Review Article
Recognizing and responding to parental mental health needs: What can we do now? Sunayna Gupta MD1, Elizabeth Ford-Jones MD2,3 S Gupta, E Ford-Jones. Recognizing and responding to parental mental health needs: What can we do now? Paediatr Child Health 2014;19(7):357-361. Early daily interactions in a child’s life, frequent and positive, are crucial to optimal human development. The negative effects of maternal depression may include her perception of the child, the child’s cognitive development and future antisocial behaviour. Emerging research investigating paternal depression is also concerning. Signs of maternal depression can be observed through either an intrusive or withdrawn maternal-infant interaction. The particular role of poverty, which affects so many Canadian families, is highlighted. Furthermore, the benefits and risks of screening for parental depression are discussed. Approaches available to the physician to address this issue using available resources are outlined. Key Words: Early years; Mental health; Parent
E
arly daily interactions in a child’s life are crucial periods of human development when neurocircuitry is being established (1). When parents experience mental illness, an atmosphere of toxic stress may be created for the child. Toxic stress is a frequent and prolonged activation of the stress response, with the absence of a buffering supportive caregiver relationship. The brains of infants and young children are particularly susceptible to the influences of hormones. An elevation of stress hormone levels released in this toxic state can disrupt neurological architecture. This leads to impairment in a young child’s learning and memory, and potentially increases fear, anxiety and disturbance of executive function (2). Objectives and focus Depression is the most common mental illness among parents of young children (3). The present article will: • Explore the negative effects of maternal and paternal depression; • Explain the risk factors and symptoms of depression among parents that a clinician can look for in an office setting; • Focus on poverty as a risk factor for depression and the importance of addressing income; • Discuss benefits and limitations to assessing parents for depression at a well-child visit; and • Discuss available follow-up options. Maternal depression It is estimated that 10% to 20% of women experience depression during the postpartum period (4). This can hinder a child’s emotional, cognitive and behavioural development.
Cerner les besoins des parents en matière de santé mentale et y répondre : que faire dès maintenant? Des interactions quotidiennes précoces fréquentes et positives dans la vie d’un enfant sont essentielles à son développement optimal. Les effets négatifs de la dépression de la mère peuvent inclure sa perception de l’enfant, le développement cognitif de l’enfant et un comportement antisocial plus tard. Des recherches émergentes sur la dépression du père sont également préoccupantes. Les signes de dépression de la mère peuvent se manifester par une interaction intrusive ou distante avec le nourrisson. Les auteurs soulignent le rôle particulier de la pauvreté, qui touche tant de familles canadiennes. Ils abordent aussi les avantages et les risques du dépistage de la dépression des parents et présentent les approches à la disposition des médecins pour sonder ce problème.
Depression can affect how a mother relates to her child. When depressed mothers were shown different infant facial expressions, they were less able to identify happy faces (5). This suggested that they are less likely to recognize and respond to happy emotions from their infant (5). Furthermore, these mothers spoke more critically about their infant (6). This could negatively affect the bond between the parent and the child, and influence a child’s emotional development (5,6). The altered interaction between depressed mothers and their children can also affect a child’s cognitive development. Children of depressed mothers had lower IQ scores than those of nondepressed mothers at 42 months of age (7). This was mediated by a decrease in responsiveness among mothers. These children also had lower scores on the Early Screening Profiles, which are designed to measure cognitive and language development in young children (7). The effects of maternal depression have also been studied in relation to children developing antisocial behaviour (ASB) (8). It was found that children were more likely to develop ASB at seven years of age if they had a mother who was depressed during the first four years of their life. The longer the mother experienced depression, the more likely the child was to develop ASB at seven years of age (8). This was consistent when controlling for child sex, as well as for maternal and paternal antisocial personality disorder. The relationship did not depend on whether the teacher or the parent was the source of data for the child’s symptoms. Genetic factors influenced the association between maternal depression and childhood ASB symptoms. However, a child’s exposure to a mother’s depression between five and seven years of age was also a major factor in predicting the development of ASB symptoms in the child. The authors emphasized the possibility that depressed
1Pediatrics,
University of Calgary, Calgary, Alberta; 2Social Pediatrics, 3The Hospital for Sick Children and University of Toronto, Toronto, Ontario Correspondence and reprints: Dr Sunayna Gupta, Pediatrics Residency, University of Calgary, 630 10th Street Northwest unit 203, Calgary, Alberta T2N 1W3. Telephone 403-829-3767, e-mail [email protected] Accepted for publication April 8, 2014
Paediatr Child Health Vol 19 No 7 August/September 2014
©2014 Pulsus Group Inc. All rights reserved
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Table 1 Signs and symptoms of postpartum depression Persistent sadness Frequent crying, even about little things Poor concentration Difficulty remembering things Feeling of worthlessness, inadequacy or guilt Irratibility, crankiness Loss of interest in caring for one self Not feeling up to doing everyday tasks Psychomotor agitation or retardation Fatigue, loss of energy Insomnia or hypersomnia Significant increase or decrease in appetite Anxiety manifested in bizarre thoughts and fears, such as obsessive thoughts of harm to the baby Feeling overwhelmed Somatic symptoms (headaches, chest pain, heart palpitations, numbness and hyperventilation) Poor bonding with the baby, lack of interest in the baby, family or activities Loss of interest or pleasure in other things that used to be enjoyable (including sex) Recurrent thoughts of death and/or suicide Adapted from reference 20
mothers are more likely to have poor-quality interactions with their children, and the children are more likely to grow up in stressful family environments. This may promote behavioural troubles in children later in their lives (8). Paternal depression Depression among fathers has also been shown to negatively affect child development. Specifically, paternal depression during the postnatal period is associated with behavioural and emotional problems in children (9). This is maintained later in life because adolescents of depressed fathers have increased rates of depression and suicidal behaviour (9). Children who had a depressed father were more likely to exhibit conduct problems and hyperactivity at 3.5 years of age (10). This correlation remained even after maternal depression was controlled for. Depressed fathers spend less time with their children than fathers who are not depressed (9). The quality of this time is less positive, with fewer activities such as reading, singing and hugging. This can negatively affect a child’s cognitive development because fatherly involvement is associated with improved language and educational achievement (9). Furthermore, paternal depression can increase maternal conflict. The risk of marital conflict is heightened, and this stressful environment can result in behavioural problems in the child (11). The role of the physician and health care team A child’s physician is in a unique position to recognize parental depression. They may be the only health care provider with whom parents have contact (12). It is important that physicians assess for depression among the parents and know the appropriate steps to take. This is especially true when parents raise concerns about the behavioural or cognitive development of their child because parental depression may be an underlying cause or an exacerbating factor (12).
