Maternal depression: an old problem that merits increased recognition by child healthcare practitioners

Going Farther by Going Together: Collaboration as a Tool in Advocacy

With greater understanding of the impact of social determinants on child health, advocacy has become essential to promoting children's health, particularly at the population level. Successful advocacy requires coalition building. Steps on how to create a productive coalition, including the selection of partner organizations, understanding how these groups enhance your activities, and strict definition of assigned roles is reviewed. Examples of successful coalitions are reviewed. A list of potential partners, who focus on various aspects of child health, is provided.

Reducing the Risk for Postpartum Depression in Adolescent Mothers: A Randomized Controlled Trial

OBJECTIVE

To estimate the effect of an interpersonal therapy-based intervention on reducing the risk of postpartum depression in adolescents.

METHODS

A randomized controlled trial enrolled 250 pregnant adolescents who were aged 18 years or younger at conception. The initial sample size calculation estimated 276 participants (324 with attrition) were needed to detect a 50% reduction in risk of the primary outcome, postpartum major depressive episode, with an alpha of 0.05% and 80% power. An interim analysis by the Data Safety and Monitoring Committee informed a revision in the sample size target to 250. Participants were randomized to the intervention (n=129) or a time-matched control group (n=121) who attended sessions about pregnancy topics. Each group received five prenatal sessions and a postpartum booster session. A structured diagnostic interview was administered at baseline and specific time points through 12-months postpartum to assess for major depressive episode onset.

RESULTS

Participants were recruited from December 2011 to May 2016 through urban prenatal care sites in the state of Rhode Island. Of the 250 participants, 58% identified as Hispanic and 20% as black or African American. The rate of major depressive episode by 12 months postpartum was 7.0% (95% CI 2.3-11.7%) in the control group and 7.6% (95% CI 2.5-12.7%) in the intervention group, with no significant difference between groups at any time point (P=.88 by log-rank test).

CONCLUSION

No benefit was shown between the intervention and control groups in the rates of major depressive episode, which is likely related to a lower than predicted rate of this outcome in the control group (7.6% actual vs 25% predicted). Enhanced local community resources available to pregnant and parenting adolescents during the study period may be an explanation for this result.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT01482832.

Maternal and Paternal Depressive Symptoms, Home Learning Environment, and Children's Early Literacy

The present study examined the influence of mothers' and fathers' depressive symptoms on children's early literacy skills. Home learning-related parenting (HLE) was examined as a mediator of these associations. Families (N = 465) were recruited through preschools. Results indicate an actor effect of fathers', but not mothers', depressive symptoms on HLE parenting such that fathers who reported more depressive symptoms engaged in fewer HLE activities. A partner effect of fathers' depressive symptoms on HLE parenting indicated that higher levels of fathers' depressive symptoms were associated with lower levels of mothers' home learning activities. Finally, fathers' depressive symptoms negatively related to children's early literacy skills indirectly through mothers' HLE parenting. Findings highlight a process of negative effect of parent depressive symptoms on children's early literacy and emphasize including both mothers and fathers in future research concerned with the influence of parents' depressive symptoms on children's development.

Relationship between maternal depression symptoms and child weight outcomes in Latino farmworker families

This study sought to characterize depressive symptoms among mothers in Latino farmworker families, determine if maternal depression increases children's risk of obesity, and ascertain whether relevant risk factors such as physical activity, diet, and feeding style mediate this relationship. Mothers from 248 families completed the 10-item Center for Epidemiologic Studies Depression Scale 9 times over a 2-year period. Four distinct patterns were used to describe mothers: few symptoms, moderate episodic symptoms, severe episodic symptoms, and chronic symptoms. Approximately two-thirds of women experienced moderate symptoms of depression at least once. Children of mothers fitting each pattern were compared. At the end of the study, children of mothers with severe episodic and chronic symptoms were significantly more likely to be overweight and obese than children of mothers with few symptoms (p < .05). After controlling for covariates, differences in weight status for children of mothers with severe episodic symptoms remained significant. Children of mothers with either moderate episodic or chronic symptoms were fed in a less responsive fashion (p < .05), and children of chronically symptomatic mothers had lower diet quality (p < .01). Although nonresponsive feeding has been linked to childhood obesity, in this analysis, feeding style did not mediate the relationship between maternal depression and diet quality. Elevated levels of depressive symptoms are common in this population, and those symptoms, especially when severe or chronic in nature, may increase children's risk of obesity. Additional research is needed to characterize the pathways through which maternal depression influences children's weight.

