PDF

POSITION STATEMENT

Maternal depression and child development

Posted: Oct 1 2004

The Canadian Paediatric Society gives permission to print single copies of this document from our website. For permission to reprint or reproduce multiple copies, please see our copyright policy.

Principal author(s)

A-C Bernard-Bonnin; Canadian Paediatric Society, Mental Health and Developmental Disabilities Committee
Paediatr Child Health 2004;9(8):575-83

Maternal depression is considered a risk factor for the socioemotional and cognitive development of children [1]. The current prevalence of depression in Canada averages at 6%, which is similar to the rates in other western countries [2] (the female-to-male ratio average is 2:1 [3]). However, the prevalence of postpartum depression is approximately 13% [4]. Women of childbearing age are particularly at risk for depression, and many of them experience high levels of social morbidity and depressive symptoms that are often unrecognized and untreated. Mothers already at risk for depression are particularly fragile during the first months postpartum. Maternal depression has consequences on the child’s development. Because physicians who care for infants and children encounter mothers repeatedly, it is important that they have the knowledge and skills for the detection of symptoms of maternal depression.

The objectives of this statement are:

  • 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 child’s physician in the detection of symptoms of maternal depression, and the coordination of appropriate support and management.

A literature search for the past 15 years was conducted using the MEDLINE database, and by reviewing the bibliographies of the retrieved articles. Of particular interest were the prospective longitudinal cohort studies in which mothers were recruited during their pregnancy or postpartum period, and the children were assessed at regular intervals.

Introduction

Postpartum psychiatric disorders are generally divided into three categories: postpartum blues, postpartum psychosis and postpartum depression. 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. At the other end of the spectrum, 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 [5]. The diagnosis requires that symptoms be present for at least one month and result in some impairment in the woman’s functioning [6]. Women who have experienced postpartum depression have a 50% to 62% risk for future depressions [7]. Other risk factors for postpartum depression include a history of mood disorders, depression symptoms during the pregnancy and a family history of psychiatric disorders [4]. Stress factors, such as negative life events, poor marital relationships, having a special needs infant or medically ‘fragile’ infant, lack of social support, drug abuse, and personal and family psychopathology, have been associated with postpartum depression in some studies, but other studies have found no association [6]. Postpartum depression tends to be milder than episodes of depression that occur at other times, with lower levels of anxiety, agitation, insomnia and somatic symptoms [8]. However, the duration seems to be the same in postpartum and nonpostpartum depression, and lasts several months [6].

The consequences on the child of maternal postpartum depression are not restricted to infancy, but can extend into toddlerhood, preschool age and even school age. Maternal depression that occurs later influences the development of the school-age child and the adolescent. Table 1 summarizes the consequences of maternal depression from prenatal issues to adolescence.

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

Behavioural

Passive noncompliance, less mature expression of autonomy, internalizing and externalizing problems, and lower interaction

Cognitive

Less creative play and lower cognitive performance

School age

Behavioural

Impaired adaptive functioning, internalizing and externalizing problems, affective disorders, anxiety disorders and conduct disorders

Academic

Attention deficit/hyperactivity disorder and lower IQ scores

Adolescent

Behavioural

Affective disorders (depression), anxiety disorders, phobias, panic disorders, conduct disorders, substance abuse and alcohol dependence

Academic

Attention deficit/hyperactivity disorder and learning disorders

The associations between maternal depression, maternal behaviour and child outcomes are complex, and not all studies have found a relationship between maternal depression and indicators of poor parenting. Variations in the type, severity, chronicity and timing of maternal depression [9], heterogeneity in sampling (community versus high-risk multiproblem samples), and potentiating risk factors, such as family adversity, low social support and financial stress [10], all contribute to differences in outcomes in children. On the other hand, stress factors can be responsible for adverse child outcomes in the absence of maternal depression.

Maternal depression and infant development

Mother-infant interactions

On a daily basis, infants repeatedly participate in interactive routines with their mothers. Maternal depression compromises the dyad’s capacity to mutually regulate the interaction, through two interactive patterns, intrusiveness or withdrawal. Intrusive mothers display a hostile affect, and disrupt the infant’s activity. The infants experience anger, turn away from the mother to limit her intrusiveness and internalize an angry and protective style of coping. Withdrawn mothers are disengaged, unresponsive, affectively flat and do little to support the infant’s activity. The infants are unable to cope or self-regulate this negative state, and develop passivity, withdrawal and self-regulatory behaviours (eg, looking away or sucking on thumb) [11][12].

Cognitive development

Infants of postnatally depressed mothers have been reported to show patterns of dysregulated attention and arousal. In a study by Murray [13], cognitive performance regarding the independent existence of objects was worse for infants of 61 postnatally depressed mothers than the infants of 42 nondepressed mothers, even after adjustment for contextual adversity. Depressed mothers are less likely to offer contingent stimulation to their infants [14], and this disrupts their performance on nonsocial learning tasks [15]. Another factor that may interfere with learning is the negative affect shown by infants of depressed mothers, even when they are interacting with nondepressed adults [16]. It has been documented that an infant’s own negative affect interferes with learning and the ability to process information [17].

Maternal depression and developmental outcome of toddlers and preschoolers

Behavioural development

Depressed mothers generally show less attentiveness and responsiveness to their children’s needs. They are also poor models for negative mood regulation and problem solving. Longitudinal studies have compared the behaviours of depressed and nondepressed mothers, and the outcome of their children. They showed that depressed mothers were less likely to set limits on their children and to follow through if they did set limits [18]. Children of depressed mothers appeared more passively noncompliant, with less mature expressions of age-appropriate autonomy [19]. They were rated by their dysphoric mothers as being more vulnerable, and having more internalizing (depressed) and externalizing problems (aggressive and destructive), which are associated with lower interaction ratings [20]. They were also 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 [21]. These aspects of child behaviour were associated with postnatal depression, even when taking adverse situations such as marital conflict, and demographic variables, such as maternal age, ethnicity, socioeconomic status, marital status, child’s age and number of siblings, into account.

