The trajectory of maternal perinatal depressive symptoms predicts executive function in early childhood.

BACKGROUND: Perinatal maternal depression may affect fetal neurodevelopment directly or indirectly via exposures such as smoking, alcohol, or antidepressant use. The relative contribution of these risk factors on child executive function (EF) has not been explored systematically. METHODS: A prospective pregnancy cohort of 197 women and their children was studied to determine whether maternal depression diagnosis and the trajectory of maternal depressive symptoms (MDSs) from early pregnancy to 12 months postpartum predicts child EF at age 4 (measured using the preschool age psychiatric assessment, NEPSY-II, and Shape School task) using latent growth curve modeling. Indirect effects of smoking, alcohol, and antidepressant use were also formally tested. RESULTS: Increasing maternal perinatal depressive symptoms over time predicted more inattentive symptoms, poorer switching, and motor inhibition, but not cognitive inhibition. When adjusted for multiple comparison, and after accounting for maternal cognition and education, the association with child inattentive symptoms remained significant. However, diagnosed depression did not predict child EF outcomes. Prenatal exposure to smoking, alcohol, and antidepressants also did not mediate pathways from depressive symptoms to EF outcomes. Our findings were limited by sample size and statistical power to detect outcome effects of smaller effect size. CONCLUSIONS: This study suggests that increasing MDSs over the perinatal period is associated with poorer EF outcomes in children at age 4 - independent of prenatal smoking, drinking, or antidepressant use. Depressive chronicity, severity, and postpartum influences may play crucial roles in determining childhood outcomes of EF.

Maternal attachment state of mind and perinatal emotional wellbeing: Findings from a pregnancy cohort study.

OBJECTIVES: Maternal attachment state of mind is an important potential predictor of risk and resilience to perinatal emotional wellbeing and early parenting. To explore maternal attachment in relation to perinatal depression and emotional wellbeing. METHODS: This study drew on data collected within an ongoing cohort from 170 women recruited in early pregnancy, including 67 who met criteria for Major Depression. Maternal attachment state of mind was assessed with the Adult Attachment Interview (AAI) in pregnancy. Additional measures included the Structured Clinical Interview for the DSM (SCID), at 12 months the Strange Situation Procedure (SSP), Child Trauma Questionnaire (CTQ), Parenting Stress Index, and antenatal maternal hair cortisol concentrations (HCC). LIMITATIONS: Sample size to be able to undertake all analyses using the 4 way classifications, cortisol measurement is limited to hair only and there is no prospectively collected measure of childhood trauma in mothers. CONCLUSIONS: This study found that maternal attachment, specifically the Non-Autonomous states of mind, adjusted for clinical depression, was associated with higher cortisol in pregnancy and higher depressive symptoms across pregnancy and the postpartum. Furthermore, separately those with depression and Non-Autonomous states of mind also had higher postpartum parenting stress. There was no significant intergenerational concordance between AAI and SSP attachment classifications. Our findings support future research exploring the role of maternal attachment state of mind in understanding perinatal depression and emotional wellbeing.

A psychometric study of the Emotional Availability Scales: Construct validity and measurement invariance between depressed and nondepressed mother-infant dyads.

The Emotional Availability Scales (EAS) are the most widely reported observational assessment measure of parent-child relationships and has been of particular interest in understanding differences between samples of depressed and nondepressed mothers and their offspring. Despite its widespread use, psychometric validation of the factor structure in normative samples and the measurement of invariance within clinical samples has not been published. We evaluated the internal structure (dimensionality, reliability, convergent, and discriminant validity) of the EAS fourth edition using a nondepressed sample of 157 Australian women and their infants aged 6 months, including testing the measurement invariance of the EAS between the same nondepressed sample (n = 157), and a depressed group (n = 185) of mother-infant dyads, using MPlus. Participants were recruited from tertiary hospitals, and depression status was established using a diagnostic measure. Higher-order confirmatory factor analyses on the EAS' six dimensions supported a unidimensional factor solution in our data. Full measurement invariance was not demonstrated due to metric noninvariance of the maternal nonintrusiveness and child responsiveness dimensions. Full scalar invariance supported mean comparisons, and a medium effect of .78SD lower mean emotional availability for the depressed group was found; Cohen's d = .63, 95% CI [.41, .85]. While arguments exist for the clinical utility of differentiating between multiple dimensions of emotional availability, the current findings do not support a multidimensional factor structure or full multigroup measurement invariance of the EAS. Similar psychometric investigations of the EAS in clinical and nonclinical samples are needed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Major depression as a predictor of the intergenerational transmission of attachment security: Findings from a pregnancy cohort study.

