Controlled trial of the short- and long-term effect of psychological treatment of post-partum depression 2. Impact on the mother-child relationship and child outcome

Background: Postnatal depression is associated with adverse child cognitive and socio-emotional outcome. It is not known whether psychological treatment affects the quality of the mother-child relationship and child outcome. Aims: To evaluate the effect of three psychological treatments on the mother-child relationship and child outcome. Method: Women with post-partum depression (n=193) were assigned randomly to routine primary care, non-directive counselling, cognitive-behavioural therapy or psychodynamic therapy The women and their children, were assessed at 43, [8 and 60 months post-partum. Results: Indications of a positive benefit were limited. All three treatments had a significant benefit on maternal reports of early difficulties in relationships with the infants, counselling gave better infant emotional and behaviour ratings at 18 months and more sensitive early mother-infant interactions. The treatments 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. Conclusions: Early intervention was of short-term benefit to the mother-child relationship and infant behaviour problems. More-prolonged intervention may be needed. Health visitors could deliver this.

The mother-infant relationship and infant attachment in a south African peri-urban settlement

A sample of 147 mother-infant dyads was recruited from a peri-urban settlement outside Cape Town and seen at 2- and 18-months postpartum. At 18 months, 61.9% of the infants were rated as securely attached (B); 4.1% as avoidant (A); 8.2% as resistant (C); and 25.8% disorganized (D). Postpartum depression at 2 months, and indices of poor parenting at both 2 and 18 months, were associated with insecure infant attachment. The critical 2-month predictor variables for insecure infant attachment were maternal intrusiveness and maternal remoteness, and early maternal depression. When concurrent maternal sensitivity was considered, the quality of the early mother-infant relationship remained important, but maternal depression was no longer predictive. Cross-cultural differences and consistencies in the development of attachment are discussed.

Improving quality of mother-infant relationship and infant attachment in socioeconomically deprived community in South Africa: randomised controlled trial

Objective To assess the efficacy of an intervention designed to improve the mother-infant relationship and security of infant attachment in a South African peri-urban settlement with marked adverse socioeconomic circumstances. Design Randomised controlled trial. Setting Khayelitsha, a peri-urban settlement in South Africa. Participants 449 pregnant women. Interventions The intervention was delivered from late pregnancy and for six months postpartum. Women were visited in their homes by previously untrained lay community workers who provided support and guidance in parenting. The purpose of the intervention was to promote sensitive and responsive parenting and secure infant attachment to the mother. Women in the control group received no therapeutic input from the research team. Main outcome measures Primary outcomes: quality of mother-infant interactions at six and 12 months postpartum; infant attachment security at 18 months. Secondary outcome: maternal depression at six and 12 months. Results The intervention was associated with significant benefit to the mother-infant relationship. At both six and 12 months, compared with control mothers, mothers in the intervention group were significantly more sensitive (6 months: mean difference=0.77 (SD 0.37), t=2.10, P<0.05, d=0.24; 12 months: mean difference=0.42 (0.18), t=-2.04, P<0.05, d=0.26) and less intrusive (6 months: mean difference=0.68 (0.36), t=2.28, P<0.05, d=0.26; 12 months: mean difference=-1.76 (0.86), t=2.28, P<0.05, d=0.24) in their interactions with their infants. The intervention was also associated with a higher rate of secure infant attachments at 18 months (116/156 (74%) v 102/162 (63%); Wald=4.74, odds ratio=1.70, P<0.05). Although the prevalence of maternal depressive disorder was not significantly reduced, the intervention had a benefit in terms of maternal depressed mood at six months (z=2.05, P=0.04) on the Edinburgh postnatal depression scale). Conclusions The intervention, delivered by local lay women, had a significant positive impact on the quality of the mother-infant relationship and on security of infant attachment, factors known to predict favourable child development. If these effects persist, and if they are replicated, this intervention holds considerable promise for use in the developing world. Trial registration Current Controlled Trials ISRCTN25664149.

Improving quality of mother-infant relationship and infant attachment in socioeconomically deprived community in South Africa: randomised controlled trail