Screening for Social Determinants of Health Among Children and Families Living in Poverty: A Guide for Clinicians

Approximately 20% of all children in the United States live in poverty, which exists in rural, urban, and suburban areas. Thus, all child health clinicians need to be familiar with the effects of poverty on health and to understand associated, preventable, and modifiable social factors that impact health. Social determinants of health are identifiable root causes of medical problems. For children living in poverty, social determinants of health for which clinicians may play a role include the following: child maltreatment, child care and education, family financial support, physical environment, family social support, intimate partner violence, maternal depression and family mental illness, household substance abuse, firearm exposure, and parental health literacy. Children, particularly those living in poverty, exposed to adverse childhood experiences are susceptible to toxic stress and a variety of child and adult health problems, including developmental delay, asthma and heart disease. Despite the detrimental effects of social determinants on health, few child health clinicians routinely address the unmet social and psychosocial factors impacting children and their families during routine primary care visits. Clinicians need tools to screen for social determinants of health and to be familiar with available local and national resources to address these issues. These guidelines provide an overview of social determinants of health impacting children living in poverty and provide clinicians with practical screening tools and resources.

Social Competence and Obesity in Elementary School

Objectives. We examined the relationship between children's weight and social competence. Methods. We used data from the third- and fifth-grade waves of the nationally representative Early Childhood Longitudinal Study, Kindergarten Class of 1998-1999 (n = 8346) to examine changes in children's weight and social competence. Results. Obesity in third grade was not associated with subsequent changes in social competence between third and fifth grade, but social competence in third grade was associated with subsequent development of obesity. Among normal-weight children, having higher social competence in third grade was associated with lower odds of becoming overweight (odds ratio [OR] = 0.80 ±0.09; P < .05) or obese (OR = 0.20 ±0.08; P < .001). In addition, obese children with higher social competence were more likely to lose weight between third and fifth grade (OR = 1.43 ±0.25; P < .05). Conclusions. Obesity and impaired social competence often occur together and have serious implications for children's well-being. More knowledge about how weight and social competence affect one another could inform interventions to promote children's social development and reduce obesity.

Maternal depressive symptoms and child obesity in low-income urban families

OBJECTIVE

To characterize the relationship between maternal depressive symptoms and child weight status, obesity-promoting feeding practices, and activity-related behaviors in low-income urban families.

METHODS

We conducted a cross-sectional survey of mothers with 5-year-old children receiving pediatric care at a federally qualified community health center. We used regression analyses to examine the relationship between maternal depressive symptoms (trichotomized: none, mild, moderate to severe) and 1) child weight status; 2) obesity-promoting feeding practices, including mealtime practices and feeding styles; and 3) activity-related behaviors, including sleep time, screen time, and outdoor playtime.

RESULTS

The sample included 401 mother-child pairs (78.3% response rate), with 23.4% of mothers reporting depressive symptoms (15.7% mild, 7.7% moderate to severe). Mothers with moderate to severe depressive symptoms were more likely to have overweight and obese children than mothers without depressive symptoms (adjusted odds ratio 2.62; 95% confidence interval 1.02-6.70). Children of mildly depressed mothers were more likely to consume sweetened drinks and to eat out at restaurants and were less likely to eat breakfast than children of nondepressed mothers. Mothers with depressive symptoms were less likely to set limits, to use food as a reward, to restrict their child's intake, and to model healthy eating than nondepressed mothers. Children with depressed mothers had less sleep and outdoor playtime per day than children of nondepressed mothers.

CONCLUSIONS

Maternal depressive symptoms are associated with child overweight and obese status and with several obesity-promoting practices. These results support the need for maternal depression screening in pediatric obesity prevention programs. Further research should explore how to incorporate needed mental health support.

Applying surveillance and screening to family psychosocial issues: implications for the medical home

Within the medical home, understanding the family and community context in which children live is critical to optimally promoting children's health and development. How to best identify psychosocial issues likely to have an impact on children's development is uncertain. Professional guidelines encourage pediatricians to incorporate family psychosocial screening within the context of primary care, yet few providers routinely screen for these issues. The authors propose applying the core principles of surveillance and screening, as applied to children's development and behavior, to also address family psychosocial issues during health supervision services. Integrating psychosocial surveillance and screening into the medical home requires changes in professional training, provider practice, and public policy. The potential of family psychosocial surveillance and screening to promote children's optimal development justifies such changes.

Can pediatricians accurately identify maternal depression at well-child visits?

BACKGROUND

The feasibility of a two-item screening tool for maternal depression in a pediatric setting was recently reported. We assessed whether the accuracy of pediatrician recognition of maternal depression during the one-month well-child visit could be improved by an educational intervention using the two-item screening tool.