OBJECTIVE: Understanding the relationship between attachment and mental health has an important role in informing management of perinatal mental disorders and for infant mental health. It has been suggested that experiences of attachment are transmitted from one generation to the next. Maternal sensitivity has been proposed as a mediator, although findings have not been as strong as hypothesised. A meta-analysis suggested that this intergenerational transmission of attachment may vary across populations with lower concordance between parent and infant attachment classifications in clinical compared to community samples. However, no previous study has examined major depression and adult attachment in pregnancy as predictors of infant-parent attachment classification at 12 months postpartum. METHODS: Data were obtained on 52 first-time mothers recruited in early pregnancy, which included 22 women who met diagnostic criteria for current major depression using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders. The Adult Attachment Interview was also administered before 20 weeks of pregnancy. A history of early trauma was measured using the Childhood Trauma Questionnaire and maternal sensitivity was measured at 6 months postpartum using the observational measure of the Emotional Availability Scales. Infant-parent attachment was measured using the Strange Situation Procedure at 12 months. RESULTS: Overall, we found no significant association between the Adult Attachment Interview and the Strange Situation Procedure classifications. However, a combination of maternal non-autonomous attachment on the Adult Attachment Interview and major depression was a significant predictor of insecure attachment on the Strange Situation Procedure. We did not find that maternal sensitivity mediated parental and infant attachment security in this sample. CONCLUSION: While previous meta-analyses identified lower concordance in clinical samples, our findings suggest women with major depression and non-autonomous attachment have a greater concordance with insecure attachment on the Strange Situation Procedure. These findings can guide future research and suggest a focus on depression in pregnancy may be important for subsequent infant attachment.

Maternal perinatal depression and child executive function: A systematic review and meta-analysis.

BACKGROUND: Maternal depression during the perinatal period predicts adverse developmental outcomes for children, via poorly understood mechanisms. One plausible pathway may involve child executive function, a suite of cognitive capacities associated with social, emotional and educational outcomes. Systematic review and meta-analysis are applied to evaluate evidence of association between maternal perinatal depression and child executive function. METHODS: Medline, Embase, PubMed, PsycInfo, and SCOPUS were searched for relevant articles to August 2020, with hand-search of relevant bibliographies. Original research published in English measuring maternal depressive symptoms during pregnancy and the first year postpartum, and child executive function outcomes at any age was included. 27 studies met criteria for review. 16 studies reporting raw data of the association between depressive symptoms and executive function were used for meta-analysis. RESULTS: Our systematic review identified inadequate assessment of maternal depression, and unreliable measures of executive function in many studies. Assessment of confounders was also inconsistent. Our meta-analysis identified a small, statistically significant relationship between perinatal depression and child executive function (effect size r = 0.07; 95% CI 0.03-0.10); equivalent to Cohen's d = 0.14. LIMITATIONS: Variable quality of available studies leads to cautious interpretation of results. CONCLUSIONS: This meta-analysis is consistent with the hypothesis that maternal perinatal depression does have an impact on executive function in offspring. Future studies must use robust measurement of depression and executive function, and account for the chronicity of maternal depression, and developmental context to produce meaningful results.

Maternal psychosocial predictors of pacifier use in a mother-infant interaction task: An observational study from the MPEWS pregnancy cohort.