Objective To assess the efficacy of an intervention designed to improve the mother-infant relationship and security of infant attachment in a South African peri-urban settlement with marked adverse socioeconomic circumstances. Design Randomised controlled trial. Setting Khayelitsha, a peri-urban settlement in South Africa. Participants 449 pregnant women. Interventions The intervention was delivered from late pregnancy and for six months postpartum. Women were visited in their homes by previously untrained lay community workers who provided support and guidance in parenting. The purpose of the intervention was to promote sensitive and responsive parenting and secure infant attachment to the mother. Women in the control group received no therapeutic input from the research team. Main outcome measures Primary outcomes: quality of mother-infant interactions at six and 12 months postpartum; infant attachment security at 18 months. Secondary outcome: maternal depression at six and 12 months. Results The intervention was associated with significant benefit to the mother-infant relationship. At both six and 12 months, compared with control mothers, mothers in the intervention group were significantly more sensitive (6 months: mean difference=0.77 (SD 0.37), t=2.10, P<0.05, d=0.24; 12 months: mean difference=0.42 (0.18), t=−2.04 , P<0.05, d=0.26) and less intrusive (6 months: mean difference=0.68 (0.36), t=2.28, P<0.05, d=0.26; 12 months: mean difference=−1.76 (0.86), t=2.28 , P<0.05, d=0.24) in their interactions with their infants. The intervention was also associated with a higher rate of secure infant attachments at 18 months (116/156 (74%) v 102/162 (63%); Wald=4.74, odds ratio=1.70, P<0.05). Although the prevalence of maternal depressive disorder was not significantly reduced, the intervention had a benefit in terms of maternal depressed mood at six months (z=2.05, P=0.04) on the Edinburgh postnatal depression scale). Conclusions The intervention, delivered by local lay women, had a significant positive impact on the quality of the mother-infant relationship and on security of infant attachment, factors known to predict favourable child development. If these effects persist, and if they are replicated, this intervention holds considerable promise for use in the developing world.

The development of children of postnatally depressed mothers: evidence from the Cambridge longitudinal study

Children with a parent who suffers from depression are at raised risk for the disorder themselves. Relatively little is known about the development of psychological vulnerability to depression through childhood, particularly during infancy and early childhood. This paper describes results from a longitudinal prospective study of the development of children, studied from birth to 16 years, of mothers who experienced postnatal depression; it highlights the roles of the developing mother-child relationship, and of physiological functioning and social relationships in the development of adolescent vulnerability.

The effects of maternal depression and parental conflict on children's peer play

Background Little is known about the relative effects of exposure to postnatal depression and parental conflict on the social functioning of school-aged children. This is, in part, because of a lack of specificity in the measurement of child and parental behaviour and a reliance on children's reports of their hypothetical responses to conflict in play. Methods In the course of a prospective longitudinal study of children of postnatally depressed and well women, 5-year-old children were videotaped at home with a friend in a naturalistic dressing-up play setting. As well as examining possible associations between the occurrence of postnatal depression and the quality of the children's interactions, we investigated the influence of parental conflict and co-operation, and the continuity of maternal depression. The quality of the current mother-child relationship was considered as a possible mediating factor. Results Exposure to postnatal depression was associated with increased likelihood, among boys, of displaying physical aggression in play with their friend. However, parental conflict mediated the effects of postnatal depression on active aggression during play, and was also associated with displays of autonomy and intense conflict. While there were no gender effects in terms of the degree or intensity of aggressive behaviours, girls were more likely to express aggression verbally using denigration and gloating whereas boys were more likely to display physical aggression via interpersonal and object struggles. Conclusions The study provided evidence for the specificity of effects, with strong links between parental and child peer conflict. These effects appear to arise from direct exposure to parental conflict, rather than indirectly, through mother-child interactions.

Cognitive, affective and behavioural characteristics of mothers with anxiety disorders in the context of child anxiety disorder

Parental emotional distress, particularly high maternal anxiety, is one of the most consistent predictors of child anxiety treatment outcome. In order to identify the cognitive, affective and behavioural parenting characteristics of mothers of children with anxiety disorders who themselves have an anxiety disorder, we assessed the expectations and appraisals of 88 mothers of anxious children (44 not anxious (NONANX) and 44 with a current anxiety disorder (ANX)) before and after interacting with their 7-12 year old children. There were no observed differences in anxiety and avoidance among children of ANX and NONANX mothers, but, compared to NONANX mothers, ANX mothers held more negative expectations and differed on observations of intrusiveness, expressed anxiety, warmth and the quality of the relationship. Associations were moderated by the degree to which children expressed anxiety during the tasks. Maternal reported negative emotions during the task significantly mediated the association between maternal anxiety status and the observed quality of the relationship. These findings suggest that maternal anxiety disorder is associated with reduced tolerance of children’s negative emotions. This may interfere with the maintenance of a positive, supportive mother-child interaction under conditions of stress, and as such impede optimum treatment outcomes. The findings identify potential cognitive, affective and behavioural targets to improve treatment outcomes for children with anxiety disorders in the context of a current maternal anxiety disorder.