Cognitive development

Studies on large samples all agree on the negative impact of maternal postpartum depression on a child’s cognitive development. Early experience with insensitive maternal interactions (as in maternal postpartum depression) appears to be predictive of poorer cognitive functioning [22]. Boys may be more sensitive than girls to the effects of the mother’s illness. In a study by Sharp et al [23], only boys showed a decrease on standardized tests of intellectual attainment (mainly on indexes of abstract intelligence, reasoning about opposites and analogies) and the “draw-a-child” task. Other aspects of cognitive development, such as cognitive-linguistic functioning [24], have also been shown to be negatively affected, and there were also deficits on the perceptual and performance scale [25]. Outcome effects were independent of birth order, maternal education, family income, marital status and social support.

Maternal depression and developmental outcome of school-age children

Behavioural development

Various studies have shown that school-age children of depressed mothers display impaired adaptive functioning, including internalizing and externalizing problems. Although the studies reviewed by Beardslee et al [26] were uncontrolled studies, a more recent review by Downey and Coyne [27] included studies using control groups (matched for age of parents, occupational status, ethnicity, marital status, and number and age of children), standardized diagnostic criteria to identify parental depression and valid measures of psychological functioning in children. Billings and Moos [28] showed that family stress and low support added to the prediction of child disturbance beyond that accounted for by having a depressed parent. However, the study of Lee and Gotlib [29] comparing children of depressed psychiatric mothers and nondepressed psychiatric mothers showed that the child’s adjustment was more strongly related to the severity of maternal psychopathology than to diagnosis status.

Children of depressed parents are also at higher risk of psychopathology, including affective (mainly depression), anxiety and conduct disorders. Hammen et al [30] compared children from four groups of mothers (mothers with unipolar disorder, bipolar disorder and chronic medical illness, and normal mothers) with no differences in ethnicity, age, socioeconomic status or educational level. They showed that, even with the effects of chronic stress statistically controlled, there were still differences in the psychosocial outcome variables among groups, and there was particular impairment in children of unipolar mothers [30]. Other studies [31]-[34], in which there were no demographic differences (age, marital status and socioeconomic level) between depressed and nondepressed parents, have confirmed an increased risk of psychopathology in the children of depressed parents. It seems that onset of a major depression disorder before 30 years of age in parents increases the risk of their children developing depression quite early during childhood [33][34]. It is somewhat difficult to delineate which behavioural disorders are due to maternal depression and other environmental factors, and which are due to genetic susceptibility.

Academic development

There seems to be an association between attention deficit/hyperactivity disorder (ADHD) in children and maternal mental health, as shown by a cross-sectional study by Lesesne et al [35]. Using the 1998 National Health Interview Study on 9529 mother-child dyads, they found an association between an activity-limiting depression, anxiety or emotional problem in mothers, and ADHD in their children aged four to 17 years, even after adjusting for the child’s age, sex, race, household income and type of family structure [35].

In a longitudinal study of 132 children by Hay et al [36], 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. In addition, boys were more affected than girls. However, academic difficulties in children of depressed mothers were not mediated by parental IQ, sociodemographic variables or the mother’s mental health after the postpartum depressive episode.

Maternal depression and developmental outcome of adolescents

Behavioural development

Generally, adolescence is a vulnerable period for affective illness and major depressive disorder, which are observed twice as often in girls than in boys [37]. Two cross-sectional studies showed that adolescents with a depressed parent suffered from psychosocial maladjustment [38] and experienced a significantly higher rate of affective disorder than adolescents of nonaffective psychiatric control parents [39].

Longitudinal studies have consistently reported 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 (age, ethnicity, socioeconomic status and educational level). Hammen et al [40] followed a cohort of 92 children/adolescents between the ages of eight and 16 years over a three-year period. They found that 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. Weissman et al [31][41][42] evaluated 91 families with 220 children between six and 23 years over a 10-year period. They observed higher rates of major depression, phobias, panic disorder and alcohol dependence in the offspring of depressed parents than in the non-ill comparison group. When major depression occurred, onset was commonly between the ages of 15 and 20 years. Beardslee et al [43] studied 81 families, randomly selected at an urban centre of a health maintenance organization, with 153 children between the ages of six and 19 years. At the initial assessment, 30% of the children/adolescents with an affectively ill parent had at least one episode of an affective illness compared with 2% in the control group. Four years later, the rates of affective disorders were 26% and 10%, respectively, and offspring of affectively ill parents had longer episodes, earlier onset and a greater number of comorbid diagnoses [44].

Academic development

Problems encountered in school-age children, mainly ADHD and learning disabilities, persist into adolescence [35].

Risk factors, vulnerability and resilience

It has been noted in many studies that some children with depressed caregivers do not display behavioural dysfunctions and that some factors may exacerbate or moderate the effects of parental depression [45].

Contextual factors

Among contextual risk factors, marital conflict [27], stressful life events [6], limited social support [6], poverty [46], lower social class [13] and lower maternal education [47] are factors that may exacerbate parental depression and maladaptive parenting. In a study of 156 toddlers (of whom 104 had mothers with major depressive disorder since the child’s birth), Cicchetti et al [48] showed that contextual risk factors mediated the relation between maternal depression and child behaviour problems.

