Perinatal Depression and Children: A Developmental Perspective
Sherryl H. Goodman, PhD, Matthew H. Rouse, MA, MSW
Emory University, USA
Perinatal depression in mothers, defined as depression occurring during pregnancy or postpartum, is of concern for all who are involved with such families. These concerns derive from common understandings of the essential role both a healthy pregnancy and mothers’ warm responsive care play in fetal and infant development and how depression might interfere. Emerging research reveals the effects of perinatal depression on the psychological development of infants and young children of depressed mothers, with a focus on vulnerabilities to the later development of psychopathology and likely mechanisms. Although many questions remain, some conclusions can be drawn about the effects of perinatal depression on child development and the implications for parents, service providers and policy makers.
Depression is common, especially in women. During pregnancy, rates of major depressive episodes, as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), range from 10-17%1-3 with significant variability among estimates.4 Additionally, one meta-analysis estimated that postpartum major or minor depression occurs in as many as 19.2% of women with the more narrowly defined major depression estimated to occur in 7.1% of new mothers.4 Antenatal depression occurs in similar rates as in the postpartum period, rates which are not significantly different from rates in non-pregnant or postpartum women. Finally, given that antenatal depression is one of the strongest predictors of postnatal depression,5 many children are exposed both during fetal and infant development.
From a developmental perspective, timing of exposure to maternal depression is an important consideration, especially in terms of particular risks to development, resiliencies that the children would be able to bring to bear, and the mechanisms by which those risks are likely to be transmitted. Of particular concern is that early on, children of depressed mothers may develop vulnerabilities to later depression or other problems. Antenatal depression may not only alter development of stress-related biological systems in the fetus, but may also increase risk of obstetrical complications.6 Postnatal depression may also be an early life stressor given known associations with lower levels of sensitive, responsive care needed for infants’ development of health attachment relationships, emotional regulation skills, interpersonal skills and stress response mechanisms.7 Early life stressors, such as those that might be associated with maternal depression, can influence brain development, which continues at a rapid pace at least for several years after birth.8 Problems in any of these aspects of development may disrupt the earliest stages of socio-emotional and cognitive development, predisposing to the later development of depression or other disorders.
Research on the development of children exposed to perinatal depression emerges from the body of work which considers the broader context within which perinatal depression is embedded, including comorbidities (e.g., anxiety and/or substance use), correlates (e.g., marital distress), and the broader environment (e.g., economic stressors).
Key Research Questions
Researchers have focused their questions on the effects of antenatal or postnatal depression on infant and later development, with a few examining the combined effect of both. Essential questions that have been addressed include: (a) effects of antenatal, postnatal, or dual exposures on infant and later development (b) primary mechanisms or mediators that help explain those effects (c) moderators of those associations such that some children are at greater risk than others. Goodman and Gotlib’s integrative model has served as an organizing framework for much of this work.9
Recent Research Results
Consistent with theorized mechanisms, antenatal depression has been found to be associated with newborns’ neurobehavioural regulation, including their ability to attend to visual and auditory stimuli and overall alertness, as measured by the Neonatal Behavioral Assessment Scale.10,11 Other adverse outcomes noted for these newborns are higher levels of fussing/crying and more sleep problems12 (with sleep problems persisting through 18 and 30 months of age)13 greater frontal electroencephalogram (EEG) asymmetry,14 higher cortisol and lower dopamine,15 and lower vagal tone,15 although the latter association was no longer in 24 week-old infants.16 Studies of infant temperament have found specific associations between prenatal depression earlier in pregnancy and negative affectivity.17 Finally, antenatal depression is associated with elevations in both externalizing and internalizing problems in 30-month-old boys,19 and increased externalizing but not internalizing problems in both sexes at 8 to 9 years of age.18 Despite much theorizing and support from the animal literature for a role of cortisol as a mediator of the associations between antenatal depression and infant and child outcomes, support has been inconsistent and primarily indirect. First, associations between depression and cortisol in pregnancy were not found in one large population based cohort study20 and may only be significant in the presence of antidepressant medication21 or co-morbid anxiety.22 Second, studies that tested either direct associations between antenatal maternal cortisol levels on infant or child outcomes or the mediational role of antenatal cortisol in associations between antenatal depression and outcomes yield mixed findings and typically have relied on small samples.23 Postpartum depression has been associated with a range of problems in infants’ and young children’s development. Associated outcomes include negative infant temperament,24 insecure attachment,25 cognitive and language development difficulties,26 lower self-esteem and other cognitive vulnerabilities to depression in five year olds,27 and poorer peer relations in early childhood.28
The primary mechanisms implicated in associations between postnatal depression and young children’s development have been problems in parenting and high stress levels, both of which have strong associations with depression in women.7,29 Depression interferes with the qualities of parenting known to be associated with infants’ and young children’s healthy development, as it is associated with parenting likely experienced as stressful by children (e.g., unresponsive/disengaged, hostile/critical or unpredictable). Support has been accumulating for parenting and stress/adversity as mediators of associations between postnatal depression and problems in child development.30
Given that antenatal depression for many women is followed by postnatal depression, many children are dually exposed. The few studies designed to test the potential added burden of postnatal depression on infants already showing vulnerabilities in association with antenatal depression have found that antenatal depression was uniquely predictive of outcomes described here, even after accounting for postnatal depression.16,17
Although research now supports a broad range of outcomes associated with perinatal depression, many unanswered questions remain. Longitudinal studies are needed to test the specific mechanisms that may explain these associations, such as prenatal health behaviours (smoking, alcohol, drug use, poor weight gain), constricted uterine placental blood flow, fetal neurobehavioural profile (e.g., heart rate), and obstetrical outcomes (e.g., low birth weight). Similarly, more studies are needed to reveal which children of perinatally depressed parents are more or less likely to develop problems, whether explained by parent characteristics, such as the severity of depression or comorbid conditions, child characteristics such as gender, or contextual factors such as poverty. Also important to study as potential moderators are genetic polymorphisms implicated in depression. Overall, more studies are needed from a developmental perspective that include multiple time points of measures of perinatal depression, and that test transactional processes such as how child factors can contribute to the development and maintenance of depression in mothers.
