Maternal Depression
and the Dynamic
Maturational Model:
How Depression
Gets Under the Skin
Nicole Letourneau PhD RN
Professor of Nursing and
Medicine (Pediatrics)
Norlien/ACHRF Chair in
Parent-Infant Mental Health
1
Objectives
1. Maternal depression and attachment
2. Maternal depression and mother-infant
interaction
3. Impact of depression on infant and child
health
4. How does maternal depression get under the
skin?
5. So what do we do?
2
1. MATERNAL DEPRESSION &
ATTACHMENT
3
MDD symptoms
Weight
Loss/Gain
Depressed
Mood
Fatigue/
Loss of
Energy
Insomnia/
Hypersomnia
Anxiety
Emotional Lability
Reduced Thinking/
Concentration/
Decisiveness
Worthlessness/
Guilt
Psychomotor Agitation
or Retardation
Loneliness
Loss of Interest
or Pleasure
Suicidal Ideation
4
Mothers
• DSM-IV indicates that mothers must experience
s/s within 4 weeks postpartum to have MDD with
postpartum onset
• Beyond 1st year, symptoms of depression are not
attributed to the postpartum period.
• Meta-analysis of 28 studies reported PPD
prevalence of 15% (Gavin et al., 2005), slightly ↑
over last review (O’hara & Swain, 1996)
• Maternal depression 5-7% (Health Canada &
NLSCY)
5
Mothers
• 50% of mothers with PPD remain
clinically depressed at 6 months
postpartum.
• 25% untreated mothers remain
depressed > 1 year.
• 63% have recurrence of depression
within 12 years. Letourneau et al. (2010) WJNR
6
Does it all begin during
pregnancy?
• MDD during pregnancy related to poor
maternal-fetal attachment (McFarlane, 2011)
• Maternal mood related to maternal cortisol
levels during pregnancy (Giesbrecht et al., 2011)
• High maternal cortisol during pregnancy
predicted parental report of poor infant
temperament
7
8
Matenal depression=serious
• 12% of maternal deaths (during pregnancy
and in the 1st year post delivery) attributed
to psychiatric illness including PPD
• #1 cause of death: suicide (10%)
• More violent methods of suicide-few by
overdose
(Oates, 2003. Confidential Enquiries into Maternal Deaths)
9
10
Disturbing thoughts
[1]
Location
Total
screened
EPDS
9+
Positive for
self harm
EPDS
12+[1]
Positive for
self harm
Fredericton
109
24 (22%)
7 (29%)
12 (11%)
5 (42%)
Moncton
299
55 (18%)
19 (35%)
34 (12%)
14 (42%)
This group is also counted in the EPDS 9+ category.
Duffett-Leger, L.. & Letourneau, N. (2009). Info Nursing
Parental distress increased the odds (OR: 1.10; CI: .99-1.21) of having
thoughts of intentional harm to child at 4 weeks postpartum (e.g.
screaming at baby, shaking baby, hitting baby, giving away baby, etc.)
(Fairbrother & Woody, 2008)
11
Suicidality and attachment
• Mothers with high suicidality (n=32)
– experienced greater mood disturbances, cognitive
distortions, and depression severity of postpartum
symptomotology
– lower maternal self-esteem, more negative
perceptions of the mother-infant relationship, and
greater parenting stress.
• During observations, mothers were less sensitive and
responsive to infants' cues, and infants demonstrated
less positive affect and involvement with their mothers.
Paris et al., 2009
12
13
Disturbing thoughts
Barr and Beck (2008) conclude: “although
women were unlikely to disclose their
infanticide thoughts to health care
professionals, they did often realize that
they needed help. In such cases, women
were more likely to mention thoughts of
suicide…”
14
There is no such
thing as a baby—
Winnicott
15
What is Attachment?
•The pattern of a specific relationship
•A self-protective strategy
Pattern reflects whether children feel secure
in the availability and responsiveness of
caregivers
Bowlby, 1988; Ainsworth, 1978; Crittenden, 2005
16
Why these strategies?
• Type A minimize awareness of feelings and do what will
be reinforced and to avoid doing what will be punished—
disorders of inhibition and compulsion.
E.g a child responded to negatively each time she cries may
develop a Type A strategy.
• Type C focus on feelings as guides to behaviour—
disorders of anxiety and obsessiveness tied to too great
a reliance on negative affect.