POVERTY AS A RISK FACTOR
It is difficult to address health care without addressing a patient’s ability to meet life’s basic necessities. It is important to understand 358
the financial backgrounds of the families in the office because it will help the physician to determine appropriate and beneficial resources for them (13). Poverty creates an environment of material deprivation and stress for the parent (13). These economic hardships and the pressure of providing for a family can lead to depression. Singleparent households are a risk factor for parental depression. However, this relationship is partly mediated through the poverty associated with single-parent households (13). When focusing on single-mother households, mothers living below the threshold poverty line were more likely to experience depression (13). The combination of depression and poverty also increased the level of physical punishment on the child, with physical punishment being associated with emotional difficulties in children (13). A personal change in financial status has a significant influence on a mother’s emotional well-being (14). This interperson effect was shown by following the economic status and depressive symptoms (as measured by Center for Epidemiological Studies Depression Scale) of mothers for three years after childbirth. Women were 1.48 times more likely to emerge from clinical depression after a transition out of poverty (14). Lifting a mother out of poverty may improve her clinical depressive symptoms, which could have a positive impact on the child’s well-being.
SIGNS AND SYMPTOMS OF MATERNAL DEPRESSION
There are two patterns of maternal-infant interactions among depressed mothers: intrusiveness and withdrawal (15). In an intrusive interaction, a mother will be hostile and overbearing. The infant will respond in anger, and will be more likely to develop an internalized and shielding coping style (15). A withdrawn mother is disengaged and will not take great measures to support her infant. The infant will be passive and withdrawn (15). A physician can look for these patterns in an office setting. Furthermore, mothers who are depressed may be less tolerant of a child’s behaviour, and be more likely to report negative attributes of their child to the physician at a well-child visit (16). Postpartum depression Postpartum depression is defined as depressive symptoms persisting beyond the first two weeks after birth (17). What distinguishes postpartum depression from the normal stress of pregnancy and delivery is symptom severity and timing (17). The symptoms of postpartum depression can be severe enough to impair a woman from performing her daily tasks (17). As well, symptoms persist much longer than a few weeks after delivery (17). Women experiencing postpartum depression will experience at least five of the symptoms presented in Table 1 (17). If many symptoms are present, the likelihood of postpartum depression is increased.
ASSESSEMENT Poverty As mentioned above, poverty is a major risk factor for depression among parents. It is important that the physician performs an initial assessment of the socioeconomic status of the child and the family. In fact, some argue that the first two questions to ask when assessing for mental health are, “How did you sleep last night?” and “Have you eaten today?” (18,19). Poverty assessment tools have been developed for the Ontario region for primary care and paediatric use, which include questions assessing financial background, along with resources available if concerns are raised (20). Paediatr Child Health Vol 19 No 7 August/September 2014
Parental depression
table 2 Patient Health Questionnaire-2 screening form Depression is a common but treatable illness that occurs more often among parents. Many people who suffer don’t realize they have a medical disease and could benefit from treatment. The US Preventive Services Task Force recommended that all adults be checked for depression when they see a doctor. Parents of children who are cared for in this practice may see us more often than any other health care provider. The Task Force is considered the authority on preventive health care and we believe it is wise to follow their advice. It’s our job because, if a parent is depressed, their child is affected. The child does better if the parent gets help. For this reason, please take a minute to respond to the 2 statements below. We’ll then take a look at your responses together during this visit. Over the past two weeks, you have felt down, depressed, or hopeless (true or false). If true, have you felt this way for (several days, more than half the days, or nearly every day)? Over the past two weeks, you have felt little interest or pleasure in doing things (true or false). If true, have you felt this way for (several days, more than half the days, or nearly every day)? Several days = 1 point; more than one-half of days = 2 points; nearly every day = 3 points. A maximum of 3 points is given for each question, with a maximum of 6 points for the overall scale. A total score ≥3 is a positive screen for depression.
Comprehensive development of these adapted poverty tools is underway in Manitoba and under consideration in at least two other provinces (personal communication, Dr Sharon Macdonald and Dr Noralou Rous, University of Manitoba, Winnipeg, Manitoba).
screening is proposed by some authors to be important in fathers because they are less likely to come forward on their own with mental health concerns (11).
