CHIPRA Connect
Maternal Depression &
Social-Emotional Development
Screening & Referral
in Primary Care
Marian F. Earls, MD, FAAP
Maternal Depression
• Of all women, up to 12% may experience
depression in a given year.
• If the woman has low income, the prevalence is
doubled.
• If a woman experiences Post Partum Mood
Disorder (PPMD), she is likely to experience it
with subsequent pregnancies.
• PPMD can affect mothers with subsequent
pregnancies even without a previous history with
earlier births.
Compounding Factors
Age and Income
– 40% - 60% of parenting teens and other
mothers who have low income report
depressive symptoms.
– 25% of parenting mothers who have low
income have depression compared to 12% in
all women.
Risk Factors for the Mother
The mother can be placed at risk for
depression if the child has
– Difficult temperament
– Hard to read cues
– Difficulty managing stress
– Insecure attachment
– Prematurity; chronic health condition
– Birth trauma
Perinatal Depression
The experience of minor or major
depression
•8.5% - 11% of women during
pregnancy
•6.5% - 12.9% of women
postpartum
The experience of major depression
•3.1% - 4.9% of women during
pregnancy
•1% - 6.8% of women in the 1st year
postpartum
Peak Occurrence
• 2-3 months postpartum is the peak for
minor depression
• 6 weeks postpartum is the peak for major
depression
Spectrum Encompasses
• Postpartum (“Maternity” or “Baby”) Blues
• Postpartum Mood Disorders (PPMD)
includes
– Postpartum Depression
– Postpartum Psychosis
Spectrum of Depressive Symptoms
50% - 80% of all mothers experience “Maternity
(Baby) Blues” after birth.
• Transient depressed mood, irritability, crying,
anxious, afraid, confused.
• Begins a few days after the birth.
• May last 2 weeks; does not impair function.
• Treat with reassurance and emotional support.
• Risk factor for later PPMD.
Spectrum of Depressive Symptoms
Postpartum Depression meets DSM IV
criteria as a minor/major depressive
disorder.
• Occurs during postpartum or within the
1st year.
• 13% - 20% of women experience PD after
birth.
Spectrum of Depression Symptoms
• 1-3 of 1,000 women experience Postpartum
Psychosis (PPP) after birth.
• Occurs in the first 4 weeks after birth.
• Impairment is serious.
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Paranoia
Mood shift
Hallucinations, delusions
Suicidal and homicidal thoughts
• Requires immediate medical attention;
hospitalization
Impact of Maternal Depression
Early brain development
– The migration of neurons, formation of synapses, and
pruning are affected by genetics and the environment.
– If an infant lives in a an environment of neglect,
there can be MRI visible changes in the frontal lobes.
– If an infant lives with others who are experiencing
depression, there is likely to be impaired social
interaction and other developmental delays.
Social-Emotional Development Why concern?
Immediate impact
– Maternal depression compromises bonding.
– Babies often avoid interaction; attachment is
at risk.
– The mother-child relationship creates an
environment for the infant in which s/he
withdraws from daily activities.
– Emotional and social development, as well as
intellectual, language, and physical
development is at risk.
Impact of Maternal Depression
– At 2 months, the infant has poor state
regulation, looks at the depressed mother
less, has less interaction with objects, and
has a lower activity level.
– Infants are at risk for Attachment Disorder,
Failure to Thrive, and to show developmental
delay at age 1 on the Bayley Scales of Infant
Development.
Impact of Maternal Depression
• Neonatally
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Poor orientation skills, tracking
Decreased tone
Lower activity level
Attribution of negative temperament
• Infants and toddlers
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Sad, lethargic; little interest in exploration; withdrawal
Eating or sleeping problems
Cries a lot; difficult to soothe; little vocalization
Difficulty with comforting self; may self-stimulate
Doesn’t turn to significant adults for comfort
No preferred caregiver; may seek comfort from anyone
Resists touch or clings
Early Response is Urgent
If the mother continues to experience
depression, and there is no intervention
for the dyad (mother-child relationship),
the child’s developmental issues are likely
to persist and be less responsive to
intervention over time
Impact of Maternal Depression
Impaired parenting
Bonding
Emotionally disengaged; less speech
Perception of child behavior
Less positive attribution; increased irritability &
hostility
Interaction
Less sensitive and attuned; more controlling
Apathy to the baby; indifference to caregiving
Social factors
Impaired social interactions; withdrawn
Impaired attention to and judgement for health and
safety
Impact of Maternal Depression
Long Term
• Infants are at risk for insecure attachment. Children
with insecure attachment are more likely to have
behavior problems and conduct disorder.