The prevalence of pacifier use is high but when it occurs outside of the recommended sleep context, it becomes more controversial. Using 211 mother-infant dyads recorded as part of the Mercy Pregnancy and Emotional Wellbeing Study, we examined the maternal psychosocial predictors of pacifier use within an interaction task (i.e., ten minutes face-to-face followed by 30-minutes unstructured play). Predictors included maternal emotional availability measured with the Emotional Availability Scales; depression measured by the Structured Clinical Interview for the DSM-IV-TR Clinician Version; and maternal history of childhood trauma measured by the Childhood Trauma Questionnaire. An unadjusted odds ratio demonstrated that women classified as non-emotionally available to their infants were three-and-a-half-times more likely to use a pacifier. Multivariate logistic regression including all maternal psychosocial predictors demonstrated that even when adjusting for cessation of breastfeeding, maternal emotional availability remained the only significant predictor of pacifier use. This is the first time that predictors of pacifier use have been examined with a sample of clinically depressed women, as well as women with childhood trauma history. The results provide preliminary evidence that women who are not emotionally available might be more likely to rely on a pacifier during mother-infant interaction.

Maternal perinatal depression, circulating oxytocin levels and childhood emotional disorders at 4 years of age: The importance of psychosocial context.

Oxytocin has been a hormone of interest in understanding both depression and parenting. Here, the role of oxytocin has been explored in understanding the interaction between perinatal depression, history of trauma and subsequent longer-term child socio-emotional outcomes. Data were obtained from 203 pregnant women from the Mercy Pregnancy and Emotional Wellbeing Study (MPEWS), a pregnancy cohort study with data collected across pregnancy, postpartum and until 4 years for mother and child. Maternal antenatal depression was measured using the Structured Clinical Interview for DSM-IV (SCID-IV) together with the Childhood Trauma Questionnaire to measure maternal trauma history. Maternal oxytocin levels were measured by enzyme immunoassay following extraction at four time points across pregnancy and the postpartum. The offspring consisted of 203 children followed up from birth until 4 years of age when they were assessed for DSM 5 depression and anxiety disorders (emotional disorders) using the Preschool Age Psychiatric Assessment. Maternal oxytocin levels increased over pregnancy and the postpartum in both control and depressed women with no difference between groups. Maternal childhood trauma and antenatal antidepressant use was also not associated with maternal oxytocin levels. Lower gestational age, maternal depression and early childhood trauma, and late pregnancy oxytocin concentrations were associated with later childhood emotional disorders; together they predicted 10% of variance for emotional disorders. Oxytocin is a hormone whose role in understanding intergenerational risk from pregnancy to child emotional disorders is dependent on relational context. Future research can expand on understanding these important early predictors of childhood mental health.

The impact of maternal perinatal depression on exposure to reading and screen time for their infants: pilot findings from the MPEWS Study.

OBJECTIVE: To explore the association between maternal depression and the screen and reading time experienced by their infants. METHODS: This study utilises data on 158 women and infants, collected within the Mercy Pregnancy and Emotional Wellbeing Study. Women less than 20 weeks gestation were diagnosed using the Structured Clinical Interview for DSM-IV Axis I Disorders. Six months postpartum they completed questionnaires about themselves, their infant and early parenting practices. RESULTS: Children of women with a past diagnosis of depression were exposed to fewer days of 15-minute reading time per week compared to the children of women with no diagnosis. While the current depression group showed a lower average reading time, this difference was not statistically significant. There were no significant differences in infant screen time between groups. CONCLUSIONS: A maternal past diagnosis of depression is correlated with decreased reading time in infants. This may present a practical point for screening and intervention or suggest a causal pathway for poorer outcomes in children of those with depression.

Pharmacological lactation suppression with D2 receptor agonists and risk of postpartum psychosis: A systematic review.

