing the parenting stress of the depressed mothers, but it was still higher than non depressed mothers. The author concluded, that even after 18month follow up period of receiving interpersonal psychotherapy, ther