Impact of postpartum depression

Numerous studies have demonstrated the marked adverse effects of maternal postpartum depression on early mother–infant interactions and child attachment to the mother, and the influence of these effects on the child’s development is still evident years later (Gress-Smith et al., 2012; Murray et al., 2011). The disturbances in the quality of the mother–child interaction between depressed mothers and their infants appear to be universal, across different cultures and socioeconomic status groups, and they include low maternal sensitivity, more intrusiveness, less involvement, and less responsiveness to infant signals (Field, 2010).

Children of mothers who have been depressed shortly after birth show less weight gain in the first year, more insecure attachment to their caregivers, lower ego-resilience, lower peer competence, and lower school adjustment than children from a community sample (Kersten-Alvarez et al., 2012). They have more eating and sleeping problems, temper tantrums, and separation difficulties (Cicchetti et al., 1998), and lower IQ scores and school performance in late childhood (Hay et al., 2001). Furthermore, they show more emotional and behavioral problems in early childhood, and elevated rates of affective disorders in adolescence compared to children of mothers without postpartum depression (Halligan et al., 2007). A recent systematic review showed that children of depressed parents run an 8–9 times larger risk of developing depression themselves, and have 3 times more risk of anxiety disorders and a 4 times larger risk of conduct disorder (van Santvoort, 2013). It is also likely that prenatal and postnatal depression and related stress factors weaken the immune system in offspring, resulting in more vulnerability to chronic diseases during adulthood (Field, 2010). These outcomes stress the multifinality of the impact of early maternal depression. Depending on the combination of risk factors and the presence of protective factors, such cognitive, emotional, and behavioral deficits could persist well into late childhood, adolescence, and even adulthood.

The relevance of strategies to prevent such deficits and to support the social-emotional development of these children is further stressed by the prevalence of postpartum depression. Averaged across many studies, 12% of the pregnant women and 13% of the postpartum women suffer from a serious depressive episode (Bennett et al., 2004). Consequently, many children are exposed to maternal depression in the first year of their life.

Transmission mechanisms and risk factors

The impact of maternal depression on the infant is mediated by different causal processes during pregnancy and the first year of life, as reflected in our developmental model of the transgenerational transmission of psychopathology (van Doesum et al., 2005; Hosman et al., 2009) that is discussed in the introductory chapter of this book (Figure 1.3). First, the child could develop an increased risk of poor social-emotional functioning through the transmission of genetic liability. There is growing evidence that genetic features contribute independently and through gene–environment interaction to child behavioral problems in the offspring of mothers with depression (Agnafors et al., 2013). Secondly, there exists ample evidence showing that depression during pregnancy has a neurobiological impact on the growing brain of the child, especially on its emotional systems. For instance, prenatal depression has been associated with excessive activity and growth delays in the fetus as well as prematurity, low birth weight, disorganized sleep, and less responsiveness to stimulation in the neonate (Field, 2010). Furthermore, prenatal and postnatal depression are both associated with higher infant cortisol reactivity, especially when there is comorbidity with maternal anxiety (Brennan et al., 2008). Thirdly, postpartum depression is found to have a negative impact on maternal emotional availability, the quality of the mother–child interaction, and child attachment as well as a heightened risk of child abuse or neglect. Several caregiving practices also seem to be compromised by postpartum depression, such as breastfeeding, sleep routines, and less regular visiting to child healthcare centers (Field, 2010). As stressed earlier, impaired mother–child interaction has a significant impact on a wide range of child outcomes. Fourth, postpartum depression could influence child development through its relation to family functioning and possible environmental conditions, such as family conflict and violence, single parenthood, poverty, refugee status, poor social support, and social isolation. Some social conditions can be outcomes of maternal depression but are also common risk factors for both maternal depression and negative child outcomes.

In the next section we focus on the third transmission mechanism, the mother–infant interaction, and, more specifically, on maternal sensitivity. Of all known mediating processes, most research and most preventive interventions have been targeted on this early interaction and related mediators.

Maternal sensitivity and mother–child interaction as mediators

Maternal sensitivity was first defined by Mary Ainsworth as “a mother’s ability to perceive and interpret accurately her infant’s signals and communications and then respond appropriately” (Ainsworth et al., 1974, p. 129). Many researchers have stressed the importance of the mediating role of maternal sensitivity and the mother–child interaction in the relation between maternal depression and adverse child outcomes (e.g., Goodman et al., 1999; van Doesum et al., 2005). The literature shows that depressed mothers are more likely to be less sensitive to their child’s signals, more intrusive, less involved, and less vocal than nondepressed mothers. They show more covert as well as overt hostility, such as anger, criticism, and irritability, towards their children. In addition, the children are less responsive to their depressed mother. They may avoid eye contact, and because of the mother’s emotional unavailability, the infants develop a pattern of limited interaction with their mother (Field, 2010). The baby’s disrupted response continues even if the mother’s depression symptoms improve (Forman et al., 2007). Since the mother–child interaction, and especially maternal sensitivity to the child’s signals and needs, has an important predictive value in many domains of child development, including the development of secure attachment to the mother, many researchers consider enhancing early maternal sensitivity as a key element in preventing adverse outcomes during childhood and adolescence (e.g., Murray et al., 1999; van Doesum et al., 2005).