Perinatal depression is associated with infants’ and young children’s problems in multiple aspects of functioning, increasing their vulnerability for the later development of depression and other disorders. Problems range from affective and interpersonal functioning to EEG and neuroendocrine abnormalities. Although most of the perinatal literature has focused on postnatal depression, studies that also measured antenatal depression suggest that antenatal depression may partially explain some effects previously attributed to postnatal depression. Both parenting qualities and stressful environments are at least partial mechanisms in pathways from postnatal depression to young children’s problems in development. Conclusions cannot yet be drawn about mechanisms to explain associations between antenatal depression and young children’s problems. Transactional processes help to explain negative cascades such as an antenatally depressed mother who gives birth to a fussy baby, who then challenges an already vulnerable mother, who then might be more likely to experience a postnatal depression. Although not reviewed here, depression, including perinatal depression, is often preventable and treatable.
Implications for Parents, Services and Policy
The findings have implications for parents in helping them to understand that perinatal depression must be taken seriously, recognized and treated. Women with histories of depression might benefit from preventive interventions when they become or consider becoming pregnant, to prevent the likelihood of a perinatal depression. Family members can be helpful in identifying early signs of perinatal depression and helping minimize barriers to care, including practical and belief-related barriers. Service providers who work with pregnant and postpartum women play key roles in being able to not only identify perinatal depression, but, equally importantly, to facilitate prompt and effective treatment. A range of pharmacological31 and nonpharmacological treatment options are available.32 A recent report issued from the National Research Council and Institute of Medicine of the National Academies has multiple recommendations for policy makers.33
- Gotlib IH, Whiffen VE, Mount JH, Milne K, Cordy NI. Prevalence rates and demographic characteristics associated with depression in pregnancy and the postpartum. Journal of Consulting and Clinical Psychology 1989;57(2):269-274.
- Johanson R, Chapman G, Murray D, Johnson I, Cox J. The North Staffordshire Maternity Hospital prospective study of pregnancy-associated depression. Journal of psychosomatic obstetrics & gynaecology 2000;21(2):93-97.
- Evans J, Heron J, Francomb H, Oke S, Golding J. Cohort study of depressed mood during pregnancy and after childbirth. British Medical Journal 2001;323(7307):257-260.
- Gavin NI, Gaynes BN, Lohr KN, Meltzer-Brody S, Gartlehner G, Swinson T. Perinatal depression: A systematic review of prevalence and incidence. Obstetrics and Gynecology 2005;106(5 Pt 1):1071-1083.
- O'Hara M, Gorman LL. Can postpartum depression be predicted? Primary Psychiatry 2004;11(3):42-47.
- Kammerer M, Taylor A, Glover V. The HPA axis and perinatal depression: A hypothesis. Archives of Women's Mental Health 2006;9(4):187-196.
- Lovejoy MC, Graczyk PA, O'Hare E, Neuman G. Maternal depression and parenting behavior: A meta-analytic review. Clinical Psychology Review 2000;20(5):561-592.
- Chugani HT, Phelps ME. Maturational changes in cerebral function in infants determined by 18FDG positron emission tomography. Science 1986;231(4740):840-843.
- Goodman SH, Gotlib IH. Risk for psychopathology in the children of depressed mothers: A developmental model for understanding mechanisms of transmission. Psychological Review 1999;106(3):458-490.
- Brazelton TB. Neonatal behavioral assessment scale. Philadelphia, PA: J.B. Lippincott Co; 1984.
- Diego MA, Field T, Hernandez-Reif M. Prepartum, postpartum and chronic depression effects on neonatal behavior. Infant Behavior & Development 2005;28(2):155-164.
- Field T, Diego M, Hernandez-Reif M, Figueiredo B, Schanberg S, Kuhn C. Sleep disturbances in depressed pregnant women and their newborns. Infant Behavior & Development 2007;30(1):127-133.