METHODS

We conducted an educational intervention for pediatric residents in a suburban hospital in Tokyo, Japan, with outcome measurement before and after. Resident education included knowledge about postpartum depression and its impact on children, use of the two-item screening tool and available management strategies. Sixteen pediatric residents examined 267 mother-infant dyads during well-child visits. Residents documented the presence or absence of postpartum depressive symptoms on medical records. Depressive symptoms were also determined using the Edinburgh Postnatal Depression Scale (EPDS) survey; residents were not aware of the results. Using the EPDS as a "gold standard," improvement in sensitivity and specificity of resident recognition of maternal depressive symptoms was determined.

RESULTS

The overall prevalence of postpartum depressive symptoms based on the EPDS was 15.4%. The sensitivity of resident recognition was 8% and specificity 98% before intervention, and 12% and 96% afterwards, respectively. The difference was not statistically significant. Residents indicated fear of maternal stigmatization and mothers' receptiveness to discussing depressive symptoms, as well as lack of time and skills, as major barriers to the identification of maternal depression.

CONCLUSIONS

A simple educational intervention using a two-item screening tool did not improve the pediatrician's accuracy in detecting depressive symptoms in mothers. Additional strategies to address perceived barriers may be needed.

Prospective relationship between maternal depressive symptoms and asthma morbidity among inner-city African American children

OBJECTIVE

To examine prospective relationships between caregiver's depressive symptoms and child asthma morbidity among inner-city African American families.

METHODS

Phone surveys were conducted 6 months apart with 262 African American mothers of children with asthma. Cross-lagged structural path analysis was used for data analyses.

RESULTS

Using goodness-of-fit indices, the final model for asthma symptoms had a good fit to the data. Time 1 (T1) maternal depressive symptoms predicted T2 child asthma symptoms (beta =.16, p <.01); however, T1 asthma symptoms did not predict T2 maternal depressive symptoms (beta =.03, non-significant). In contrast, in the final model for emergency department (ED) visits there was no predictive association between maternal depressive symptoms and ED visits.

CONCLUSION

Maternal depressive symptoms may have a detrimental effect on child asthma morbidity among inner-city African American families, rather than vice versa. Ameliorating maternal depressive symptoms may result in better asthma outcomes for inner-city children.

Maternal mental health and pediatric health care use among a national sample of Medicaid- and SCHIP-insured children

While the literature has shown that health care use is associated with mental health status, little is known about the relationship between a mother's mental health status and her children's health care use. This study examined the association of maternal mental health status and pediatric health care for their children in a nationally representative sample of 17,830 women parenting children ages 0-17 insured through Medicaid or a State Children's Health Insurance Program (SCHIP). Mothers with a mental health problem were significantly more likely to be poorer, single parents, with lower levels of education, fewer parenting supports, and greater difficulty coping with parenting than mothers without a mental health problem; however, they reported comparable receipt of pediatric health care for their children, indicating their resilience as caretakers. The findings also suggest that all Medicaid- or SCHIP-eligible families could benefit from targeted engagement strategies linking them with consistent and appropriate sources of pediatric health care.

Early parental depression and child language development

OBJECTIVE

To examine the effects of early maternal and paternal depression on child expressive language at age 24 months and the role that parent-to-child reading may play in this pathway.

PARTICIPANTS AND METHODS

The 9-month and 24-month waves from a national prospective study of children and their families, the Early Childhood Longitudinal Study - Birth Cohort (ECLS-B), provided data on 4,109 two-parent families. Depressive symptoms were measured with a short form of the Center for Epidemiologic Studies Depression Scale (CES-D). Parents reported on positive parent-infant interactions, child expressive vocabulary, and demographic and health information at child age 9 and 24 months. Linear regression was used to estimate associations between depression, parenting, and child vocabulary. Structural equation modeling was used to test the hypothesis that parent reading behavior mediates the parent depression to child vocabulary pathway. These models were adjusted for demographic indicators.

RESULTS

As previously reported from this national sample, 14% of mothers and 10% of fathers exhibited elevated levels of depressive symptoms at 9 months. For both mothers and fathers, depression at 9 months was negatively associated with contemporaneous parent-to-child reading. Only for fathers, however, was earlier depression associated with later reading to child and related child expressive vocabulary development. A model describing this pathway demonstrated a significant indirect pathway from depression to vocabulary via parent reading to child.

CONCLUSIONS

Depression is a significant problem among both mothers and fathers of young children, but has a more marked impact on the father's reading to his child and, subsequently, the child's language development.

