Maternal Depression and the Dynamic Maturational Model: How Depression Gets Under the Skin

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Maternal Depression and the Dynamic Maturational
Model How Depression Gets Under the Skin

• Nicole Letourneau PhD RN
• Professor of Nursing and Medicine (Pediatrics)
• Norlien/ACHRF Chair in
• Parent-Infant Mental Health

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Objectives

• Maternal depression and attachment
• Maternal depression and mother-infant interaction
• Impact of depression on infant and child health
• How does maternal depression get under the skin?
• So what do we do?

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1. Maternal depression attachment
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MDD symptoms
Depressed Mood
Weight Loss/Gain
Psychomotor Agitation or Retardation
Fatigue/ Loss of Energy
Insomnia/ Hypersomnia
Anxiety
Emotional Lability
Reduced Thinking/ Concentration/ Decisiveness
Loneliness
Suicidal Ideation
Worthlessness/Guilt
Loss of Interest or Pleasure
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Mothers

• DSM-IV indicates that mothers must experience s/s
  within 4 weeks postpartum to have MDD with
  postpartum onset
• Beyond 1st year, symptoms of depression are not
  attributed to the postpartum period.
• Meta-analysis of 28 studies reported PPD
  prevalence of 15 (Gavin et al., 2005), slightly
  ? over last review (Ohara Swain, 1996)
• Maternal depression 5-7 (Health Canada NLSCY)

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Mothers

• 50 of mothers with PPD remain clinically
  depressed at 6 months postpartum.
• 25 untreated mothers remain depressed gt 1 year.
• 63 have recurrence of depression within 12
  years. Letourneau et al. (2010) WJNR

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Does it all begin during pregnancy?

• MDD during pregnancy related to poor
  maternal-fetal attachment (McFarlane, 2011)
• Maternal mood related to maternal cortisol levels
  during pregnancy (Giesbrecht et al., 2011)
• High maternal cortisol during pregnancy predicted
  parental report of poor infant temperament

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Matenal depressionserious

• 12 of maternal deaths (during pregnancy and in
  the 1st year post delivery) attributed to
  psychiatric illness including PPD
• 1 cause of death suicide (10)
• More violent methods of suicide-few by
  overdose
• (Oates, 2003. Confidential Enquiries into
  Maternal Deaths)

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Disturbing thoughts
Location Total screened EPDS 9 Positive for self harm EPDS 121 Positive for self harm
Fredericton 109 24 (22) 7 (29) 12 (11) 5 (42)
Moncton 299 55 (18) 19 (35) 34 (12) 14 (42)

1 This group is also counted in the EPDS 9
category.
Duffett-Leger, L.. Letourneau, N. (2009). Info
Nursing
Parental distress increased the odds (OR 1.10
CI .99-1.21) of having thoughts of intentional
harm to child at 4 weeks postpartum (e.g.
screaming at baby, shaking baby, hitting baby,
giving away baby, etc.) (Fairbrother Woody,
2008)
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Suicidality and attachment

• Mothers with high suicidality (n32)
• experienced greater mood disturbances, cognitive
  distortions, and depression severity of
  postpartum symptomotology
• lower maternal self-esteem, more negative
  perceptions of the mother-infant relationship,
  and greater parenting stress.
• During observations, mothers were less sensitive
  and responsive to infants' cues, and infants
  demonstrated less positive affect and involvement
  with their mothers.
• Paris et al., 2009

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Disturbing thoughts

• Barr and Beck (2008) conclude although women
  were unlikely to disclose their infanticide
  thoughts to health care professionals, they did
  often realize that they needed help. In such
  cases, women were more likely to mention thoughts
  of suicide

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There is no such thing as a babyWinnicott
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What is Attachment?

• The pattern of a specific relationship
• A self-protective strategy
• Pattern reflects whether children feel secure
  in the availability and responsiveness of
  caregivers
• Bowlby, 1988 Ainsworth, 1978 Crittenden, 2005

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Why these strategies?