Maternal depression At least 81% of paediatricians use observation as the basis of their suspicion of parental depression (22). However, through relying on observation, it has been found that paediatricians were only able to identify 34% of mothers who were most likely to receive a diagnosis of major depressive disorder as determined by the Psychiatric Symptom Index (22). Various tools have been used to study the effect of screening. For example, the Patient Health Questionnaire 2:2 – Question Screen (PHQ-2) has been tested in the setting of a paediatric wellchild visit (23) (Table 2). It asks about the two cardinal features of depression: depressed mood and anhedonia. The PHQ-2 has a sensitivity of 83% and 92% in detecting major depression when comparing it with a research psychiatric interview (24). One study involved asking mothers to complete a paper version of the questionnaire in the waiting room, with a follow-up discussion for positive results (25). The study showed promising results, with 56.5% of screen-positive mothers believing they may be depressed, and 83.5% of these mothers being willing to take some action. As well, 89.6% of paediatricians found that they were able to practically work this screen into their everyday practice (25). However, screening comes with the burden of false positives, and it is important to ensure that our screening tools have a measured benefit (26). When considering the postpartum period, some argue that there is insufficient evidence to mandate screening for maternal depression (26). This is due to a lack of consensus on the criteria to screen for (major versus major and minor depression) and the screening tool to use (26). Although there is evidence that screening improves maternal outcomes, this benefit is dependent on resources available in the community. As well, the long-term sustainability of this improvement, as well as improvement in the well-being of the child, is not clear (26). Therefore, it may be too early to implement screening in the postpartum period. The Canadian Paediatric Society recommends that physicians stay alert to the signs of mother-child interaction difficulties and behavioural or developmental problems in children. Under these circumstances, they should consider maternal depression, ask relevant questions and encourage contact with the mother’s physician or psychiatric services (15).
If concerns about depression arise in a paediatrician’s office, the physician can educate parents about why it is important that they seek help in a supportive fashion (25). They should acknowledge feelings of self-blame, reassure parents and outline further avenues of help (25). Such avenues include referrals to adult primary care physicians, adult mental health professionals or accessing various local community supports (23,25). Paediatricians have also found it helpful to have educational pamphlets to hand to parents that review the effects of parental depression, and self-help techniques that may reduce the impact of depression on their child (23).
Paternal depression Currently, there is insufficient evidence to recommend national screening specifically for paternal depression (11). However, Paediatr Child Health Vol 19 No 7 August/September 2014
IMPORTANT RESOURCES
Clinician home visiting Clinician home visiting involves multiple sessions in which parents are taught parenting skills and positive ways to think about their child. This has been shown to be beneficial during the infant stage in the setting of maternal depression. Sessions improved maternal sensitivity to their children, infant attachment to the mother, infant initiation of interactions with the mother and maternal structuring of interactions (27). Public health early visiting programs are offered in every province and territory in Canada. Child care A Canadian study following 1800 children born in Quebec showed that having a child engaged in a form of child care appeared to lessen the effect of maternal depression (28). This was especially true for children enrolled in group-based child care (28). The group setting gives the child structure and allows him or her to interact with other children (28). Furthermore, care is provided by a trained professional. Best Start Best Start is a helpful resource designed for health care providers across Ontario, and is universally available to all health care providers through their website (29). It supports these providers as they work to better the health of expectant and new parents, newborns and young children (29). One service that Best Start provides (among many) is a readily accessible workshop providers can work through specific to parental depression. There are case-based formulas that educate providers on the impact of parental mental health on children, strategies to help parents who are experiencing a mental health crisis, tools to support parents experiencing mental health problems, and links for education and support (30). 359
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Municipal community health help lines (eg, 211) Live information and referral specialists at community health help lines, such as 211, in many parts of Ontario provide answers quickly, 24 h per day every day of the year in >150 languages, anonymously and unrecorded (31). This number connects callers with information and contacts for local social, health and government services. Of the many services offered, some include child care resources, child and family services, financial assistance and health care services (31). There are many resources offered that address parental mental health, and the risk factors that may affect a parent’s mental health. Physicians should direct families to telephone a help line should they stand to benefit from the offered services. Role of the lawyer Unmet legal needs can contribute to the family’s ability to manage or prevent the child’s health condition. Inclusion of a lawyer to address issues related to family, education, income and employment has been highly constructive and family legal health models are becoming increasingly popular in Canadian children’s hospitals (32,33).
GAPS
The effect of poverty on a parent-child interaction is an area that can be further addressed in future research. In this way, physicians can understand how financial barriers can specifically hinder families and children, and how to appropriately tailor their management. Furthermore, research showing that screening for parental depression improves child development is insufficient or unavailable. Also, while screening will identify more mothers at risk of depression, it is important to ensure that the benefit to the mother has long-term sustainability. The amount of research investigating paternal depression pales in comparison with maternal depression. More research should be performed addressing depression in fathers to further our understanding of how to identify and address the issue. Finally, considering the significant delays in accessing psychiatric care, there is a need to explore optimal management of a patient during these wait times, as well as possible prenatal preventive strategies that a physician could offer. References
1. Hertzman C. The significance of early childhood adversity. Paediatr Child Health 2013;13:127-8. 2. Shonkoff J, Garner A, Siegel B, et al. The lifelong effects of early childhood adversity and toxic stress. Pediatrics 2011;129:e232-e246. 3. Horwitz SC, Briggs-Gowan MJ, Storfer-Isser A, Carter AS. Prevalence, correlates and persistence of maternal depression. J Women’s Health 2007;16:678-91. 4. O’Hara M, Swain A. Rates and risk of postpartum depression: A meta analysis. Int Rev Psychiatry 1996;8:37-54. 5. Arteche A, Joormann J, Harvey A, et al. The effects of postnatal maternal depression and anxiety on the processing of infant faces. J Affect Disord 2011;133:197-203. 6. Murray L, Kempton C, Woolgar W, Hooper R. Depressed mother’s speech to their infants gender and cognitive development. J Child Psychol Psychiatr 1993;34:1083-101. 7. Milgrom J, Westley D, Gemmill A. The mediating role of maternal responsiveness in some longer term effects of postnatal depression on infant development. Infant Behav Dev 2004;434-54. 8. Kim-Cohen J, Moffitt T, Taylor A, Pawlby S, Caspi A. Maternal depression and children’s antisocial behavior. Arch Gen Psychiatry 2005;62:173-81. 9. Ramchandani P, Psychogiou L. Paternal psychiatric disorders and children’s psychosocial development. Lancet 2009;374:647-53. 10. Ramchandani P, Stein A, Evans J, O’Connor T. Paternal depression in the postnatal period and child development: A prospective population study. Lancet 2005;365:2201-5.