Role of fathers

The role of fathers and paternal distress in child development are understudied, meanwhile, primary emphasis continues to be placed on mothers, possibly because the main caregiver for the young infant is usually the mother. However, in their study of three- to six-month-old infants, Hossain et al [49] showed that infants of depressed mothers interacted better with their nondepressed fathers who could ‘buffer’ the effects of the mother’s depression on infant interaction behaviour. In addition, a cross-sectional study [50] of 96 families with children between the ages of five and 10 years showed that in families in which the mother was depressed, children showed lower social and emotional competence if the father also had a psychiatric disorder. The role of fathers has been studied indirectly in the context of marital discord. According to a review by Downey and Coyne [27], marital distress contributes directly to children externalizing problems, and increases their risk for clinical depression by inducing and maintaining parental depression.

Characteristics of the child

Sex differences have been described in some studies [13][23][36], with boys being more vulnerable and distressed by maternal depression than girls.

Temperament of the child also contributes to the interpersonal processes of parental depression. It has been shown that depresssed mothers make more negative appraisals of their child’s behaviours, feel less confident in their parental efficacy and use maladaptive parenting techniques more often [27][51][52]. A child with a more robust and easy-going temperament will be more impervious to their depressed mother’s negative behaviour and will not show a reciprocal pattern of negativity [27]. Other sources of resilience in children include social and cognitive skills that help them receive positive attention from adults other than their depressed parents and help reduce their depressed parent’s feeling of noncompetence and rejection. It seems that an understanding of the parent’s illness and recognition by the child that he or she is not to blame for the parent’s illness-related behaviour is very important to the development of resiliency in a child [53].

Although the interaction between parents and their handicapped child is beyond the scope of the present paper, it has been described that parents of mentally retarded children report higher depression scores than control parents [54], and that caregiving difficulty is a predictor of maternal depression [55].

Treatment options

Pharmacotherapy

Because many depressive episodes occur during childbearing years, the decision to give antidepressant drugs must be balanced between the mother’s well-being and fetal safety. If a woman who just recently recovered from depression treated with antidepressants becomes pregnant, she is at high risk of relapse [7]. Depression during pregnancy is associated with inadequate prenatal care, poor nutrition, higher preterm birth, low birth weight, pre-eclampsia, spontaneous abortion, substance abuse and dangerous risk-taking behaviour. The substantial morbidity of untreated depression during pregnancy must be weighed against the risk of medication [56]. Tricyclic antidepressants have been replaced by selective serotonin reuptake inhibitors (SSRIs) that are associated with a low risk of toxic effects.

Both tricyclic antidepressants and SSRIs cross the placental barrier. However, Kulin et al [57] did not find any increase in major fetal malformations or pregnancy-related complications in 267 women taking SSRIs compared with 267 controls. Another study [58] on 228 pregnant women taking fluoxetine showed an increase in minor perinatal complications when the medication was taken during the third trimester.

In the neonatal period, it seems that behavioural and heart rate responses to pain are reduced in newborn infants exposed to SSRIs in utero [59]. Nulman et al [60] compared 46 children of mothers treated with a tricyclic antidepressant during pregnancy, 40 children of mothers treated with fluoxetine and 36 control children of nondepressed mothers who did not take any medication during pregnancy. After adjusting for the duration and severity of maternal depression, duration of treatment, number of depressive episodes after delivery, maternal IQ and socioeconomic status, the study showed that tricyclic antidepressants and fluoxetine had no adverse effects on the global IQ, language development or behaviour of children between 15 and 71 months of age [60]. In a smaller sample, Casper et al [61] compared 13 children born to depressed mothers who elected not to take medication during pregnancy and 31 children born to mothers treated with SSRIs. Although the scores on the Bayley Mental Development indexes were similar in both groups of children (aged six to 40 months), children exposed to SSRIs scored lower on the Bailey Psychomotor Development indexes and the motor quality factors of the Bailey Behavioural Rating Scale [61].

One of the numerous benefits of breastfeeding is the enhancement of maternal-infant bonding. It is therefore very important that a depressed mother who wishes to breastfeed be given adequate information. If the antidepressant medication is discontinued in the postnatal period, there is a risk of relapse, with negative consequences on the emotional and behavioural development of the infant. On the other hand, all antidepressants are excreted in breast milk. Most of the information available comes from case reports, case series, and pharmacokinetic investigations [62]. According to a review by Ito [63], tricyclic antidepressants and the SSRIs, sertraline and fluoxetine, are the drugs of choice. No neurological or developmental abnormalities have yet been demonstrated in children exposed SSRIs [64][65] or tricyclic antidepressants [66] through breast milk.

To reduce infant exposure when treating postpartum depressed mothers, it is important to document all maternal use of medication, alcohol, tobacco, herbal remedies and drugs, and to encourage the discontinuation of any environmental and nonessential exposures. If maternal illness is adversely impacting interaction with the infant or other children, it is better to err on the side of treatment exposure. If it is decided to use antidepressant therapy, the selection of the antidepressant should be based on the mother’s prior response and experience of adverse effects with a particular agent, risk of interactions with concurrent medications and published adverse effects associated with a particular agent on breastfeeding mothers and their infants. Maternal doses should be monitored to aim for the lowest possible dose that provides complete control of the depressive symptoms. Monotherapy is preferable, and the medication used in pregnancy should be continued in the postnatal period. The infant’s exposure to SSRIs can be reduced by emptying the breasts of milk and discarding it (‘pump and dump’) approximately 8 h to 9 h after the mother has taken the medication [67].