Test performance of two-question screening for postpartum depressive symptoms

BACKGROUND

The Edinburgh Postnatal Depression Scale (EPDS) is commonly used to screen for postpartum depression, but it is difficult to consistently administer it to all mothers during busy well-child visits owing to the fact that it is time-consuming. The purpose of the present paper was to evaluate the performance of a concise, two-question screening tool in the detection of mothers with postpartum depressive symptoms who had a high EPDS score.

METHODS

The study involved 103 mothers attending a single hospital for 1 month well-child visits. The primary outcome measure was the detection of mothers with postpartum depressive symptoms, using the EPDS score as the reference standard. Visiting mothers were asked to complete both the EPDS questionnaire and a two-question questionnaire covering depressive mood and anhedonia while in the hospital waiting room. The sensitivity, specificity, predictive value, and likelihood ratio of the two-question instrument was evaluated using the EPDS as standard.

RESULTS

Taking EPDS as standard, sensitivity of the two-question instrument was 88% (95% confidence interval [CI]: 64-99%), specificity was 76% (95%CI: 65-84%), positive predictive value was 42% (95%CI: 26-59%), and negative predictive value was 97% (95%CI: 90-100%). The stratified likelihood ratios of each of the two-question instrument test scores 0, 1, and 2 were 0.2 (95%CI: 0.04-0.6), 3.4 (95%CI: 1.8-6.2) and 4.2 (95%CI: 1.5-12.3), respectively.

CONCLUSIONS

With the cut-off point set at 1, the two-question instrument had high sensitivity in detecting postpartum depressive symptoms at 1 month well-child visits. In primary care setting, negative result with the two-question instrument may be a good indicator of no need for further evaluation for postpartum depression.

Does education influence pediatricians' perceptions of physician-specific barriers for maternal depression?

Pediatric residency reforms have increased emphasis on psychosocial issues, but we do not know whether this has changed pediatricians' perceptions of barriers to addressing maternal depression. A survey of 1600 members of the American Academy of Pediatrics investigated whether training in adult mental health issues and perceived barriers to addressing maternal depression differed for current pediatric residents, pediatricians in practice <5 years, and those in practice >or=5 years. Training did not differ for respondents who were currently in training, in practice <5 years, or in practice >or=5 years. Those in practice >or=5 years reported more barriers to addressing maternal depression compared with current residents. Current residents with training in adult mental techniques reported fewer barriers to the care of maternal depression. However, in spite of residency reforms, 81% of current residents reported no training in adult mental health issues.

The co-occurrence of smoking and a major depressive episode among mothers 15 months after delivery

OBJECTIVE

To examine the association between maternal smoking 15 months after delivery and the occurrence of a major depressive episode in the prior 12 months.

METHODS

Data were obtained from the Fragile Families and Child Wellbeing Study, a birth cohort study. In 20 U.S. cities, 4898 mothers were surveyed at delivery in the years 1998 to 2000. In a survey 15 months later, 4353 (89%) of the mothers reported their smoking behavior and symptoms of a major depressive episode during the prior 12 months.

RESULTS

At the follow-up survey, 26.6% of mothers reported that they were current smokers and 13.6% reported that they had symptoms of a major depressive episode during the prior 12 months. After adjusting for sociodemographic characteristics, the prevalence (95% confidence interval) of a major depressive episode was higher among smokers than nonsmokers: 17.7% (15.7%, 19.8%) vs. 12.1% (10.9%, 13.3%). Smoking was also more common among mothers with a major depressive episode than in those without one: 34.0% (30.6%, 37.4%) vs. 25.5% (24.1%, 26.8%).

CONCLUSION

Smoking and depression often co-occur among mothers with infants. This suggests that these conditions should not be diagnosed or treated in isolation from each other and that the care of mothers and children should be integrated.

Maternal depression and cognitive features of 9-year-old children prenatally-exposed to cocaine

This study evaluated cocaine exposure and maternal characteristics as competing predictors of school-age cognitive, achievement, and language performance. One group of 47 exposed 9-year-old children were first studied in an earlier prenatal study. A non-exposed contrast group (n = 46) served as a reference. Maternal measures included: IQ, psychopathology, drugs, demographics, and environment. Child intelligence, language, and achievement scores were inversely related to maternal IQ and depression scores, with cocaine exposure significant secondary or tertiary predictors for many children. Verbal IQ scores of exposed children strongly reflected maternal depression (r = .54) but no such relationship was found among the non-exposed cohort (r = .00).