E.g. a child who is ignored by a passive parent unless acts out may
develop Type C strategy
18
19
20
21
22
Attachment & development
Over the lifespan, insecure attachment
is associated with:
• Behavioural, academic and mental
health problems
• Problems with intimacy and affection
• Trust issues
• Low self-esteem
• Difficulty maintaining relationships
23
Insecure attachment
Primary caregiver :
 Insensitive
 Disengaged
 Uninvolved
 Emotionally flat
 Controlling
Infants develop:
 Self-protective strategies
PPD & attachment: infancy
Non-depressed
Type C
10%
Depressed
Type A
10%
Type D
10%
Type A
17%
Type C
23%
Type B
20%
Type B
70%
Type D
40%
Teti, Gelfand, Messinger, & Isabella (1995)
25
PPD & attachment: preschoolers
Non-Depressed
Depressed
Type ADType A
A/ C-IO 9%
Type C
29%
26%
Type C
Type A
19%
Type B
13%
22%
Type ADA/C-IO
29%
Type B
43%
Teti, et al. (1995).
26
Forman et al. (2007)
• Depressed moms
• Children of depressed
less responsive,
mothers, compared to
viewed their infants
children in nonmore negatively
depressed control
• 18 mos. later,
group, were
depressed moms
significantly lower in
rated their kids lower
attachment security
in attachment,
behaviour &
temperament
27
2. POSTPARTUM DEPRESSION
AND MATERNAL-INFANT
INTERACTION
28
29
30
States of arousal
•
•
•
•
•
•
Flooded (e.g. crying)
Hyper-alert (e.g. fussy)
Calmly focused & alert
Hypo-alert
Drowsy
Asleep
31
Maternal-child interaction &
self-regulation
Critical aspect of regulating a baby’s
states involves modulating the intensity of
stimulus to engage and sustain the baby’s
attention i.e not trigger the impulse to cry,
avert gaze, or shut down.
32
Adult sensitivity is any pattern
of behavior that pleases the
infant and increases the infant’s
comfort and attentiveness and
reduces its distress and/or
disengagement. (Crittenden,
2011)
33
Mothers are “hidden” regulators
of their infants’ endocrine &
nervous systems
34
What interferes with
maternal sensitivity?
Attachment & trauma history
Mental health problems
Family violence
Maternal addictions
Current
or Past
stress
35
PPD & maternal-infant
interaction
When I tried to encourage some social
interaction with her newborn, Stephanie
would respond that she often just stared
at Emma. While other relatives laughed
and cooed to the baby, Stephanie
claimed that she did not know how and
had no desire to do that. Some of her
responses were “ I don’t know what to
say”, “Is it bad that I just stare at her?”
and “Am I being a bad mother?”
From Zauderer (2008)
36
Depressed mothers
• negative perceptions • ↓ sensitive and
of normal infant
appropriate
behavior
interactions
• ↓ likely to pick up on • ↑ negative in their
infants’ cues or
play
respond to needs
• speak more slowly
• ↓ emotionally
and ↓ often
expressive
• ↓ affectionate and ↑
anxious
37
Relationships with infants
• PPD ↓ maternal-child
interaction quality and
enjoyment in maternal role-moderate to large effect (Beck,
1995; Murray et al. 2003)
• Disturbances in mother-child
interactions are observed at
one year postpartum, even
when mothers are no longer
depressed.
38
Secure attachment
Sensitivity and
parental availability are
key determinants of
secure attachment
(Cassidy & Shaver, 1999; Trapolini et
al., 2007)
39
4. IMPACT OF MATERNAL
DEPRESSION ON INFANT AND
CHILD HEALTH
40
Infant development
• Meta-analysis and systematic review
both suggest that PPD has a significant
effect on infants’ cognitive and social
development (Beck, 1998; Grace,
Evindar & Stewart, 2003)
• More behaviour problems
– Depression, withdrawal,
hyperactivity, aggression
• Lower cognitive functioning
– Verbal, perceptual, quantitative skills
(Beck ,1998)
41
Infant behaviour
<12 month old infants:
• more tense, less content
• fewer positive facial
expressions
• more negative
expressions and protest
behavior
• drowsy, withdrawn,
avoidant
• more crying--fussy and
disruptive
• reduced sociability to
strangers and
performance on learning
tasks
• disengaged in maternalinfant interactions and in
toy play
• more sleep problems
(Whiffen & Gotlib, 1993 Field,
1984; Murray et al., 1996; Grace
et al., 2003)
42
Infant behaviour
12 to 36 month olds:
• show less sharing,
concentration, and
sociability to strangers
• show decreased positive
affect
• lower overall rate of
interaction
• less responsive and
interactive
(Lyons-Ruth et al., 1986; Murray, 1992; Righetti-Veltema et al., 2003)
43
Child behaviour
3 to 5 year old children:
• are more “difficult”
• respond in negative
manner to friendly
approaches by other
children
• boys most likely to show
behaviour problems
12 year olds:
• behavioral and
adjustment problems and
substance abuse (esp.
boys)
(Leinonen 2003)
(Murray et al., 1999; Sinclair et al., 1996)
44
2.25
Depressed: Aggression
Depressed: Anxiety
Depressed: Hyperactivity
Non-Depressed: Aggression
2
Non-Depressed: Anxiety
Behavioral Score
Non-Depressed: Hyperactivity
1.75
1.5
1.25
1
2
4
6
Age (Years)
8
45
However parenting more
powerful predictor than whether
or not mother was depressed
46
Offspring of postnatally
depressed mothers at increased
risk for depression by age 16
years, partially explained by
insecure infant attachment.