BACKGROUND: It has been suggested that D2 receptor agonists commonly used postpartum for the physiological suppression of lactation, such as bromocriptine and cabergoline, may increase the risk of illness onset or relapse in women where there is a predisposition for or history of schizophrenia, bipolar disorder or postpartum psychosis. This is based on two lines of reasoning: current models of psychosis assume episodes are triggered by dysregulation of brain dopaminergic activity and treated by medications that universally have D2 receptor antagonist properties; and limited research suggesting these agents may be associated with psychotic episodes in vulnerable individuals outside of the postpartum period. AIM: The aim of this study was to examine whether D2 agonists trigger psychosis in previously well mothers, or psychotic relapse or exacerbation of symptoms in mothers with known psychotic illnesses, when used to suppress lactation during the early postpartum period. MATERIALS AND METHODS: A systematic review of the literature was undertaken of electronic databases, including: MEDLINE, EMBASE and PsychINFO from 1950 to 2015 using keywords. RESULTS: Eight case reports, three case series and a pharmacovigilance survey were identified. CONCLUSION: Whilst D2 receptor agonists appear to increase the risk of triggering psychosis in previously well mothers and those previously diagnosed with schizophrenia, bipolar disorder and postpartum psychosis, bromocriptine appears to pose a much greater risk than cabergoline. When considering the use of pharmacological agents to suppress lactation, physicians should carefully screen patients for a history of psychosis and consider alternatives to moderate this risk.

Borderline Personality Disorder in the perinatal period: early infant and maternal outcomes.

OBJECTIVE: This study examines pregnancy and early infant outcomes of pregnant women with a clinical diagnosis of Borderline Personality Disorder presenting for obstetric services to a major metropolitan maternity hospital in Victoria, Australia. METHOD: A retrospective case review of pregnancy and early infant outcomes on 42 women who had been diagnosed with Borderline Personality Disorder via psychiatric assessment using DSM-IV-R criteria was undertaken. Outcomes were compared with a control group of 14,313 consisting of women and infants of non-affected women from the same hospital over the same period of time. RESULTS: Women presenting for obstetric services with a clinical diagnosis of Borderline Personality Disorder experienced considerable psychosocial impairment. They anticipated birth as traumatic and frequently requested early delivery. High comorbidity with substance abuse was found and high rates of referral to child protective services. Mothers with Borderline Personality Disorder were significantly more likely to have negative birth outcomes such as lowered Apgar scores, prematurity and special care nursery referral when compared with controls. CONCLUSIONS: These findings offer preliminary evidence to be considered by clinicians in developing treatments and services for the perinatal care of women with Borderline Personality Disorder and their infants. Further research is required in order to develop evidence informed clinical guidelines for the management of women with Borderline Personality Disorder and their infants.

Antipsychotic drugs in pregnancy: a review of their maternal and fetal effects.

Understanding the risks of antipsychotic medication use in pregnancy is becoming an important clinical concern given the evidence of their increasing rate of prescription in the general population for a range of disorders. Despite antipsychotics being amongst the earliest of psychotropic medications to be introduced, the evidence for their effects secondary to pregnancy exposure is extremely limited. While this review does not identify clear evidence for a risk of malformation, there is evidence for risks associated with pregnancy and neonatal outcomes. Studies identified found risks that included prematurity, low and high birth weight, and gestational diabetes. There have also been studies that suggest neonatal withdrawal and abnormal muscles movements. The longer term neurodevelopmental outcomes for children exposed in utero remain unclear with only four studies identified: two of first generation antipsychotics and two of second generation antipsychotics. When considering the risk of these medications in pregnancy, the risk of untreated maternal illness (particularly schizophrenia and bipolar disorder) on both maternal and child outcomes is relevant. Future research needs to focus on prospective, longitudinal studies with adequate measures of key confounding variables including maternal mental illness, other exposures (such as smoking, alcohol and illicit drug use) and adequate length of follow up where accurate child developmental measures are obtained.

Perinatal mental health services: what are they and why do we need them?

OBJECTIVE: To review the evidence for perinatal mental health as a sub-specialist area of mental health and describe the development of a service model. CONCLUSIONS: Perinatal mental health is emerging as a sub-specialist area of mental health with specific knowledge and expertise in assessment, diagnosis and treatment. It requires services to ensure that women and infants receive optimal care across pregnancy and the postpartum.