Although there is no final consensus on the use of antidepressants during pregnancy and lactation, antidepressant therapy should be considered in the context of a comprehensive risk-benefit assessment, as illustrated by the decision model of Wisner et al [68]. Antidepressant therapy should be considered in women who have moderate to severe symptoms and who have not responded to nonpharmacological treatments. Recent reviews [56][67]-[69] show that tricyclic antidepressants and SSRIs appear to be quite effective during pregnancy and the postnatal period, and may be used during pregnancy and lactation.

Social support and psychoeducational interventions during infancy

Because of the consequences of maternal depression on an infant’s development, many intervention studies have targeted postnatal mothers. Interventions have focused on altering the mother’s mood state, increasing her sensitivity to or awareness of the infant’s cues and diminishing the negative perceptions about the infant’s behaviours [16]. Interaction coaching techniques aim to improve the quality of mother-infant interactions, either by instructing overstimulating intrusive mothers to imitate their infants or by showing withdrawn mothers how to attract and maintain their infants’ attention [70].

Social support and home visiting interventions have been successful in improving depressed mothers’ moods and attitudes [71][72], as well as their infants’ attachment security and psychomotor development [46][73].

More comprehensive treatment approaches have been promising. McDonnough [74] described an interactive guidance treatment directed at problems identified by the mother in the management of her infant that gives support, practical advice and education, together with strong reinforcement of good parenting practices. Field [75] studied 80 depressed mothers and their infants, offering a comprehensive social/educational/vocational rehabilitation program and free daycare in a model infant nursery over a three-month period to one-half of them. Six months later, mothers from the intervention group showed more positive interaction behaviours, and their infants had superior Bailey Mental and Motor scores, as well as more positive interaction behaviours than subjects in the control group [75].

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. In a study by Beardslee et al [76], 37 families who had an eight- to 15-year-old child and a parent with an affective disorder were randomly assigned to a lecture group discussion or a clinician-facilitated psychoeducational intervention. Both interventions gave parents information about the causes and symptoms of childhood and adult depression, and emphasized the need for communication within the family. However, the clinician-facilitated intervention linked cognitive material to the life experiences of the family. Those in the clinician group showed more behaviour and attitude changes among parents and children, including higher levels of communication from parents to children about the illness and better understanding by the child of the parent’s affective illness [76].

Psychotherapy

Robert-Tissot et al [77] compared psychodynamic therapy with interaction guidance therapy. The psychodynamic treatment focuses on the mother’s representation of her infant and her relationship with the infant, and explores aspects of the mother’s own childhood and early attachment history. As already described, the interaction guidance therapy seeks to identify positive caregiving behaviours and to suggest alternative interpretations of an infant’s behaviour. After a maximum of 10 sessions, there was a significant improvement in both groups. The infants’ sleep and feeding disturbances improved, separation difficulties diminished, maternal sensitivity to infants’ cues increased and intrusive control decreased. In addition, maternal self-esteem improved, and infants became more cooperative, less compulsive-compliant and showed more happiness.

Interpersonal therapy focuses on interpersonal relationships and problems experienced by depressed postpartum mothers. In a study of 120 depressed postpartum women [78], interpersonal psychotherapy reduced depressive symptoms and improved social adjustment in the subjects compared with the control group on the waiting list. Interpersonal therapy has also been used in the prevention of postpartum depression in pregnant women with at least one risk factor for postpartum depression [79].

Complementary and alternative therapies

Complementary and alternative therapies are becoming increasingly common, and St John’s Wort is the second best-selling herb in Canada [80]. St John’s Wort seems to be effective for mild to moderate depression, although it has many drug interactions [81]. There are almost no data on its reproductive safety and it cannot be recommended as safe therapy during pregnancy [82]. Data on its safety during breastfeeding are scarce. From a case report [83], it was observed that hyperforin was excreted in breast milk at a low level, while hyperforin and hypericin remained below the lower limit of quantification in the infant’s plasma. A prospective observational study of 33 breastfeeding women receiving St John’s Wort [84] found no differences in the frequency of decreased milk production nor in infants’ weight over the first year of life compared with a control group.

Role of the primary care physician/paediatrician

According to the 1994 guidelines of the Canadian Task Force on the Periodic Health Examination [85], fair evidence exists to exclude routine testing of asymptomatic persons for depression using the General Health Questionnaire or the Zung-Self-Rating Depression Scale (Class of recommendation: D, Level of evidence: I) from the Periodic Health Examination. However, it is strongly suggested that clinicians maintain a high degree of clinical suspicion for depression among their patients [85]. In their 2002 statement [86], the United States Preventive Services Task Force recommended screening adults for depression in clinical practices that have systems in place to assure accurate diagnosis, effective treatment and follow-up (Class of recommendation: B, Level of evidence: I). In their 2003 recommendations for paediatric practice, the American Academy of Pediatrics Task Force on the Family [87] stated that paediatricians should ascertain the physical and mental health of the parents in their practice, and periodically review the importance of parents’ attention to their own mental health needs.

In a broad survey of 559 women across three clinical settings, Kahn et al [88] reported that more than 80% of mothers recognized the potential impact of depression on the child’s health and well-being, and that more than 85% of mothers accepted the paediatricians role in screening and referral to adult primary care. However, a recent study [89] showed that maternal depression was under-recognized by paediatric health care providers. Moreover, Olson et al [90] reported that paediatricians lacked confidence in their ability to diagnose maternal depression and limited their involvement because of incomplete knowledge and training.

The paediatricians’ role in maternal depression should be one of screening, followed by guidance for additional evaluation and treatment. There should be a systematic inquiry about family history of depression and about previous episodes of maternal depression. Screening questionnaires have been developed and validated specifically to detect postpartum depression [91]-[93]. Examples of questions that may elicit information about postpartum depression are listed in Table 2 [90][94][95]. Once depression is suspected, the paediatrician can give advice and discuss with the mother’s physician or make an appropriate referral to psychiatric services. Collaboration between the mother’s physician and the child’s physician is very important.