Legal and ethical considerations: risks and benefits of postpartum depression screening at well-child visits

Pediatric professionals are being asked to provide an increasing array of services during well-child visits, including screening for psychosocial and family issues that may directly or indirectly affect their pediatric patients. One such service is routine screening for postpartum depression at pediatric visits. Postpartum depression is an example of a parental condition that can have serious negative effects for the child. Because it is a maternal condition, it raises a host of ethical and legal questions about the boundaries of pediatric care and the pediatric provider's responsibility and liability. In this article we discuss the ethical and legal considerations of, and outline the risks of screening or not screening for, postpartum depression at pediatric visits. We make recommendations for pediatric provider education and for the roles of national professional organizations in guiding the process of defining the boundaries of pediatric care.

Individual and combined effects of postpartum depression in mothers and fathers on parenting behavior

BACKGROUND

Pediatric anticipatory guidance has been associated with parenting behaviors that promote positive infant development. Maternal postpartum depression is known to negatively affect parenting and may prevent mothers from following anticipatory guidance. The effects of postpartum depression in fathers on parenting is understudied.

OBJECTIVE

Our purpose with this work was to examine the effects of maternal and paternal depression on parenting behaviors consistent with anticipatory guidance recommendations.

METHODS

The 9-month-old wave of data from a national study of children and their families, the Early Childhood Longitudinal Study, provided data on 5089 2-parent families. Depressive symptoms were measured with a short form of the Center for Epidemiologic Studies Depression Scale. Interviews with both parents provided data on parent health behaviors and parent-infant interactions. Logistic and linear regression models were used to estimate the association between depression in each parent and the parenting behaviors of interest. These models were adjusted for demographic and socioeconomic status indicators.

RESULTS

In this national sample, 14% of mothers and 10% of fathers exhibited levels of depressive symptoms on the Center for Epidemiologic Studies Depression Scale that have been associated with clinical diagnoses, confirming other findings of a high prevalence of postpartum maternal depression but highlighting that postpartum depression is a significant issue for fathers as well. Mothers who were depressed were approximately 1.5 times more likely to engage in less healthy feeding and sleep practices with their infant. In both mothers and fathers, depressive symptoms were negatively associated with positive enrichment activity with the child (reading, singing songs, and telling stories).

CONCLUSIONS

Postpartum depression is a significant problem in both mothers and fathers in the United States. It is associated with undesirable parent health behaviors and fewer positive parent-infant interactions.

Maternal depressive symptoms and children's receipt of health care in the first 3 years of life

BACKGROUND

Maternal depression is widely recognized to negatively influence mother-child interactions and children's behavior and development, but little is known about its relation to children's receipt of health care.

OBJECTIVE

To determine if maternal depressive symptoms reported at 2 to 4 and 30 to 33 months postpartum are associated with children's receipt of acute and preventive health care services in the first 30 months.

DESIGN

Cohort study of data collected prospectively as part of the National Evaluation of Healthy Steps for Young Children (HS). Data sources included medical records abstracted for the first 32 months, enrollment questionnaires, and parent interviews when children were 2 to 4 and 30 to 33 months old. Acute care use included hospitalizations and emergency department visits. Preventive care included well-child visits and vaccinations. Maternal depressive symptoms were assessed by using the Center for Epidemiologic Studies-Depression Scale. Generalized linear models (logistic regression for dichotomous outcomes and Poisson regression for count outcomes) were used to estimate the effect of maternal depressive symptoms on children's receipt of care. The models were adjusted for baseline demographic characteristics, child health status, participation in HS, and site of enrollment.

RESULTS

Of the 5565 families enrolled in HS, 88% completed 2- to 4-month parent interviews, 67% completed 30- to 33-month parent interviews, and 96% had medical records abstracted. The percentages of mothers reporting depressive symptoms were 17.8% at 2 to 4 months, 15.5% at 30 to 33 months, and 6.4% at both. Children whose mothers had depressive symptoms at 2 to 4 months had increased use of acute care reported at 30 to 33 months including emergency department visits in the past year (odds ratio [OR]: 1.44; confidence interval [CI]: 1.17, 1.76). These children also had decreased receipt of preventive services including age-appropriate well-child visits (eg, at 12 months [OR: 0.80; CI: 0.67, 0.95]) and up-to-date vaccinations at 24 months for 4 doses of diphtheria, tetanus, pertussis, 3 doses of polio vaccine, and 1 dose of measles-mumps-rubella (OR: 0.79; CI: 0.68, 0.93). There was no association of maternal depressive symptoms at 30 to 33 months with children's preceding use of care.

CONCLUSIONS

Maternal depressive symptoms in early infancy contribute to unfavorable patterns of health care seeking for children. Increased provider training for recognizing maternal depressive symptoms in office settings, more effective systems of referral, and development of partnerships between adult and pediatric providers could contribute to enhanced receipt of care among young children.