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CONCLUSION
Depression among parents has serious developmental consequences for the child. Physicians are continuously and in endless ways striving to optimize and improve their patients’ health. Just as nutritional recommendations help to ensure appropriate child development, attention to parental well-being should also be at the forefront of a paediatrician’s approach to each patient. Parental mental health has a major impact on a child’s health and development and may be improved through some of the aforementioned suggestions. While the majority of depressed parents may not be living in poverty, a major risk factor for depression among parents is poverty. Economic struggle within families also contributes to increased rates of health issues among youth, such as asthma, obesity and attention-deficit/hyperactivity disorder (34). Raising income could dramatically increase health for mothers and infants (34). Fundamental shifts in how the economy is structured make it difficult for many parents to invest in the goods, services and time that promote optimal neurobehavioural development in their children (34). Efforts should continue to find ways to support physicians in their efforts to optimize income and access community resources using methods such as the Poverty Tools to support families and optimize well-being. In this way, the physician can understand a family’s economic restraints and how it factors into their mental and physical health. Acknowledgements: The authors thank Andrea Feller MD (Niagara Region Public Health Department, Thorold, Ontario), Anne Biscaro MscN (Niagara Region Public Health Department), Jane Bertrand (Ontario Institute of Studies in Education, Toronto, Ontario), Leo Levin MD (Social Pediatrics, The Hospital for Sick Children and University of Toronto, Children’s Aid Society, Toronto, Ontario), Chaya Kulkarni PhD (Infant Mental Health Program, Toronto, Ontario), Maureen MacDonald MEd (Mothercraft, Toronto, Ontario), Sue Makin (Children’s Services, Toronto Public Health, Toronto, Ontario), Cindy Lee Denis PhD (Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Canada Research Chair in Perinatal Community Health, Toronto, Ontario) and Jean Clinton MD (Department of Child Psychiatry, Offord Center, McMaster University, Hamilton, Ontario) for their assistance in supporting the development of this review and for their insight and expertise in this topic. 11. Habib C. Paternal perinatal depression: An overview and suggestions towards an intervention model. J Family Studies 2012;18:4-16. 12. Olson A, Kemper K, Kelleher K, Hammond C, Zuckerman B, Dietrich A. Primary care pediatricians’ role and perceived responsibilities in the identification and management of maternal depression. Pediatrics 2002;110:1169-76. 13. Eamon M, Zuehl R. Maternal depression and physical punishment as mediators of the effect of poverty on socioemotional problems of children in single-mother families. Am J Orthopsychiatry 2001;71;218-26. 14. Dearing E, Taylor B, McCartney K. Implications of family income dynamics for women’s depressive symptoms during the first 3 years after childbirth. Am J Public Health 2004;94:1372-7. 15. Bernard-Bonnin A; Canadian Paediatric Society, Mental Health and Developmental Disabilities Committee. Maternal depression and child development. Paediatr Child Health 2004;9:575-83. 16. Sia J, Leventhal J, Northrup V, Arunyanart W, Weitzman C. Markers of maternal depressive symptoms in an urban pediatric clinic. J Pediatr 2013;162:189-94. 17. Najman J, Anderson M, Bor W, O’Callaghan M, Williams G. Postnatal depression – myth and reality: Maternal depression before and after the birth of a child. Soc Psychiatry Psychiatr Epidemiol 2000;35:19-27. 18. Lopez A. Taking a second: Reflection on social pediatrics. Scrub-In 2013;8:12.
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Parental depression 19. Harel-Sterling M. “How did you sleep last night? Have you eaten today?” Pediatr Child Health 2013;18:513-4 20. Poverty: A Clinical Tool for Primary Care in Ontario. (Accessed November 5, 2013). 21. Child Poverty: A Practical Tool for Primary Care (Ontario) (Accessed November 5, 2013). 22. Heneghan A, Silver E, Bauman L, Stein R. Do pediatricians recognize mothers with depressive symptoms? Pediatrics 2000;106:1367-73. 23. Olson A, Dietrich A, Prazar G, Hurley J. Brief maternal depression screening at well-child visits. Pediatrics 2006;118:207-16. 24. Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: Validity of a two-item depression screener. Med Care 2003;41:1284-92. 25. Olson A, Dietrich A, Prazar G, et al. Two approaches to maternal depression screening during well child visits. Dev Behav Pediatr 2005;26:170-6. 26. Agency for Healthcare Research and Quality. Rockville: Efficacy and safety of screening for postpartum depression. (Accessed November 5, 2013).
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27. Pan-Canadian inventory of public health early child home visiting: Key facts and glossary. National Collaboration Center for Determinants of Health. (Accessed November 5, 2013). 28. Herba C, Tremblay R, Bovin M, et al. Maternal depressive symptoms and children’s emotional problems: Can early child care help children of depressed mothers? JAMA Psychiatry 2013;70:830-8. 29. Health Nexus. Toronto: Best start. (Accessed November 5, 2013). 30. Health Nexus. Toronto: Best start: Supporting parents when parents experience mental health challenges: Ready to use workshops for service providers. (Accessed November 5, 2013). 31. 211: When you don’t know where to turn. (Accessed November 5, 2013). 32. Zuckerman B. Medicine and law: New opportunities to close the disparity gap. Pediatrics 2012;130:943-4. 33. Jackson S, Miller W, Chapman L, Ford-Jones E, Ghent E, Pai N. Hospital-legal partnership at Toronto Hospital for Sick Children: The first Canadian experience. Healthcare Law 2012;15:55-61. 34. Halfon N. Socioeconomic influences on child health building new ladders of social opportunity. JAMA 2014;311:915-7.