TABLE 2
Trigger questions to elicit information about postpartum depression
  • How are you feeling about being a new mother?
  • Are you enjoying your baby?
  • Do you find that your baby is easy or difficult to care for?
  • How are things going in your family?
  • Are you getting enough rest?
  • How is your appetite?
  • During the past month, have you often been bothered by feeling down, depressed or hopeless?
  • During the past month, have you often been bothered by having little interest or pleasure in doing things?

Data from references [90][ 94] and[ 95]

For many mothers, well-baby care visits may be their sole consistent ongoing contact with health care providers. The child’s physician may be the first professional to learn of the infant- and child-rearing difficulties of a distressed mother. Moreover, the child’s physician can help the depressed mother understand how her mood might affect her parenting and contribute to the child’s problems. Main areas of assistance include infant sleep problems, child temperament issues, developmental delay, social isolation and family stress. It is important to keep a high index of suspicion of maternal depression when child behaviour problems are discussed during a medical visit. Moreover, interventions for the depression of the mother should take priority over behavioural therapy for the child. Because postpartum depression can have long-term effects on mothers and children and its peak prevalence occurs at approximately three months, it has been suggested to screen for postpartum depression at the two-, six- and 12-month well-baby care visits [95].

In school-age children and adolescents, the presence of difficulties in child adjustment and impaired functioning at home and in school should alert the physician to the possibility of maternal depression. Moreover, in families with a history of depression, one should keep in mind that offspring may become depressed or display other psychopathology, mostly at adolescence. These conditions often stay undiagnosed and untreated for a long time, perpetuating suffering for the whole family. The child’s physician has a key role in facilitating referral to the appropriate services for the child/adolescent and the parent.

Finally, while acknowledging that children of depressed mothers are at risk for developmental and behavioural problems, as well as their predisposition for developing a depressive disorder themselves, the physician should conduct regular developmental surveillance of the child, offer anticipatory guidance, and refer them early for more comprehensive assessment and management of developmental and behavioural disorders.

Conclusions

  • Postpartum depression occurs in approximately 13% of women, and often goes unrecognized. When it is recognized, there is often a long lapse of time between referral and psychiatric evaluation and treatment because of the lack of resources.
  • The infant of a depressed mother is at risk for developing insecure attachment, negative affect and dysregulated attention and arousal.
  • Toddlers and preschoolers of depressed mothers are at risk for developing poor self-control, internalizing and externalizing problems, and difficulties in cognitive functioning and in social interactions with parents and peers.
  • School-age and adolescent children of depressed parents are at risk for impaired adaptive functioning and psychopathology, including conduct disorders, affective disorders and anxiety disorders. They are also at risk for ADHD and learning disabilities.
  • Contextual risk factors such as poverty, marital conflict and stressful life events may exacerbate parental depression and child behaviour problems. On the other hand, some children develop resiliency through an easy-going temperament, good social cognitive skills and understanding of the parent’s illness.
  • Experience with SSRIs during pregnancy and lactation is limited, but no major malformations or physical and developmental risks to the fetus or the breastfed infant have been described. The risks of the mother’s depression seem to outweigh the low risks of antidepressant medication on the fetus or the breastfed infant.

Recommendations

  • Through the surveillance of the well-being and development of infants and children, the physician should stay alert to signs of mother-child interaction difficulties, and behavioural and developmental problems in the child. Under such circumstances, they should keep in mind the possibility of maternal depression, ask a few screening questions and facilitate contact with the mother’s physician or psychiatric services.
  • Mothers who have taken antidepressant medication during pregnancy should be reassured that much of the evidence to date shows that there is no increased risk of teratogenicity or fetal anomalies.
  • Mothers who have taken antidepressant medication during pregnancy should be reassured about the neuro-development of their child because long-term studies have not shown adverse effects, except for subtle differences whose clinical significance remains to be confirmed.
  • Mothers who have taken antidepressant medication during lactation should be reassured that much of the evidence to date shows that there are no neurological or developmental abnormalities in children exposed to such medication through breast milk.
  • Mothers should be told that data on St John’s Wort are scarce and that such herbal remedies should not be taken during pregnancy and lactation.

PSYCHOSOCIAL PAEDIATRICS COMMITTEE 

Members: Kim Burrows MD; Anthony Ford-Jones MD; Gilles Fortin MD; Sally Longstaffe MD (chair); Theodore Prince MD; Sarah Shea MD (board representative)
Liaisons: Jane Foy MD, Committee on Psychosocial Aspects of Child and Family Health, American Academy of Pediatrics; Rose Geist MD, Canadian Academy of Child Psychiatry; Anton Miller MD, Developmental Paediatrics Section, Canadian Paediatric Society
Principal author: Anne-Claude Bernard-Bonnin MD