• Type A minimize awareness of feelings and do what
  will be reinforced and to avoid doing what will
  be punisheddisorders of inhibition and
  compulsion.
• E.g a child responded to negatively each time
  she cries may develop a Type A strategy.
• Type C focus on feelings as guides to
  behaviourdisorders of anxiety and obsessiveness
  tied to too great a reliance on negative affect.
• E.g. a child who is ignored by a passive parent
  unless acts out may develop Type C strategy

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Attachment development

• Over the lifespan, insecure attachment is
  associated with
• Behavioural, academic and mental health problems
• Problems with intimacy and affection
• Trust issues
• Low self-esteem
• Difficulty maintaining relationships

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Insecure attachment

• Primary caregiver
• Insensitive
• Disengaged
• Uninvolved
• Emotionally flat
• Controlling
• Infants develop
• Self-protective strategies

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PPD attachment infancy
Depressed
Non-depressed
Teti, Gelfand, Messinger, Isabella (1995)
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PPD attachment preschoolers
Non-Depressed
Depressed
Teti, et al. (1995).
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Forman et al. (2007)

• Depressed moms less responsive, viewed their
  infants more negatively
• 18 mos. later, depressed moms rated their kids
  lower in attachment, behaviour temperament

• Children of depressed mothers, compared to
  children in non-depressed control group, were
  significantly lower in attachment security

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2. Postpartum depression and maternal-infant
interaction
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States of arousal

• Flooded (e.g. crying)
• Hyper-alert (e.g. fussy)
• Calmly focused alert
• Hypo-alert
• Drowsy
• Asleep

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Maternal-child interaction self-regulation

• Critical aspect of regulating a babys states
  involves modulating the intensity of stimulus to
  engage and sustain the babys attention i.e not
  trigger the impulse to cry, avert gaze, or shut
  down.

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Adult sensitivity is any pattern of behavior that
pleases the infant and increases the infants
comfort and attentiveness and reduces its
distress and/or disengagement. (Crittenden, 2011)
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Mothers are hidden regulators of their infants
endocrine nervous systems
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What interferes with maternal sensitivity?

• Attachment trauma history
• Mental health problems Current
• Family violence or Past
• Maternal addictions stress

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PPD maternal-infant interaction

• When I tried to encourage some social
  interaction with her newborn, Stephanie would
  respond that she often just stared at Emma. While
  other relatives laughed and cooed to the baby,
  Stephanie claimed that she did not know how and
  had no desire to do that. Some of her responses
  were I dont know what to say, Is it bad that
  I just stare at her? and Am I being a bad
  mother?
• From Zauderer (2008)

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Depressed mothers

• negative perceptions of normal infant behavior
• ? likely to pick up on infants cues or respond
  to needs
• ? emotionally expressive
• ? affectionate and ? anxious

• ? sensitive and appropriate interactions
• ? negative in their play
• speak more slowly and ? often

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Relationships with infants

• PPD ? maternal-child interaction quality and
  enjoyment in maternal role--moderate to large
  effect (Beck, 1995 Murray et al. 2003)
• Disturbances in mother-child interactions are
  observed at one year postpartum, even when
  mothers are no longer depressed.

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Secure attachment
Sensitivity and parental availability are key
determinants of secure attachment
(Cassidy Shaver, 1999 Trapolini et al., 2007)
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4. Impact of Maternal depression on infant and
child health
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Infant development

• Meta-analysis and systematic review both suggest
  that PPD has a significant effect on infants
  cognitive and social development (Beck, 1998
  Grace, Evindar Stewart, 2003)
• More behaviour problems
• Depression, withdrawal, hyperactivity, aggression
• Lower cognitive functioning
• Verbal, perceptual, quantitative skills
• (Beck ,1998)

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Infant behaviour

• lt12 month old infants
• more tense, less content
• fewer positive facial expressions
• more negative expressions and protest behavior
• drowsy, withdrawn, avoidant

• more crying--fussy and disruptive
• reduced sociability to strangers and performance
  on learning tasks
• disengaged in maternal-infant interactions and in
  toy play
• more sleep problems

(Whiffen Gotlib, 1993 Field, 1984 Murray et
al., 1996 Grace et al., 2003)
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Infant behaviour

• 12 to 36 month olds
• show less sharing, concentration, and sociability
  to strangers
• lower overall rate of interaction
• less responsive and interactive

• show decreased positive affect

(Lyons-Ruth et al., 1986 Murray, 1992
Righetti-Veltema et al., 2003)
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Child behaviour

• 3 to 5 year old children
• are more difficult
• respond in negative manner to friendly approaches
  by other children
• boys most likely to show behaviour problems