4. HOW DOES MATERNAL
DEPRESSION GET UNDER
THE SKIN?
48
49
50
Hypothalamic-Pituitary Adrenal
(HPA) Axis
Cortisol is secreted by the
adrenal cortex via
pulsations that follow a 24hour (diurnal) circadian
profile (Hellhammer, 2009)
Stressors (like PPD)
stimulate the
activation of the HPA
which triggers the
release of the steroid
hormone cortisol from
the adrenal gland
(Essex, 2002)
Glucocorticoids/
cortisol
HPA Axis
 Sensitive periods of enhanced brain plasticity
vulnerable to long-term effects of cortisol
 Over-activation of the HPA system related to:




decreases in brain volume
inhibition of neurogenesis
disruption of neuronal plasticity
abnormal synaptic connectivity
(Gunnar, 2009)
HPA Axis
Prolonged exposure to elevated levels of cortisol predict:
 increased insulin resistance
 obesity
 diminished immune responses
 reduced cognition, memory
 fear behaviours, hypervigilance
 attention deficits, behavioural problems
 disturbances with emotional regulation & self control
(Essex, 2002, Gunnar, 1998)
Depression &
child cortisol
• Infants, 3 year olds, 6-8 year olds,
(r=.22, p<.005; Lupien et al., 2000) and13 year
olds of depressed mothers display
higher cortisol levels than children
of non-depressed mothers.
• Months of exposure to PPD in
child’s first year of life is potent
predictor of ↑cort levels.
55
Maternal Child
Interaction
Quality?
Diurnal Rhythm
Predicted Reduction in the Daily Decrease of
AUC
199
Cortisol Area Under Curve
198
197
196
195
Reduction in the decrease
of cortisol due to socioemotional growth below
average
194
193
b=.07, p=.01
192
191
Morning
Noon
Afternoon
Evening
58
Predicted Cortisol For Different Cognitive
Growth Fostering Interaction Levels
250
b=.06, p=.04
Area Under the Curve
200
150
100
50
0
One Standard Deviation Above
Average
Average
One Standard Deviation Below
Average
Summary: Infant Cortisol
• Infants show an afternoon flattened
pattern.
• ↑ cognitive growth fostering activities
predict ↓ concentrations of infant cort over
the day
• ↓ average social-emotional growth
fostering activities predict ↓ of a decline in
cort over the day (flatter decline).
Symptoms or strategies?
•
•
•
•
•
•
•
Attentional problems
Hypervigilance
Compulsions
Agitation
Aggressiveness
Provocativeness
Acting the victim
(Crittenden, A&P)
61
5. SO WHAT DO WE DO?
62
63
Reviews of Tx interventions
• 2 reviews of non-biological tx conclude that: “any
psychosocial or psychological intervention,
compared with usual postpartum care, was
associated with reduced likelihood of continued
depression within the first year postpartum”.
(Dennis, 2004; Dennis et al., 2007)
• 2 reviews of biological tx have contrasting
findings--Inconclusive (Dennis, 2004) and SSRI’s
effective (Arroll et al. 2009).
64
65
The treatments (focused on S/S) had no
significant impact on maternal management
of early infant behaviour problems, security
of infant-mother attachment, infant
cognitive development or any child outcome
66
at 5 years.
67
Professional MCI for PPD
• Group support for mothers with PPD
provided by professionals
• Same intervention as in MOMS trial
provided in group setting; no focus on
symptoms of PPD
• Mother-infant interaction improved, PPD
did not change
• No control group; n=17
Jung, Short, Letourneau (2006). JAD
68
69
Professional MCI for PPD
• Professional phone (focused on s/s) v. homebased maternal-child interaction guidance for
mothers with PPD (n=71)
• Video feedback by trained professionals
• Home-based professional support provided
greater impact on MCI and attachment
• Depression reduced in both groups, but no
difference b/w groups
vanDoesum et al. (2008). Child Development.
70
Health care implications
Screen all mothers with EPDS
• Direct, but sensitive questions to explore
whether mothers have thoughts of
infanticide, esp. when suicide is
mentioned (Barr & Beck, 2008)
71
Health care implications
• Psychotherapeutic or psychological
support for mother (Dennis Reviews)
• Parent-infant interaction/relationship
guidance (Jung et al., 2007; Van Doesum et al., 2008)
• AAI and CARE-Index as assessment tools
to guide relationship-focused intervention
72
Thank you
nicole.letourneau@ualberta.ca
73