• Maternal depression in infancy is predictive of cortisol
levels in preschoolers, which is linked with anxiety, social
wariness and withdrawal
• When mothers experienced major depression, then
attachment disorders, behavior problems, and
depression and other mood disorders can occur in
childhood and adolescence
Pending AAP Statement
• Post Partum Depression leads to
– Adverse affects on infant brain development
– Family dysfunction
– Cessation of breastfeeding
– Inappropriate medical treatment of the infant
– Increased costs of medical care
• To have a positive impact on the health of the child and
family, Medical Homes can be timely and proactive by
– Implementing screening
– Supporting the mother-child relationship
– Identifying and using community resources for
referral and treatment
Impact of Maternal Depression
Long Term
When mothers experience depression, the
children, as they age, often have
– Poor self-control
– Poor peer relationships
– School problems
– Aggression.
– Special education
– Grade retention
– Early school exit
Pending AAP Statement
• Advocate for and support
– Awareness of the need for screening in the obstetric
and pediatric periodicity of care schedules.
– Use of evidence-based interventions focused on
healthy attachment and parent-child relationships.
– Training for professionals who care for very young
children.
– Appropriate payment.
AAP Mental Health Competencies
The “primary care advantage”
• Longitudinal, trusting relationship
• Family centeredness
• Unique opportunities for prevention &
anticipatory guidance
• Understanding of common social-emotional &
learning issues in context of development
• Experience in coordinating with specialists in
the care of CSHCN
• Familiarity with chronic care principles &
practice improvement
Mental Health Competencies
• Systems-based practice – MH advocacy,
collaborative relationships
• Patient Care – build resilience, identify risk,
partner with family
• Medical Knowledge – DSM-PC, evidence base
for screening and interventions
• Practice-based Learning & Improvement
• Interpersonal &Communication Skills –
common factors approaches
• Professionalism
Bright Futures
Health Promotion Themes include:
• Promoting Family Support: Bright Futures
now includes parental social-emotional wellbeing surveillance.
• Promoting Child Development
• Promoting Mental Health
Opportunities for Prevention and
Promotion in Primary Care
• Psychosocial and maternal depression screening
• Developmental & behavioral screening and
surveillance in pediatric and family practice
offices
• Social/emotional screening for children
identified “at risk”
• Prenatal Visits
Psycho-social screening and surveillance for risk and
protective factors is an integral part of routine care and
the relationship with the child and family.
Implementation requires a QI approach to office process
Use of a Preventive Services Prompting Sheet to increase reliability of process
Name
Visit
1 wk
Date
length/ht
wt
hc
bmi
bp
hearing
vision
Edinburgh
ASQ
autism risk?
MCHAT
lead
hgb
dental var
TB ?'s
ROR book
DOB
Chart #
Place X in box when done.
(or date in box if off schedule)
1 mo 2 mo 4 mo 6 mo 9 mo 12 mo 15 mo 18 mo 2 yr
or
or
or
if indic
30 mo 3 yr
4yr
5yr
Edinburgh Postpartum
Depression Scale
– Completed by the mother
– At 2 month, 4 month, 6 month visits
– Simple 10 multiple choice questions
– Score of 10 or greater indicates possible
depression
– English and Spanish
– Sensitivity – 86%; Specificity – 78%
– Free download
USPSTF – PHQ-2
– Not specific to postpartum; can be used
during pregnancy and for surveillance and to
indicate risk of depression in adults in
general.
– “Over the past 2 weeks,
(1) have you ever felt down, depressed, or
hopeless? and (2) have you felt little interest
or pleasure in doing things?”