As is assumed in our theoretical model (Chapter 1, Figure 1.3), early mother–infant interaction is influenced by more variables than just postpartum depression. Other risk factors may also play a significant role as independent factors or as moderators of the relationship between postpartum depression and mother–infant interaction. Such factors include, for instance, comorbidity with other mental disorders, pre-existing parenting skills, and the absence of social support from the partner or the wider social network. For this reason, some preventive interventions that aim to improve mother–child interactions in depressed mothers simultaneously address other risk and protective factors in the mother, family, and social network to ensure an effective and comprehensive preventive approach.

Evidence-based interventions to enhance depressed mothers’ sensitivity

Interventions directed at mothers with postpartum depression have mainly focused on treatment of the depression of the mother without including the disturbed relationship with her infant. Several studies show that treatment of the depressive symptoms is not enough to improve quality of the mother–infant interaction (Forman et al., 2007; Kersten-Alvarez et al., 2011). There is a need for effective and evidence-based interventions that focus on the mother–baby relationship to prevent the development of social-emotional problems in children. In this section, we will review various interventions that have been evaluated in controlled outcome-studies, and present evidence of their effectiveness.

To identify such interventions, we first examined a meta-analysis of intervention programs to enhance depressed mothers’ sensitivity (Kersten-Alvarez et al., 2011). Secondly, we did publication searches for papers published in English with PsycINFO and PubMed, using key terms (postpartum depression, maternal depression, maternal sensitivity, interventions, and infant’s age 0–18 months) with no date limits. We included studies on interventions that are evidence-based (controlled studies, randomized, controlled trials, multiple studies) where the outcome variables contain maternal sensitivity / mother–infant interaction / mother–infant communication, and which are available as electronic publications.

In total, twenty-five publications were retrieved. Eleven studies met the inclusion criteria (reporting on ten programs overall). Studies 10a and 10b investigated the same intervention, respectively at 6 months and 5 years after intervention. Table 21.1 gives an overview of the characteristics of the eleven studies, including types of interventions, methods, and results.

Table 21.1 Interventions focused on enhancing maternal sensitivity in depressed mothers with infants