- O'Connor TG, Caprariello P, Blackmore ER, Gregory AM, Glover V, Fleming P, ALSPAC Study Team. Prenatal mood disturbance predicts sleep problems in infancy and toddlerhood. Early Human Development 2007;83(7):451-458.
- Field T, Diego M, Hernandez-Reif M, Vera Y, Gil K, Schanberg S, Kuhn C, Gonzalez-Garcia A. Prenatal predictors of maternal and newborn EEG. Infant Behavior and Development 2004;27(4):533-536.
- Field T, Diego M, Dieter J, Hernandez-Reif M, Schanberg S, Kuhn C, Yando R, Bendell D. Prenatal depression effects on the fetus and the newborn. Infant Behavior & Development 2004;27(2):216-229.
- DiPietro JA, Novak MF, Costigan KA, Atella LD, Reusing SP. Maternal psychological distress during pregnancy in relation to child development at age two. Child Development 2006;77(3):573-587.
- Davis EP, Glynn LM, Schetter CD, Hobel C, Chicz-Demet A, Sandman CA. Prenatal exposure to maternal depression and cortisol influences infant temperament. Journal of the American Academy of Child & Adolescent Psychiatry 2007;46(6):737-746.
- Luoma I, Tamminen T, Kaukonen P, Laippala P, Puura K, Salmelin R, Almqvist F. Longitudinal study of maternal depressive symptoms and child well-being. Journal of the American Academy of Child & Adolescent Psychiatry 2001;40(12):1367-1374.
- Carter AS, Garrity-Rokous FE, Chazan-Cohen R, Little C, Briggs-Gowan MJ. Maternal depression and comorbidity: Predicting early parenting, attachment security, and toddler social-emotional problems and competencies. Journal of the American Academy of Child and Adolescent Psychiatry 2001;40(1):18-26.
- Drewett R, Blair P, Emmett P, Emond A, ALSPAC Study Team. Failure to thrive in the term and preterm infants of mothers depressed in the postnatal period: a population-based birth cohort study. Journal of Child Psychology and Psychiatry 2004;45(2):359-366.
- Shea AK, Streiner DL, Fleming A, Kamath MV, Broad K, Steiner M. The effect of depression, anxiety and early life trauma on the cortisol awakening response during pregnancy: Preliminary results. Psychoneuroendocrinology 2007;32(8-10):1013-1020.
- Evans LM, Myers MM, Monk C. Pregnant women's cortisol is elevated with anxiety and depression - but only when comorbid. Archives of Women's Mental Health 2008;11(3):239-248.
- Diego MA, Field T, Hernandez-Reif M, Cullen C, Schanberg S, Kuhn C. Prepartum, postpartum, and chronic depression effects on newborns. Psychiatry: Interpersonal and Biological Processes 2004;67(1):63-80.
- Beck CT. A meta-analysis of the relationship between postpartum depression and infant temperament. Nursing Research 1996;45(4):225-230.
- Martins C, Gaffan E. Effects of early maternal depression on patterns of infant-mother attachment: A meta-analytic investigation. Journal of Child Psychology and Psychiatry 2000;41(6):737-746.
- Sohr-Preston SL, Scaramella LV. Implications of timing of maternal depressive symptoms for early cognitive and language development. Clinical Child & Family Psychology Review 2006;9(1):65-83.
- Murray L, Woolgar M, Cooper P, Hipwell A. Cognitive vulnerability to depression in 5-year-old children of depressed mothers. Journal of Child Psychology and Psychiatry 2001;42(7):891-899.
- Cummings EM, Keller PS, Davies PT. Towards a family process model of maternal and paternal depressive symptoms: Exploring multiple relations with child and family functioning. Journal of Child Psychology and Psychiatry 2005;46(5):479-489.
- Hammen C. Context of stress in families of children with depressed parents. In: Goodman SH, Gotlib IH, eds. Children of depressed parents: Mechanisms of risk and implications for treatment. Washington, DC: American Psychological Association; 2002:175-202.
- Goodman SH, Brand SR. Maternal depression and infant mental health. In: Zeanah C, ed. Handbook of infant mental health. 3rd Ed. New York, NY: Guilford; 2009.
- Stowe Z. Psychiatric disorders in pregnancy: Foreword. Clinical Obstetrics & Gynecology. 2009;52(3):423-424.
- Dimidjian SP, Goodman SP. Nonpharmacologic intervention and prevention strategies for depression during pregnancy and the postpartum. Clinical Obstetrics & Gynecology 2009;52(3):498-515.
- National Research Council (U.S.). Committee on Depression, Parenting Practices, and the Healthy Development of Children. Depression in parents, parenting, and children: Opportunities to improve identification, treatment, and prevention. Washington, DC : National Academies Press; 2009.
How to cite this article:
Goodman SH, Rouse MH. Perinatal Depression and Children: A Developmental Perspective. In: Tremblay RE, Boivin M, Peters RDeV, eds. Encyclopedia on Early Childhood Development [online]. http://www.child-encyclopedia.com/maternal-depression/according-experts/perinatal-depression-and-children-developmental-perspective. Published February 2010. Accessed June 18, 2018.