References

  1. Cummings EM, Davies PT. Maternal depression and child development. J Child Psychol Psychiatry 1994;35:73-112.
  2. Stephens T, Dulberg C, Joubert N. Mental health of the Canadian population: A comprehensive analysis. Chronic Dis Can 1999;20:118-26. http://www.hc-sc.gc.ca/pphb-dgspsp/publicat/cdic-mcc/20-3/c_e.html (Version current at September 15, 2004).
  3. Bland RC. Epidemiology of affective disorders: A review. Can J Psychiatry 1997;42:367-77.
  4. O’Hara MW, Swain AM. Rates and risk of postpartum depression: A meta analysis. Int Rev Psychiatry 1996;8:37-54.
  5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edn. Washington, District of Columbia: American Psychiatric Association, 1994.
  6. O’Hara MW. The nature of postpartum depressive disorders. In: Murray L, Cooper P, eds. Postpartum Depression and Child Development. New York, New York: Guilford Press,1997:3-27.
  7. Llewellyn AM, Stowe ZN, Nemeroff CB. Depression during pregnancy and the puerperium. J Clin Psychiatry 1997;58(Suppl 15):26-32.
  8. Whiffen VE, Gotlib IH. Comparison of postpartum and non-postpartum depression: Clinical presentation, psychiatric history, and psychosocial functioning. J Consult Clin Psychol 1993;61:485-94.
  9. Campbell SB, Cohn JF, Meyers T. Depression in first-time mothers: Mother-infant interaction and depression chronicity. Dev Psychol 1995;31:349-57.
  10. Sameroff AJ, Seifer R, Baldwin A, Baldwin C. Stability of intelligence from preschool to adolescence: The influence of social and family risk factors. Child Dev 1993;64:80-97.
  11. Cohn JF, Tronick E. Specificity of infants’ response to mothers’ affective behavior. J Am Acad Child Adolesc Psychiatry 1989;28:242-8.
  12. Hart S, Field T, del Valle C, Pelaez-Nogueras M. Depressed mothers’ interactions with their one-year-old infants. Infant Behav Dev 1998;21:519-25.
  13. Murray L. The impact of postnatal depression on infant development. J Child Psychol Psychiatry 1992;33:543-61.
  14. Murray L, Fiori-Cowley A, Hooper R, Cooper P. The impact of postnatal depression and associated adversity on early mother-infant interactions and later infant outcome. Child Dev 1996;67:2512-26.
  15. Dunham P, Dunham F, Hurshman A, Alexander T. Social contingency effects on subsequent perceptual-cognitive tasks in young infants. Child Dev 1989;60:1486-96.
  16. Field T. Infants of depressed mothers. Dev Psychopathol 1992;4:49-66.
  17. Singer JM, Fagen JW. Negative affect, emotional expression, and forgetting in young infants. Dev Psychol 1992;28:48-57.
  18. Kochanska G, Kuczynski L, Radke-Yarrow M, Welsh JD. Resolutions of control episodes between well and affectively ill mothers and their young children. J Abnorm Child Psychol 1987;15:441-56.
  19. Kuczynski L, Kochanska G. Development of children’s non-compliance strategies from toddlerhood to age 5. Dev Psychol 1990;26:398-408.
  20. Field T, Lang C, Martinez A, Yando R, Pickens J, Bendell D. Preschool follow-up of infants of dysphoric mothers. J Clin Child Psychol 1996;25:272-9.
  21. Murray L, Sinclair D, Cooper P, Ducournau P, Turner P, Stein A. The socioemotional development of 5-year-old children of postnatally depressed mothers. J Child Psychol Psychiatry 1999;40:1259-71.
  22. Murray L, Hipwell A, Hooper R, Stein A, Cooper P. The cognitive development of 5-year-old children of postnatally depressed mothers. J Child Psychol Psychiatry 1996;37:927-35.
  23. Sharp D, Hay DF, Pawlby S, Schmücker G, Allen H, Kumar R. The impact of postnatal depression on boys’ intellectual development. J Child Psychol Psychiatry 1995;36:1315-36.
  24. NICHD Early Child Care Research Network. Chronicity of maternal depressive symptoms, maternal sensitivity, and child functioning at 36 months. Dev Psychol 1999;35:1297-310.
  25. Cogill SR, Caplan HL, Alexandra H, Robson KM, Kumar R. Impact of maternal postnatal depression on cognitive development of young children. BMJ 1986;292:1165-7.
  26. Beardslee WR, Bemporad J, Keller MB, Klerman GL. Children of parents with a major affective disorder: A review. Am J Psychiatry 1983;140:825-32.
  27. Downey G, Coyne JC. Children of depressed parents: An integrative review. Psychol Bull 1990;108:50-76.
  28. Billings AG, Moos RH. Comparison of children of depressed and nondepressed parents: A social-environmental perspective. J Abnorm Child Psychol 1983;11:463-85.
  29. Lee CM, Gotlib IH. Maternal depression and child adjustment: A longitudinal analysis. J Abnorm Psychol 1989;98:78-85.
  30. Hammen C, Gordon D, Burge D, Adrian C, Jaenicke C, Hiroto D. Maternal affective disorders, illness and stress: Risk for children’s psychopathology. Am J Psychiatry 1987;144:736-41.
  31. Weissman MM, Gammon GD, John K, et al. Children of depressed parents. Increased psychopathology and early onset of major depression. Arch Gen Psychiatry 1987;44:847-53.
  32. Orvaschel H, Walsh-Allis G, Ye W. Psychopathology in children of parents with recurrent depression. J Abnorm Child Psychol 1988;16:17-28.
  33. Wickramaratne PJ, Weissman MN. Onset of psychopathology in offspring by developmental phase and parental depression. J Am Acad Child Adolesc Psychiatry 1998;37:933-42.
  34. Beardslee WR, Versage EM, Gladstone TRG. Children of affectively ill parents: A review of the past 10 years. J Am Acad Child Adolesc Psychiatry 1998;37:1134-41.