Child anxiety and parenting in England and Italy: the moderating role of maternal warmth

BACKGROUND: Parenting factors have been implicated in the aetiology and maintenance of child anxiety. Most research has been correlational with little experimental or longitudinal work. Cross-cultural comparison could be illuminating. A comparison of Italian and British children and their mothers was conducted. METHODS: A sample of 8- to 10-year old children, 60 Italian and 49 English, completed the Spence Child Anxiety Scale. Mothers also completed two questionnaires of parenting: the Skills of Daily Living Checklist (assessing maternal autonomy granting) and the Parent-Child Interaction Questionnaire (assessing maternal intrusiveness). Parenting was assessed in two video-recorded blindly rated mother-child interaction tasks, the 'belt-buckling tasks and the 'etch-a-sketch', providing objective indices of overcontrol, warmth, lack of autonomy granting, and overprotection. RESULTS: There were no differences between the children in overall anxiety and specific forms of anxiety. Parenting, however, was markedly different for the two countries. Compared to English mothers, on the two questionnaires, Italian mothers were significantly less autonomy granting and more intrusive; and in terms of the observed indices, a significantly greater proportion of the Italian mothers displayed a high level of both overprotection and overcontrol, and a low level of autonomy granting. Notably, Italian mothers evidenced significantly more warmth than English mothers; and maternal warmth was found to moderate the impact of self-reported maternal intrusiveness on the level of both overall child anxiety and the level of child separation anxiety; and it also moderated the relationship between both observed maternal intrusiveness and overall child anxiety and observed maternal overprotectiveness and child separation anxiety. CONCLUSIONS: Although, compared to the British mothers, the Italian mothers were more likely to evidence high levels of parenting behaviours previously found to be anxiogenic, the high levels of warmth displayed by these mothers to their children appears to have neutralised the adverse impact of these behaviours.

Cost-effectiveness of a preventive counseling and support package for postnatal depression

Objectives: This study reports the cost-effectiveness of a preventive intervention, consisting of counseling and specific support for the mother-infant relationship, targeted at women at high risk of developing postnatal depression. Methods: A prospective economic evaluation was conducted alongside a pragmatic randomized controlled trial in which women considered at high risk of developing postnatal depression were allocated randomly to the preventive intervention (n = 74) or to routine primary care (n = 77). The primary outcome measure was the duration of postnatal depression experienced during the first 18 months postpartum. Data on health and social care use by women and their infants up to 18 months postpartum were collected, using a combination of prospective diaries and face-to-face interviews, and then were combined with unit costs ( pound, year 2000 prices) to obtain a net cost per mother-infant dyad. The nonparametric bootstrap method was used to present cost-effectiveness acceptability curves and net benefit statistics at alternative willingness to pay thresholds held by decision makers for preventing 1 month of postnatal depression. Results: Women in the preventive intervention group were depressed for an average of 2.21 months (9.57 weeks) during the study period, whereas women in the routine primary care group were depressed for an average of 2.70 months (11.71 weeks). The mean health and social care costs were estimated at 2,396.9 pound per mother-infant dyad in the preventive intervention group and 2,277.5 pound per mother-infant dyad in the routine primary care group, providing a mean cost difference of 119.5 pound (bootstrap 95 percent confidence interval [Cl], -535.4, 784.9). At a willingness to pay threshold of 1,000 pound per month of postnatal depression avoided, the probability that the preventive intervention is cost-effective is .71 and the mean net benefit is 383.4 pound (bootstrap 95 percent Cl, -863.3- pound 1,581.5) pound. Conclusions: The preventive intervention is likely to be cost-effective even at relatively low willingness to pay thresholds for preventing 1 month of postnatal depression during the first 18 months postpartum. Given the negative impact of postnatal depression on later child development, further research is required that investigates the longer-term cost-effectiveness of the preventive intervention in high risk women.

The effect of cleft lip and palate, and the timing of lip repair on mother-infant interactions and infant development

Background: Children with cleft lip and palate are at risk for psychological problems. Difficulties in mother-child interactions may be relevant, and could be affected by the timing of lip repair. Method: We assessed cognitive development, behaviour problems, and attachment in 94 infants with cleft lip (with and without cleft palate) and 96 non-affected control infants at 18 months; mother-infant interactions were assessed at two, six and 12 months. Index infants received either 'early', neonatal, lip repair, or 'late' repair (3-4 months). Results: Index infants did not differ from controls on measures of behaviour problems or attachment, regardless of timing of lip repair; however, infants having late lip repair performed worse on the Bayley Scales of Mental Development; the cognitive development of early repair infants was not impaired. Difficulties in early mother-infant interactions mediated the effects of late lip repair on infant cognitive outcome. Conclusions: Early interaction difficulties between mothers and infants having late repair of cleft lip are associated with poor cognitive functioning at 18 months. Interventions to facilitate mother-infant interactions prior to surgical lip repair should be explored.