• 12 year olds
• behavioral and adjustment problems and substance
  abuse (esp. boys) (Leinonen 2003)

(Murray et al., 1999 Sinclair et al., 1996)
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However parenting more powerful predictor than
whether or not mother was depressed
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Offspring of postnatally depressed mothers at
increased risk for depression by age 16 years,
partially explained by insecure infant
attachment.
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4. How does Maternal Depression get underthe
skin?
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Hypothalamic-Pituitary Adrenal (HPA) Axis

• Cortisol is secreted by the adrenal cortex via
  pulsations that follow a 24-hour (diurnal)
  circadian profile (Hellhammer, 2009)

• Stressors (like PPD) stimulate the activation of
  the HPA which triggers the release of the steroid
  hormone cortisol from the adrenal gland (Essex,
  2002)

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Glucocorticoids/ cortisol
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HPA Axis

• Sensitive periods of enhanced brain plasticity
  vulnerable to long-term effects of cortisol
• Over-activation of the HPA system related to
• decreases in brain volume
• inhibition of neurogenesis
• disruption of neuronal plasticity
• abnormal synaptic connectivity
• (Gunnar, 2009)

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HPA Axis

• Prolonged exposure to elevated levels of
  cortisol predict
• increased insulin resistance
• obesity
• diminished immune responses
• reduced cognition, memory
• fear behaviours, hypervigilance
• attention deficits, behavioural problems
• disturbances with emotional regulation self
  control
• (Essex, 2002, Gunnar, 1998)

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Depression child cortisol

• Infants, 3 year olds, 6-8 year olds,
• (r.22, plt.005 Lupien et al., 2000) and13 year
  olds of depressed mothers display higher cortisol
  levels than children of non-depressed mothers.
• Months of exposure to PPD in childs first year
  of life is potent predictor of ?cort levels.

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Maternal Child Interaction Quality?
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Diurnal Rhythm
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b.07, p.01
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b.06, p.04
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Summary Infant Cortisol

• Infants show an afternoon flattened pattern.
• ? cognitive growth fostering activities predict ?
  concentrations of infant cort over the day
• ? average social-emotional growth fostering
  activities predict ? of a decline in cort over
  the day (flatter decline).

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Symptoms or strategies?

• Attentional problems
• Hypervigilance
• Compulsions
• Agitation
• Aggressiveness (Crittenden, AP)
• Provocativeness
• Acting the victim

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5. So what do we do?
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Reviews of Tx interventions

• 2 reviews of non-biological tx conclude that
  any psychosocial or psychological intervention,
  compared with usual postpartum care, was
  associated with reduced likelihood of continued
  depression within the first year postpartum.
  (Dennis, 2004 Dennis et al., 2007)
• 2 reviews of biological tx have contrasting
  findings--Inconclusive (Dennis, 2004) and SSRIs
  effective (Arroll et al. 2009).

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The treatments (focused on S/S) had no
significant impact on maternal management of
early infant behaviour problems, security of
infant-mother attachment, infant cognitive
development or any child outcome at 5 years.
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Professional MCI for PPD

• Group support for mothers with PPD provided by
  professionals
• Same intervention as in MOMS trial provided in
  group setting no focus on symptoms of PPD
• Mother-infant interaction improved, PPD did not
  change
• No control group n17
• Jung, Short, Letourneau (2006). JAD

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Professional MCI for PPD

• Professional phone (focused on s/s) v. home-based
  maternal-child interaction guidance for mothers
  with PPD (n71)
• Video feedback by trained professionals
• Home-based professional support provided greater
  impact on MCI and attachment
• Depression reduced in both groups, but no
  difference b/w groups
• vanDoesum et al. (2008). Child Development.

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Health care implications
Screen all mothers with EPDS

• Direct, but sensitive questions to explore
  whether mothers have thoughts of infanticide,
  esp. when suicide is
• mentioned (Barr Beck, 2008)

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Health care implications

• Psychotherapeutic or psychological support for
  mother (Dennis Reviews)
• Parent-infant interaction/relationship guidance
  (Jung et al., 2007 Van Doesum et al., 2008)
• AAI and CARE-Index as assessment tools to guide
  relationship-focused intervention

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Thank you

• nicole.letourneau_at_ualberta.ca