  35. Lesesne CA, Visser SN, White CP. Attention-deficit/hyperactivity disorder in school-aged children: Association with maternal mental health and use of health care resources. Pediatrics 2003;111:1232-7.
  36. Hay DF, Pawlby S, Sharp D, Asten P, Mills A, Kumar R. Intellectual problems shown by 11-year-old children whose mothers had postnatal depression. J Child Psychol Psychiatry 2001;42:871-89.
  37. Hirsch BJ, Moos RH, Reischl TM. Psychosocial adjustment of adolescent children of a depressed, arthritic, or normal parent. J Abnorm Psychol 1985;54:154-64.
  38. Klein DN, Depue RA, Slater JF. Cyclothymia in the adolescent offspring of parents with bipolar affective disorder. J Abnorm Psychol 1985;54:115-27.
  39. Lewinsohn AM, Hops H, Roberts RE, Seeley JR, Andrews JA. Adolescent psychopathology, I: Prevalence and incidence of depression and other DSM-III-R disorders in high school students. J Abnorm Psychol 1993;102:133-44.
  40. Hammen C, Burge D, Burney E, Adrian C. Longitudinal study of diagnoses in children of women with unipolar and bipolar affective disorder. Arch Gen Psychiatry 1990;47:1112-7.
  41. Weissman MM, Fendrich M, Warner V, Wickramaratne P. Incidence of psychiatric disorder in offspring at high and low risk for depression. J Am Acad Child Adolesc Psychiatry 1992;31:640-8.
  42. Weissman MM, Warner V, Wickramaratne P, Moreau D, Olfson M. Offspring of depressed parents: Ten years later. Arch Gen Psychiatry 1997;54:932-40.
  43. Beardslee WR, Keller MB, Lavori PW, Klerman GK, Dorer DJ, Samuelson H. Psychiatric disorder in adolescent offspring of parents with affective disorders in a non-referred sample. J Affect Disord 1988;15:313-22.
  44. Beardslee WR, Keller MB, Lavori PW, Staley JE, Sacks N. The impact of parental affective disorder on depression in offspring: A longitudinal follow-up in a non-referred sample. J Am Acad Child Adolesc Psychiatry 1993;32:723-30.
  45. Cicchetti D, Toth SL. The development of depression in children and adolescents. Am Psychol 1998;53:221-41.
  46. Lyons-Ruth K, Connell D, Grunebaum H, Botein S. Infants at social risk: Maternal depression and family support services as mediators of infant development and security of attachment. Child Dev 1990;61:85-98.
  47. Hay DF, Kumar R. Interpreting the effects of mother’s postnatal depression on children’s intelligence: A critique and re-analysis. Child Psychiatry Hum Dev 1995;25:165-81.
  48. Cicchetti D, Rogosch FA, Toth SL. Maternal depressive disorder and contextual risk: Contributions to the development of attachment insecurity and behavior problems in toddlerhood. Dev Psychopathol 1998;10:283-300.
  49. Hossain Z, Field T, Gonzalez J, Malphurs J, Del Valle C, Pickens J. Infants of “depressed” mothers interact better with their nondepressed fathers. Infant Ment Health J 1994;15:348-57.
  50. Goodman SH, Brogan D, Lynch ME, Fielding B. Social and emotional competence in children of depressed mothers. Child Dev 1993;64:516-31.
  51. Field T, Morrow C, Adlestein D. Depressed mothers’ perceptions of infant behavior. Infant Behav Dev 1993;16:99-108.
  52. Gross D, Conrad B, Fogg L, Wothke W. A longitudinal model of maternal self-efficacy, depression, and difficult temperament during toddlerhood. Res Nurs Health 1994;17:207-15.
  53. Beardslee W, Podorefski D. Resilient adolescents whose parents have serious affective and other psychiatric disorders: Importance of self-understanding and relationships. Am J Psychiatry 1988;145:63-9.
  54. Olsson MB, Hwang CP. Depression in mothers and fathers of children with intellectual disability. J Intellect Disabil Res 2001;45:535-43.
  55. Gowen JW, Johnson-Martin N, Goldman BD, Appelbaum M. Feelings of depression and parenting competence of mothers of handicapped and nonhandicapped infants: A longitudinal study. Am J Ment Retard 1989;94:259-71.
  56. Marcus SM, Barry KL, Flynn HA, Tandon R, Greden JF. Treatment guidelines for depression in pregnancy. Int J Gynaecol Obstet 2001;72:61-70.
  57. Kulin NA, Pastuszak A, Sage SR, et al. Pregnancy outcome following maternal use of the new selective serotonin reuptake inhibitors: A prospective controlled multicenter study. JAMA 1998;279:609-10.
  58. Chambers CD, Johnson KA, Dick LM, Felix RJ, Jones KL. Birth outcomes in pregnant women taking fluoxetine. N Engl J Med 1996;335:1010-5.
  59. Oberlander TF, Eckstein Grunau R, Fitzgerald C, et al. Prolonged prenatal psychotropic medication exposure alters neonatal acute pain response. Pediatr Res 2002;51:443-53.
  60. Nulman I, Rovet J, Stewart DE, et al. Child development following exposure to tricyclic antidepressants or fluoxetine throughout fetal life: A prospective, controlled study. Am J Psychiatry 2002;159:1889-95.
  61. Casper RC, Fleischer BE, Lee-Ancajas JC, et al. Follow-up of children of depressed mothers exposed or not exposed to antidepressant drugs during pregnancy. J Pediatr 2003;142:402-8.
  62. Yoshida K, Smith B, Kumar R. Psychotropic drugs in mothers’ milk: A comprehensive review of assay methods, pharmacokinetics and of safety of breast-feeding. J Psychopharmacol 1999;13:64-80.
  63. Ito S. Drug therapy for breast-feeding women. N Engl J Med 2000;343:118-26.