	Study	Method	Intervention	Outcomes variables	Addressed factors	Results
1	Clark et al. (2003) Clinically depressed mothers n = 39	RCT Mother–infant therapy group (M-ITG) (n = 13); waiting-list group (WLC) (n = 11), comparison group interpersonal therapy (IPT) (n = 15) Observation mother–baby interaction: PCERA scales, infant development BSID, depression CES-D, and BDI pre- and post-test	M-ITG: including mother-group, infant group, and mother–infant dyadic group: ameliorating mother’s depressive symptoms (CBT), parenting enhancing relationship, prevention of developing delays IPT: treatment of depression, no focus on mother–child relation Both M-ITG and IPT groups had 12 weeks, 1.5 h	Observation mother–baby interaction, level of depression	Mother–baby interaction, Reduction of depression	Maternal positive affective involvement and verbalization improved in M-ITG and IPT compared to WLC, Positive effect size 0.95* M-ITG and IPT both reduced depression level, largest improvement in M-ITG group
2	Gelfand et al. (1996) Clinically depressed mothers with 3–13-month-old infants. n = 73	RCT matched groups C = 36, I = 37 Measures: BDI, PSI, parental self-efficacy, Caldwell Home inventory:	Home-visiting intervention Interaction coaching, enhance parenting skills 29 home visits. 16 months (average)	Depression, parenting skills, maternal sensitivity, attachment	Mother–child interaction, attachment, Reduction of depression	Small effect in maternal responsiveness. Effect size 0.11* Intervention group lower levels of depression No improvement in secure attachment
		maternal responsiveness Strange situation pre- and post-test
3	Horowitz et al. (2001) Depressed mothers with infants n = 117	RCT C = 57, I = 60 Video recordings of interactions: Dyadic Mutuality Code (DMC) Mother Information Tool, EPDS, PPD Screening Scale (PDSS), three measurements: at 4–8, 10–14, and 14–18 weeks postpartum	Interaction coaching for at-risk parents and their infants (ICAP) 5-min observation of mother–infant Interaction coaching using six key elements to discuss with parent 4 home visits of 15 min	Mother’s responsiveness	Mother–baby interaction	Small improvement in maternal responsiveness Effect size 0.32*
4	Horowitz et al. (2013) Depressed mothers and infants n = 125	RCT C = 63, I = 62 Video recordings of interactions Mother Information Tool, EPDS, Postpartum Depression Screening Scale (PDSS), Nursing Child	Communicating and Relating Effectively (CARE) Home visiting Relationship focused behavioral intervention Behavioral coaching tailored to mother’s need based on	Quality of mother–infant interactions	Mother–baby interaction	No difference between intervention and control group; both groups improved positively in quality of mother–child interactions
		Assessment Teaching Scale (NCATS) Measurements 6 weeks and 3, 6, and 9 months postpartum	observation with NCAST Two visits for 40 min
5	Letoruneau et al. (2011) Mothers with depression EPDS ≥ 12 n = 60	RCT C = 33, I = 27 randomization EPDS, NCAST, Bayley Mental Development Index, Social support (SPS), salivary cortisol Measurements baseline, 6 and 12 weeks postpartum	Home-based peer support 12 weeks home visits by peers (mother recovered from PPD) including maternal infant interaction teaching	Mother–infant interaction, level depression, social support, stress level (cortisol), mother and baby	Mother–baby interaction Reduction of depression Improvement in social support	No effect in favor of the intervention; instead positive changes in the control group: mother–baby interaction, social support, and depression level
6	Mayers et al. (2008) High-risk teenage mothers n = 85, subgroup depressed with infants (M = 11 months)	Quasi-experimental design, matched groups Treatment group n = 32, Comparison group n = 19, CES-D, PSI, Maternal Behaviour Rating Scale (MBRS) Measurements pre- and postpartum	Chances for Children project: Teen Parent–infant Project: (1) education and development guidance (support group), (2) supportive treatment, (3) intensive infant–parent therapy	Maternal interacting behavior, depression	Mother–baby interaction	Positive effect on maternal responsiveness Large effect size 1.76* Significant effect interaction
	n = 51		Tailored to mothers’ needs, duration 6–20 months
7	O’Higgins et al. (2008) Mothers with 1-month-old infants with EPDS score above 12, highly educated group n = 62	Pilot study Participants were randomly assigned to baby massage classes (n = 31) or support group (n = 31) Control group of nondepressed mothers and their babies (EPDS below 9, n = 34) EPDS, SSAI (anxiety) and global ratings for mother–infant Interactions Pre-, post-, and 1 year later	Baby massage classes (6 sessions), 1 h per week, focus on infants’ cues and responding appropriately to different massage strokes and amounts of massage Support group: 6 weekly group meetings	Level of depression, sensitivity in interaction with baby	Mother–baby interaction Reduction of depression	No difference between two interventions in sensitivity. Already high score on interaction at baseline. Both intervention groups showed reduction of depression scores. The massage group did a little bit better at 1 year same level compared to nondepressed mothers but effects were small
8	Onozawa et al. (2001) Depressed mothers, ≥13 EPDS n = 25	RCT C = 13, I = 12 EPDS, video recording: global rating mother–infant interactions	Infant massage group, 5 meetings weekly 1 h: teaching infant massage, encouraging	Effect of intervention on mother–infant interaction, depression	Mother–child interaction Reduction of depression	Significant effect mother–baby interaction, effect size 1.17* Improvement in mood in both groups,
		scale, Murray et al. (1996) Pre- and post-test	parents to observe and respond to infant’s body language and cues and adjust their touch Control support group 5 meetings, 1.5 h: information, practical support, discussing of coping strategies			improvement significantly larger in massage group
9	Sidor et al. (2013) Families at risk with infants 0–1-year-old including maternal mental health problem (347%) n = 302	Controlled comparison groups design C = 152, I = 150 Videotape CARE-index Pre-, post-, and at age 1 year	Keiner Fällt Durchs Netz (KfdN) support, psychoeducation, enhance parenting skills Home visits by family midwives Average 14 home visits Mother–child interaction not main focus	Effect of the intervention on maternal competence (sensitivity), child development, severity stress level, perception mother–child relationship, and child behavior	Mother–baby interaction Parenting stress	Positive effect on child development and reduction of dysfunctional mother–child interaction No effect on maternal sensitivity, improved in both groups. Also no effect on exposure to stress
10a	van Doesum et al. (2008) Clinically depressed mothers, infant 6 months, n = 71, all	RCT C = 36, I = 35 EAS: quality of mother–child interaction, Attachment security Attachment Q-sort	Mother–baby intervention 8–10 home visits weekly: video-interaction guidance, psychoeducation, social support, and	Effect of the intervention on quality mother–baby interaction, attachment, depression, social emotional development	Mother-baby interaction Attachment relationship	Significant effect maternal sensitivity Effect size 0.86* Attachment security and social emotional development children in intervention group
	mothers received treatment for depression	Social emotional development: ITSEA Level of depression BDI Pre-, post-, and 6-month follow-up	infant massage, cognitive restructuring. Tailored to mother and infant needs			Decrease of level of depression in both groups, no difference
10b	Kersten-Alvarez et al. (2010) Clinically depressed mother, school-aged children 5–6 years, n = 58	Follow-up 5 years later RCT van Doesum et al. (2008) C = 29, I = 29 Maternal interactive behavior, attachment security, child behaviour problems, child cognitive development Follow-up measurement 5 years later	Mother–baby intervention See study 10a	Effect of the intervention: quality of mother’s interactive behavior, attachment security, child behavior problems, self-esteem, ego-resiliency, verbal intelligence, pro-social behavior, school adjustment	Mother–baby interaction Attachment relationship	No lasting treatment effects on quality mother–child interaction but intervention families with higher stressful life events children developed fewer externalizing problems Limitations: small sample and differential attrition

* Effect sizes retrieved from the meta-analysis on intervention programs of Kersten-Alvarez et al. (2011).

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