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Recognizing and responding to parental mental health needs: What can we do now? Sunayna Gupta MD1, Elizabeth Ford-Jones MD2,3 S Gupta, E Ford-Jones. Recognizing and responding to parental mental health needs: What can we do now? Paediatr Child Health 2014;19(7):357-361. Early daily interactions in a child’s life, frequent and positive, are crucial to optimal human development. The negative effects of maternal depression may include her perception of the child, the child’s cognitive development and future antisocial behaviour. Emerging research investigating paternal depression is also concerning. Signs of maternal depression can be observed through either an intrusive or withdrawn maternal-infant interaction. The particular role of poverty, which affects so many Canadian families, is highlighted. Furthermore, the benefits and risks of screening for parental depression are discussed. Approaches available to the physician to address this issue using available resources are outlined. Key Words: Early years; Mental health; Parent
E
arly daily interactions in a child’s life are crucial periods of human development when neurocircuitry is being established (1). When parents experience mental illness, an atmosphere of toxic stress may be created for the child. Toxic stress is a frequent and prolonged activation of the stress response, with the absence of a buffering supportive caregiver relationship. The brains of infants and young children are particularly susceptible to the influences of hormones. An elevation of stress hormone levels released in this toxic state can disrupt neurological architecture. This leads to impairment in a young child’s learning and memory, and potentially increases fear, anxiety and disturbance of executive function (2). Objectives and focus Depression is the most common mental illness among parents of young children (3). The present article will: • Explore the negative effects of maternal and paternal depression; • Explain the risk factors and symptoms of depression among parents that a clinician can look for in an office setting; • Focus on poverty as a risk factor for depression and the importance of addressing income; • Discuss benefits and limitations to assessing parents for depression at a well-child visit; and • Discuss available follow-up options. Maternal depression It is estimated that 10% to 20% of women experience depression during the postpartum period (4). This can hinder a child’s emotional, cognitive and behavioural development.
Cerner les besoins des parents en matière de santé mentale et y répondre : que faire dès maintenant? Des interactions quotidiennes précoces fréquentes et positives dans la vie d’un enfant sont essentielles à son développement optimal. Les effets négatifs de la dépression de la mère peuvent inclure sa perception de l’enfant, le développement cognitif de l’enfant et un comportement antisocial plus tard. Des recherches émergentes sur la dépression du père sont également préoccupantes. Les signes de dépression de la mère peuvent se manifester par une interaction intrusive ou distante avec le nourrisson. Les auteurs soulignent le rôle particulier de la pauvreté, qui touche tant de familles canadiennes. Ils abordent aussi les avantages et les risques du dépistage de la dépression des parents et présentent les approches à la disposition des médecins pour sonder ce problème.
Depression can affect how a mother relates to her child. When depressed mothers were shown different infant facial expressions, they were less able to identify happy faces (5). This suggested that they are less likely to recognize and respond to happy emotions from their infant (5). Furthermore, these mothers spoke more critically about their infant (6). This could negatively affect the bond between the parent and the child, and influence a child’s emotional development (5,6). The altered interaction between depressed mothers and their children can also affect a child’s cognitive development. Children of depressed mothers had lower IQ scores than those of nondepressed mothers at 42 months of age (7). This was mediated by a decrease in responsiveness among mothers. These children also had lower scores on the Early Screening Profiles, which are designed to measure cognitive and language development in young children (7). The effects of maternal depression have also been studied in relation to children developing antisocial behaviour (ASB) (8). It was found that children were more likely to develop ASB at seven years of age if they had a mother who was depressed during the first four years of their life. The longer the mother experienced depression, the more likely the child was to develop ASB at seven years of age (8). This was consistent when controlling for child sex, as well as for maternal and paternal antisocial personality disorder. The relationship did not depend on whether the teacher or the parent was the source of data for the child’s symptoms. Genetic factors influenced the association between maternal depression and childhood ASB symptoms. However, a child’s exposure to a mother’s depression between five and seven years of age was also a major factor in predicting the development of ASB symptoms in the child. The authors emphasized the possibility that depressed
1Pediatrics,
University of Calgary, Calgary, Alberta; 2Social Pediatrics, 3The Hospital for Sick Children and University of Toronto, Toronto, Ontario Correspondence and reprints: Dr Sunayna Gupta, Pediatrics Residency, University of Calgary, 630 10th Street Northwest unit 203, Calgary, Alberta T2N 1W3. Telephone 403-829-3767, e-mail [email protected] Accepted for publication April 8, 2014
Paediatr Child Health Vol 19 No 7 August/September 2014
©2014 Pulsus Group Inc. All rights reserved
357
Gupta and Ford-Jones
Table 1 Signs and symptoms of postpartum depression Persistent sadness Frequent crying, even about little things Poor concentration Difficulty remembering things Feeling of worthlessness, inadequacy or guilt Irratibility, crankiness Loss of interest in caring for one self Not feeling up to doing everyday tasks Psychomotor agitation or retardation Fatigue, loss of energy Insomnia or hypersomnia Significant increase or decrease in appetite Anxiety manifested in bizarre thoughts and fears, such as obsessive thoughts of harm to the baby Feeling overwhelmed Somatic symptoms (headaches, chest pain, heart palpitations, numbness and hyperventilation) Poor bonding with the baby, lack of interest in the baby, family or activities Loss of interest or pleasure in other things that used to be enjoyable (including sex) Recurrent thoughts of death and/or suicide Adapted from reference 20
mothers are more likely to have poor-quality interactions with their children, and the children are more likely to grow up in stressful family environments. This may promote behavioural troubles in children later in their lives (8). Paternal depression Depression among fathers has also been shown to negatively affect child development. Specifically, paternal depression during the postnatal period is associated with behavioural and emotional problems in children (9). This is maintained later in life because adolescents of depressed fathers have increased rates of depression and suicidal behaviour (9). Children who had a depressed father were more likely to exhibit conduct problems and hyperactivity at 3.5 years of age (10). This correlation remained even after maternal depression was controlled for. Depressed fathers spend less time with their children than fathers who are not depressed (9). The quality of this time is less positive, with fewer activities such as reading, singing and hugging. This can negatively affect a child’s cognitive development because fatherly involvement is associated with improved language and educational achievement (9). Furthermore, paternal depression can increase maternal conflict. The risk of marital conflict is heightened, and this stressful environment can result in behavioural problems in the child (11). The role of the physician and health care team A child’s physician is in a unique position to recognize parental depression. They may be the only health care provider with whom parents have contact (12). It is important that physicians assess for depression among the parents and know the appropriate steps to take. This is especially true when parents raise concerns about the behavioural or cognitive development of their child because parental depression may be an underlying cause or an exacerbating factor (12).