  64. Yoshida K, Smith B, Craggs M, Channi Kumar R. Fluoxetine in breast-milk and developmental outcome of breast-fed infants. Br J Psychiatry 1998;172:175-9.
  65. Burt VK, Suri R, Altshuler L, Stowe Z, Hendrick VC, Muntean E. The use of psychotropic medications during breast-feeding. Am J Psychiatry 2001;158:1001-9.
  66. Yoshida K, Smith B, Craggs M, Kumar RC. Investigation of pharmacokinetics and of possible adverse effects in infants exposed to tricyclic antidepressants in breast-milk. J Affect Disord 1997;43:225-37.
  67. Newport DJ, Hostetter A, Arnold A, Stowe ZN. The treatment of postpartum depression: Minimizing infant exposures. J Clin Psychiatry 2002;63(Suppl 7):31-44.
  68. Wisner KL, Zarin DA, Holmboe ES, et al. Risk-benefit decision making for treatment of depression during pregnancy. Am J Psychiatry 2000;157:1933-40.
  69. Misri S, Kostaras X. Benefits and risks to mother and infant of drug treatment for postnatal depression. Drug Safety 2002;25:903-11.
  70. Malphurs J, Larrain C, Field T, et al. Altering withdrawn and intrusive interaction behaviors of depressed mothers. Infant Ment Health J 1996;17:152-60.
  71. Holden JM, Sagovsky R, Cox JL. Counselling in a general practice setting: Controlled study of health visitor intervention in treatment of postnatal depression. Br Med J 1989;298:223-6.
  72. Fleming AS, Klein E, Corter C. The effects of a social support group on depression, maternal attitudes and behavior in new mothers. J Child Psychol Psychiatry 1992;33:685-98.
  73. Gelfand DM, Teti DM, Seiner SA, Jameson PB. Helping mothers fight depression: Evaluation of a home-based intervention program for depressed mothers and their infants. J Clin Child Psychol 1996;25:406-42.
  74. McDonnough SC. Interaction guidance: Understanding and treating early infant-caregiver relationship disturbances. In: Zeanah CH Jr, ed. Handbook of Infant Mental Health. New York, New York: Guilford Press, 1993:414-26.
  75. Field T. The treatment of depressed mothers and their infants. In: Murray L, Cooper P, eds. Postpartum Depression and Child Development. New York, New York: Guilford Press, 1997:221-36.
  76. Beardslee WR, Versage EM, Wright EJ, et al. Examination of preventive interventions for families with depression: Evidence of change. Dev Psychopathol 1997;9:109-30.
  77. Robert-Tissot C, Cramer B, Stern DN, et al. Outcome evaluation in brief mother-infant psychotherapies: Report on 75 cases. Infant Ment Health J 1996;17:97-114.
  78. O’Hara MW, Stuart S, Gorman LL, Wenzel A. Efficacy of interpersonal psychotherapy for postpartum depression. Arch Gen Psychiatry 2000;57:1039-45.
  79. Zlotnick C, Johnson SL, Miller IW, Pearlstein T, Howard M. Postpartum depression in women receiving public assistance: Pilot study of an interpersonal-therapy-oriented group intervention. Am J Psychiatry 2001;158:638-40.
  80. Einarson A, Lawrimore T, Brand P, Gallo M, Rotatone C, Koren G. Attitudes and practices of physicians and naturopaths toward herb products, including use during pregnancy and lactation. Can J Clin Pharmacol 2000;7:45-9.
  81. Tesch BJ. Herbs commonly used by women: An evidence-based review. Am J Obstet Gynecol 2003;188(Suppl 5):S44-S55.
  82. Goldman RD, Koren G. Taking St John’s Wort during pregnancy. Can Fam Physician 2003;49:29-30.
  83. Klier CM, Schafer MR, Schmid-Siegel B, Lenz G, Mannel M. St John’s Wort (Hypericum perforatum) – is it safe during breastfeeding? Pharmacopsychiatry 2002;35:29-30.
  84. Lee A, Minhas R, Matsuda N, Lam M, Ito S. The safety of St John’s Wort (Hypericum perforatum) during breastfeeding. J Clin Psychiatry 2003;64:966-8.
  85. Feightner JW. Early detection of depression. In: Canadian Task Force on the Periodic Health Examination. Canadian Guide to Clinical Preventive Health Care. Ottawa: Health Canada, 1994:450-4.
  86. U.S. Preventive Services Task Force. Screening for depression: Recommendations and Rationale. Ann Intern Med 2002;136:760-4.
  87. American Academy of Pediatrics Task Force on the Family. Family pediatrics: Report of the Task Force on the Family. Pediatrics 2003;111:1541-71.
  88. Kahn RS, Wise PH, Finkelstein JA, Berstein HH, Lowe JA, Homer CJ. The scope of unmet maternal health needs in pediatric settings. Pediatrics 1999;103:576-81.
  89. Heneghan AM, Silver EJ, Bauman LJ, Stein REK. Do pediatricians recognize mothers with depressive symptoms? Pediatrics 2000;106:1367-73.
  90. Olson AL, Kemper KJ, Kelleher KJ, Hammond CS, Zuckerman BS, Dietrich AJ. Primary care pediatricians’ roles and perceived responsibilities in the identification and management of maternal depression. Pediatrics 2002;110:1169-76.
  91. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression: Development of the Edinburgh Postnatal Depression Scale. Br J Psychiatry 1987;150:782-6.
  92. Beck C. Screening methods for postpartum depression. J Obstet Gynecol Neonatal Nurs 1995;24:308-12.
  93. Beck C, Gable R. Postpartum Depression Screening Scale: Development and psychometric testing. Nurs Res 2000;49:272-82.
  94. Green M. Diagnosis, management, and implications of maternal depression for children and pediatricians. Curr Opin Pediatr 1994;6:525-9.
  95. Chaudron LH. Postpartum depression: What pediatricians want to know. Pediatr Rev 2003;24:154-60.

Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.