ASQ -SE
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Parent/caregiver completes in 10-15 minutes
English and Spanish
1-3 minutes to score
Handouts on social-emotional milestones and
activities
• Used in conjunction with the ASQ or another
validated screening tool that provides
information on overall development
ASQ -SE
• Use the 6 month tool for ages 3 – 8
months
• Completed by mother
• Single cutoff score
• Provides information about infant
caregiver interaction
• Screens affect, self-regulation, adaptive
functioning, autonomy, compliance,
communication, and interaction
Infant Attachment
• DC 0 – 3
• 206: Reactive Attachment Deprivation /
Maltreatment Disorder of Infancy
• Observed in the context of evidence of
deprivation or maltreatment manifested by:
1. Persistent parental neglect or abuse of a physical or psychological nature, of
sufficient intensity and duration to undermine the child’s basic sense of
security and attachment;
2. Frequent changes in, or inconsistent availability of, the primary caregiver,
making an attachment to an individual caregiver impossible; or
3. Other environmental compromises and situations beyond the control of the
parent & child which are prolonged, interfere with the appropriate care of
the child, and prevent stable attachments.
Coding for Screening
• AAP recognizes the Edinburgh as a
measure of risk in the infant’s
environment.
• Billing is appropriate at the infant’s visit.
• CPT code 99420 (final AAP code
recommendation pending) for the
Edinburgh
• CPT code for ASQ-SE 96110 or 99420
When Screening Shows a Concern
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Communication
Demystification
Support Resources – family, community
Referrals:
– Integrated/Co-located Mental Health Provider
– For mom
– For dyad
– For child for targeted prevention and early
intervention
Demystification and Emotional
Reassurance
• Remove the mystery about maternal depression.
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PPD happens with many women to varying degrees.
It is not her fault; doesn’t mean she is a bad mom.
She will feel better; depression is treatable.
You are a resource. Other helps are available.
• Having a baby is a time of transition for every
family.
– The transition time can be difficult when there are
more stressors; The transition time can be easier
when there are more supports.
Intervention
• For Mom – Ranges from
support, to
therapy, to
therapy plus medication, to
emergency mental health services/hospitalization.
• For Dyad Relationship – Includes
therapy with child mental health professional re
attachment and bonding;
follow-up ASQ SE, and
if Attachment Disorder of Infancy, referral to Part C.
Immediate Action
If the Edinburgh Score is 20 or greater, or
If the mother expresses concern about her or
her baby’s safety, or
If the PCP suspects the mother is suicidal,
homicidal, severely depressed/manic or
psychotic,
– Refer for emergency mental health services
– Be sure she leaves with a support person (not
alone) and has a safety plan
Brief Intervention
• Strengthen the mother-child relationship.
• Understand and respond to baby’s cues.
• Encourage routines for predictability and
security.
• Focus on wellness: sleep, diet, exercise, stress
relief.
• Acknowledge, accept and heal personal
experiences.
• Realistic expectations; prioritize important
things.
• Encourage social connections
Role of Fathers
• Paternal depression is estimated at 6%;
20% of fathers in Early Head Start.
• Incidence of depression is higher when the
mother has PPD.
• If both parents experience depression, the
effect on the children is compounded.
• A father who is not depressed can be a
protective factor.
With Integrated MH Provider
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Immediate triage for positive screens
Secondary screens
Support and follow-up
Referral
Coordination with PCP
Referral for Mom
• Who?
– Mother’s PCP
– Mother’s obstetrician
– Mental health provider
• For
– Individual and/or couple’s therapy
– Medication management
Referral for the Dyad
• The mother and child need to be referred to a
professional with expertise in the treatment of very
young children.
• Evidenced based treatments
• Circle of Security (www.circleofsecurity.org)
• Child-Parent Psychotherapy
• ABC (Attachment & Biobehavioral Catch up)
• Part C services can provide modeling for interaction and
play with the infant to promote healthy development
Other Community Resources
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Public Health Nurses
Lactation Specialists
Parent Educators
Family Support Groups
Parent-child groups
Mother’s morning out
Early Head Start
Mentoring and Home Visitation
– Parents as Teachers Program
– Healthy Families America Program
– Faith based and other volunteers
Summary
• Early brain development research highlights the
importance of a healthy parent-child relationship.
• The non-stigmatizing longitudinal pediatric relationship
lends itself to identifying maternal depression and
supporting parental and child mental health.
• Universal early routine structured psycho-social
screening opens the door to broader communication
within families, and between families and the medical
staff about mental health related concerns.
• Medical providers show they are concerned with all
aspects of a patient’s health and well-being, including
their mental health.