POVERTY AS A RISK FACTOR
It is difficult to address health care without addressing a patient’s ability to meet life’s basic necessities. It is important to understand 358
the financial backgrounds of the families in the office because it will help the physician to determine appropriate and beneficial resources for them (13). Poverty creates an environment of material deprivation and stress for the parent (13). These economic hardships and the pressure of providing for a family can lead to depression. Singleparent households are a risk factor for parental depression. However, this relationship is partly mediated through the poverty associated with single-parent households (13). When focusing on single-mother households, mothers living below the threshold poverty line were more likely to experience depression (13). The combination of depression and poverty also increased the level of physical punishment on the child, with physical punishment being associated with emotional difficulties in children (13). A personal change in financial status has a significant influence on a mother’s emotional well-being (14). This interperson effect was shown by following the economic status and depressive symptoms (as measured by Center for Epidemiological Studies Depression Scale) of mothers for three years after childbirth. Women were 1.48 times more likely to emerge from clinical depression after a transition out of poverty (14). Lifting a mother out of poverty may improve her clinical depressive symptoms, which could have a positive impact on the child’s well-being.
SIGNS AND SYMPTOMS OF MATERNAL DEPRESSION
There are two patterns of maternal-infant interactions among depressed mothers: intrusiveness and withdrawal (15). In an intrusive interaction, a mother will be hostile and overbearing. The infant will respond in anger, and will be more likely to develop an internalized and shielding coping style (15). A withdrawn mother is disengaged and will not take great measures to support her infant. The infant will be passive and withdrawn (15). A physician can look for these patterns in an office setting. Furthermore, mothers who are depressed may be less tolerant of a child’s behaviour, and be more likely to report negative attributes of their child to the physician at a well-child visit (16). Postpartum depression Postpartum depression is defined as depressive symptoms persisting beyond the first two weeks after birth (17). What distinguishes postpartum depression from the normal stress of pregnancy and delivery is symptom severity and timing (17). The symptoms of postpartum depression can be severe enough to impair a woman from performing her daily tasks (17). As well, symptoms persist much longer than a few weeks after delivery (17). Women experiencing postpartum depression will experience at least five of the symptoms presented in Table 1 (17). If many symptoms are present, the likelihood of postpartum depression is increased.
ASSESSEMENT Poverty As mentioned above, poverty is a major risk factor for depression among parents. It is important that the physician performs an initial assessment of the socioeconomic status of the child and the family. In fact, some argue that the first two questions to ask when assessing for mental health are, “How did you sleep last night?” and “Have you eaten today?” (18,19). Poverty assessment tools have been developed for the Ontario region for primary care and paediatric use, which include questions assessing financial background, along with resources available if concerns are raised (20). Paediatr Child Health Vol 19 No 7 August/September 2014
Parental depression
table 2 Patient Health Questionnaire-2 screening form Depression is a common but treatable illness that occurs more often among parents. Many people who suffer don’t realize they have a medical disease and could benefit from treatment. The US Preventive Services Task Force recommended that all adults be checked for depression when they see a doctor. Parents of children who are cared for in this practice may see us more often than any other health care provider. The Task Force is considered the authority on preventive health care and we believe it is wise to follow their advice. It’s our job because, if a parent is depressed, their child is affected. The child does better if the parent gets help. For this reason, please take a minute to respond to the 2 statements below. We’ll then take a look at your responses together during this visit. Over the past two weeks, you have felt down, depressed, or hopeless (true or false). If true, have you felt this way for (several days, more than half the days, or nearly every day)? Over the past two weeks, you have felt little interest or pleasure in doing things (true or false). If true, have you felt this way for (several days, more than half the days, or nearly every day)? Several days = 1 point; more than one-half of days = 2 points; nearly every day = 3 points. A maximum of 3 points is given for each question, with a maximum of 6 points for the overall scale. A total score ≥3 is a positive screen for depression.
Comprehensive development of these adapted poverty tools is underway in Manitoba and under consideration in at least two other provinces (personal communication, Dr Sharon Macdonald and Dr Noralou Rous, University of Manitoba, Winnipeg, Manitoba).
screening is proposed by some authors to be important in fathers because they are less likely to come forward on their own with mental health concerns (11).