The role played by the interaction between genetic factors and attachment in the stress response in infancy

Background: The importance of understanding which environmental and biological factors are involved in determining individual differences in physiological response to stress is widely recognized, given the impact that stress has on physical and mental health. Methods: The child-mother attachment relationship and some genetic polymorphisms (5-HTTLPR, COMT and GABRA6) were tested as predictors of salivary cortisol and alpha amylase concentrations, two biomarkers of hypothalamic-pituitary-adrenocortical (HPA) axis and sympathetic adrenomedullary (SAM) system activity, during the Strange Situation (SS) procedure in a sample of more than 100 healthy infants, aged 12 to 18 months. Results: Individual differences in alpha amylase response to separation were predicted by security of attachment in interaction with 5-HTTLPR and GABRA6 genetic polymorphisms, whereas alpha amylase basal levels were predicted by COMT x attachment interaction. No significant effect of attachment, genetics and their interaction on cortisol activity emerged. Conclusions: These results help to disentangle the role played by both genetic and environmental factors in determining individual differences in stress response in infancy. The results also shed light on the suggestion that HPA and SAM systems are likely to have different characteristic responses to stress.

Treatment of child anxiety. an exploratory study of the role of maternal anxiety and behaviours in treatment outcome

Anxiety disorders are common among parents of anxious children and have been found to impede child treatment outcomes, yet it is unclear whether it is parental anxiety that needs to be targeted in therapy or associated parental behaviours. Twenty-two children (6-12 years) with a current anxiety disorder and their mothers received cognitive-behavioural treatment (CBT) for child anxiety. In addition, of the 12 mothers who met criteria for a current anxiety disorder, 6 received CBT for their own disorder. Assessments were made of the mother-child interaction. The main findings were: (1) children did less well from treatment where their mothers had a current anxiety disorder; (2) treatment of maternal anxiety disorder did not improve child treatment outcome; and (3) maternal overinvolvement and expression of fear was associated with child treatment outcome. The results suggest that in the context of maternal anxiety disorder, child treatment outcome may be improved by specifically targeting parenting behaviours. Copyright (C) 2008 John Wiley & Sons, Ltd.

Making an effort to feel positive: insecure attachment in infancy predicts the neural underpinnings of emotion regulation in adulthood

Background: Animal research indicates that the neural substrates of emotion regulation may be persistently altered by early environmental exposures. If similar processes operate in human development then this is significant, as the capacity to regulate emotional states is fundamental to human adaptation. Methods: We utilised a 22-year longitudinal study to examine the influence of early infant attachment to the mother, a key marker of early experience, on neural regulation of emotional states in young adults. Infant attachment status was measured via objective assessment at 18-months, and the neural underpinnings of the active regulation of affect were studied using fMRI at age 22 years. Results: Infant attachment status at 18-months predicted neural responding during the regulation of positive affect 20-years later. Specifically, while attempting to up-regulate positive emotions, adults who had been insecurely versus securely attached as infants showed greater activation in prefrontal regions involved in cognitive control and reduced co-activation of prefrontal cortex and nucleus accumbens, consistent with relative inefficiency in the neural regulation of positive affect. Conclusions: Disturbances in the mother-infant relationship may persistently alter the neural circuitry of emotion regulation, with potential implications for adjustment in adulthood.

Socioemotional development in adolescents at risk for depression: the role of maternal depression and attachment style

We examined the impact on adolescent socioemotional functioning of maternal postnatal depression (PND) and attachment style. We also investigated the role of earlier aspects of the child's development-attachment in infancy, and 5-year representations of family relationships. Ninety-one mother-child pairs, recruited in the postnatal period, were followed tip at 13 years. Adolescents were interviewed about their friendships, and their level of emotional sensitivity and maturity were rated. Emotional sensitivity was heightened in girls whose mothers experienced PND; notably, its occurrence was also linked to insecure attachment in infancy and raised awareness of emotional components of family relationships at 5 years. High emotional sensitivity was also associated with adolescent depressed mood. Raised social maturity was predicted by a secure maternal attachment style and, for girls, by exposure to maternal PND. Precursors of adolescent social maturity were evident in the narrative coherence of 5-year family representations. Higher social maturity in the friendship interview was also associated with overall good adjustment.

Mental health of parents caring for infants

The postpartum period is a sensitive time due to the presence and demands of the developing infant. The care provided by a mother to her infant during this period may be compromised if she is suffering from postnatal depression or postpartum psychosis. Evidence has been emerging which suggests that postnatal depression and postpartum psychoses have adverse effects on the quality of the mother-infant relationship and also on the infants subsequent cognitive and emotional development. Presented is a review of the literature relating to how these conditions impact on parenting and infant outcomes, what measures are in place to detect these conditions and evidence-based models of best clinical practice are proposed.