Maternal depression At least 81% of paediatricians use observation as the basis of their suspicion of parental depression (22). However, through relying on observation, it has been found that paediatricians were only able to identify 34% of mothers who were most likely to receive a diagnosis of major depressive disorder as determined by the Psychiatric Symptom Index (22). Various tools have been used to study the effect of screening. For example, the Patient Health Questionnaire 2:2 – Question Screen (PHQ-2) has been tested in the setting of a paediatric wellchild visit (23) (Table 2). It asks about the two cardinal features of depression: depressed mood and anhedonia. The PHQ-2 has a sensitivity of 83% and 92% in detecting major depression when comparing it with a research psychiatric interview (24). One study involved asking mothers to complete a paper version of the questionnaire in the waiting room, with a follow-up discussion for positive results (25). The study showed promising results, with 56.5% of screen-positive mothers believing they may be depressed, and 83.5% of these mothers being willing to take some action. As well, 89.6% of paediatricians found that they were able to practically work this screen into their everyday practice (25). However, screening comes with the burden of false positives, and it is important to ensure that our screening tools have a measured benefit (26). When considering the postpartum period, some argue that there is insufficient evidence to mandate screening for maternal depression (26). This is due to a lack of consensus on the criteria to screen for (major versus major and minor depression) and the screening tool to use (26). Although there is evidence that screening improves maternal outcomes, this benefit is dependent on resources available in the community. As well, the long-term sustainability of this improvement, as well as improvement in the well-being of the child, is not clear (26). Therefore, it may be too early to implement screening in the postpartum period. The Canadian Paediatric Society recommends that physicians stay alert to the signs of mother-child interaction difficulties and behavioural or developmental problems in children. Under these circumstances, they should consider maternal depression, ask relevant questions and encourage contact with the mother’s physician or psychiatric services (15).
If concerns about depression arise in a paediatrician’s office, the physician can educate parents about why it is important that they seek help in a supportive fashion (25). They should acknowledge feelings of self-blame, reassure parents and outline further avenues of help (25). Such avenues include referrals to adult primary care physicians, adult mental health professionals or accessing various local community supports (23,25). Paediatricians have also found it helpful to have educational pamphlets to hand to parents that review the effects of parental depression, and self-help techniques that may reduce the impact of depression on their child (23).
Paternal depression Currently, there is insufficient evidence to recommend national screening specifically for paternal depression (11). However, Paediatr Child Health Vol 19 No 7 August/September 2014
IMPORTANT RESOURCES
Clinician home visiting Clinician home visiting involves multiple sessions in which parents are taught parenting skills and positive ways to think about their child. This has been shown to be beneficial during the infant stage in the setting of maternal depression. Sessions improved maternal sensitivity to their children, infant attachment to the mother, infant initiation of interactions with the mother and maternal structuring of interactions (27). Public health early visiting programs are offered in every province and territory in Canada. Child care A Canadian study following 1800 children born in Quebec showed that having a child engaged in a form of child care appeared to lessen the effect of maternal depression (28). This was especially true for children enrolled in group-based child care (28). The group setting gives the child structure and allows him or her to interact with other children (28). Furthermore, care is provided by a trained professional. Best Start Best Start is a helpful resource designed for health care providers across Ontario, and is universally available to all health care providers through their website (29). It supports these providers as they work to better the health of expectant and new parents, newborns and young children (29). One service that Best Start provides (among many) is a readily accessible workshop providers can work through specific to parental depression. There are case-based formulas that educate providers on the impact of parental mental health on children, strategies to help parents who are experiencing a mental health crisis, tools to support parents experiencing mental health problems, and links for education and support (30). 359
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Municipal community health help lines (eg, 211) Live information and referral specialists at community health help lines, such as 211, in many parts of Ontario provide answers quickly, 24 h per day every day of the year in >150 languages, anonymously and unrecorded (31). This number connects callers with information and contacts for local social, health and government services. Of the many services offered, some include child care resources, child and family services, financial assistance and health care services (31). There are many resources offered that address parental mental health, and the risk factors that may affect a parent’s mental health. Physicians should direct families to telephone a help line should they stand to benefit from the offered services. Role of the lawyer Unmet legal needs can contribute to the family’s ability to manage or prevent the child’s health condition. Inclusion of a lawyer to address issues related to family, education, income and employment has been highly constructive and family legal health models are becoming increasingly popular in Canadian children’s hospitals (32,33).
GAPS
The effect of poverty on a parent-child interaction is an area that can be further addressed in future research. In this way, physicians can understand how financial barriers can specifically hinder families and children, and how to appropriately tailor their management. Furthermore, research showing that screening for parental depression improves child development is insufficient or unavailable. Also, while screening will identify more mothers at risk of depression, it is important to ensure that the benefit to the mother has long-term sustainability. The amount of research investigating paternal depression pales in comparison with maternal depression. More research should be performed addressing depression in fathers to further our understanding of how to identify and address the issue. Finally, considering the significant delays in accessing psychiatric care, there is a need to explore optimal management of a patient during these wait times, as well as possible prenatal preventive strategies that a physician could offer. References
1. Hertzman C. The significance of early childhood adversity. Paediatr Child Health 2013;13:127-8. 2. Shonkoff J, Garner A, Siegel B, et al. The lifelong effects of early childhood adversity and toxic stress. Pediatrics 2011;129:e232-e246. 3. Horwitz SC, Briggs-Gowan MJ, Storfer-Isser A, Carter AS. Prevalence, correlates and persistence of maternal depression. J Women’s Health 2007;16:678-91. 4. O’Hara M, Swain A. Rates and risk of postpartum depression: A meta analysis. Int Rev Psychiatry 1996;8:37-54. 5. Arteche A, Joormann J, Harvey A, et al. The effects of postnatal maternal depression and anxiety on the processing of infant faces. J Affect Disord 2011;133:197-203. 6. Murray L, Kempton C, Woolgar W, Hooper R. Depressed mother’s speech to their infants gender and cognitive development. J Child Psychol Psychiatr 1993;34:1083-101. 7. Milgrom J, Westley D, Gemmill A. The mediating role of maternal responsiveness in some longer term effects of postnatal depression on infant development. Infant Behav Dev 2004;434-54. 8. Kim-Cohen J, Moffitt T, Taylor A, Pawlby S, Caspi A. Maternal depression and children’s antisocial behavior. Arch Gen Psychiatry 2005;62:173-81. 9. Ramchandani P, Psychogiou L. Paternal psychiatric disorders and children’s psychosocial development. Lancet 2009;374:647-53. 10. Ramchandani P, Stein A, Evans J, O’Connor T. Paternal depression in the postnatal period and child development: A prospective population study. Lancet 2005;365:2201-5.
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CONCLUSION
Depression among parents has serious developmental consequences for the child. Physicians are continuously and in endless ways striving to optimize and improve their patients’ health. Just as nutritional recommendations help to ensure appropriate child development, attention to parental well-being should also be at the forefront of a paediatrician’s approach to each patient. Parental mental health has a major impact on a child’s health and development and may be improved through some of the aforementioned suggestions. While the majority of depressed parents may not be living in poverty, a major risk factor for depression among parents is poverty. Economic struggle within families also contributes to increased rates of health issues among youth, such as asthma, obesity and attention-deficit/hyperactivity disorder (34). Raising income could dramatically increase health for mothers and infants (34). Fundamental shifts in how the economy is structured make it difficult for many parents to invest in the goods, services and time that promote optimal neurobehavioural development in their children (34). Efforts should continue to find ways to support physicians in their efforts to optimize income and access community resources using methods such as the Poverty Tools to support families and optimize well-being. In this way, the physician can understand a family’s economic restraints and how it factors into their mental and physical health. Acknowledgements: The authors thank Andrea Feller MD (Niagara Region Public Health Department, Thorold, Ontario), Anne Biscaro MscN (Niagara Region Public Health Department), Jane Bertrand (Ontario Institute of Studies in Education, Toronto, Ontario), Leo Levin MD (Social Pediatrics, The Hospital for Sick Children and University of Toronto, Children’s Aid Society, Toronto, Ontario), Chaya Kulkarni PhD (Infant Mental Health Program, Toronto, Ontario), Maureen MacDonald MEd (Mothercraft, Toronto, Ontario), Sue Makin (Children’s Services, Toronto Public Health, Toronto, Ontario), Cindy Lee Denis PhD (Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Canada Research Chair in Perinatal Community Health, Toronto, Ontario) and Jean Clinton MD (Department of Child Psychiatry, Offord Center, McMaster University, Hamilton, Ontario) for their assistance in supporting the development of this review and for their insight and expertise in this topic. 11. Habib C. Paternal perinatal depression: An overview and suggestions towards an intervention model. J Family Studies 2012;18:4-16. 12. Olson A, Kemper K, Kelleher K, Hammond C, Zuckerman B, Dietrich A. Primary care pediatricians’ role and perceived responsibilities in the identification and management of maternal depression. Pediatrics 2002;110:1169-76. 13. Eamon M, Zuehl R. Maternal depression and physical punishment as mediators of the effect of poverty on socioemotional problems of children in single-mother families. Am J Orthopsychiatry 2001;71;218-26. 14. Dearing E, Taylor B, McCartney K. Implications of family income dynamics for women’s depressive symptoms during the first 3 years after childbirth. Am J Public Health 2004;94:1372-7. 15. Bernard-Bonnin A; Canadian Paediatric Society, Mental Health and Developmental Disabilities Committee. Maternal depression and child development. Paediatr Child Health 2004;9:575-83. 16. Sia J, Leventhal J, Northrup V, Arunyanart W, Weitzman C. Markers of maternal depressive symptoms in an urban pediatric clinic. J Pediatr 2013;162:189-94. 17. Najman J, Anderson M, Bor W, O’Callaghan M, Williams G. Postnatal depression – myth and reality: Maternal depression before and after the birth of a child. Soc Psychiatry Psychiatr Epidemiol 2000;35:19-27. 18. Lopez A. Taking a second: Reflection on social pediatrics. Scrub-In 2013;8:12.
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Parental depression 19. Harel-Sterling M. “How did you sleep last night? Have you eaten today?” Pediatr Child Health 2013;18:513-4 20. Poverty: A Clinical Tool for Primary Care in Ontario. (Accessed November 5, 2013). 21. Child Poverty: A Practical Tool for Primary Care (Ontario) (Accessed November 5, 2013). 22. Heneghan A, Silver E, Bauman L, Stein R. Do pediatricians recognize mothers with depressive symptoms? Pediatrics 2000;106:1367-73. 23. Olson A, Dietrich A, Prazar G, Hurley J. Brief maternal depression screening at well-child visits. Pediatrics 2006;118:207-16. 24. Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: Validity of a two-item depression screener. Med Care 2003;41:1284-92. 25. Olson A, Dietrich A, Prazar G, et al. Two approaches to maternal depression screening during well child visits. Dev Behav Pediatr 2005;26:170-6. 26. Agency for Healthcare Research and Quality. Rockville: Efficacy and safety of screening for postpartum depression. (Accessed November 5, 2013).
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27. Pan-Canadian inventory of public health early child home visiting: Key facts and glossary. National Collaboration Center for Determinants of Health. (Accessed November 5, 2013). 28. Herba C, Tremblay R, Bovin M, et al. Maternal depressive symptoms and children’s emotional problems: Can early child care help children of depressed mothers? JAMA Psychiatry 2013;70:830-8. 29. Health Nexus. Toronto: Best start. (Accessed November 5, 2013). 30. Health Nexus. Toronto: Best start: Supporting parents when parents experience mental health challenges: Ready to use workshops for service providers. (Accessed November 5, 2013). 31. 211: When you don’t know where to turn. (Accessed November 5, 2013). 32. Zuckerman B. Medicine and law: New opportunities to close the disparity gap. Pediatrics 2012;130:943-4. 33. Jackson S, Miller W, Chapman L, Ford-Jones E, Ghent E, Pai N. Hospital-legal partnership at Toronto Hospital for Sick Children: The first Canadian experience. Healthcare Law 2012;15:55-61. 34. Halfon N. Socioeconomic influences on child health building new ladders of social opportunity. JAMA 2014;311:915-7.
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