Perinatal maternal mental health and infant socio-emotional development: A growth curve analysis using the MPEWS cohort
Introduction
In recent years there is increasing interest in the manner in which maternal physical and mental health shapes the fetus’ early environment and influences the later development of a number of psychiatric disorders (Galbally & Lewis, 2017; Hameed & Lewis, 2016; Lewis, Austin, & Galbally, 2016; Lewis, 2015). Accumulating evidence suggests that maternal mental health across pregnancy influences fetal development through epigenetic, vascular, nutrition and endocrine changes (O’Connor, Heron, Golding, Glover, & ALSPAC Study Team, 2003). Additionally, evidence suggests that these changes may occur in combination with postnatal environmental influences, and may interact with inherited genetic risk (O’Connor et al., 2003). However, relatively little is known about variation in child outcomes resulting from differences in the timings of these mental health exposures over early development (Galbally & Lewis, 2017).
Symptoms of maternal emotional distress (including depressive and anxiety symptoms) appear to be heightened during and after pregnancy, particularly for women with pre-existing vulnerabilities to mood disorders (Fontein-Kuipers et al., 2015; Schmied et al., 2013). The perinatal period refers to the period from pregnancy until one year after delivery (Gaynes, Gavin, & Meltzer-Brody, 2005). Studies suggest that prevalence rates of women reporting depressive symptoms vary between 10–20%, are as high in pregnancy as in the postpartum period, and tend to be as high or higher in non-western and developing countries (Andersson, Sundström-Poromaa, Wulff, Åström, & Bixo, 2006; Fredriksen, von Soest, Smith, & Moe, 2018; Fisher et al., 2011; Gavin et al., 2005; Husain et al., 2006; Schmied et al., 2013). Rates of perinatal anxiety have also been reported in up to 25% of women across a number of studies, figures which reflect significantly higher rates of anxiety compared to the general population (Field, 2017).
Possible reasons for the increase in maternal depression and anxiety symptoms during and after pregnancy are complex, and may involve the increased physical demands of pregnancy, and the major physical and emotional life adjustments associated with pregnancy, giving birth and redefining the family unit (Field, 2017). These symptoms may be more common in the first and last trimesters of pregnancy, as the mother firstly adjusts to the physical, emotional and hormonal changes associated with pregnancy, and as delivery approaches experiences anxiety about the labour period and increased physical discomfort (Rallis, Skouteris, McCabe, & Milgrom, 2014).
Additionally, there may be a range of psychosocial factors which may be impactful for mothers' mental health during this period. In particular, partner tension, history of mental health issues, low social support, low self-esteem, and greater job stress have been identified as risk factors for prenatal anxiety (Bayrampour, McDonald, & Tough, 2015; Dunkel-Schetter, Niles, Guardino, Khaled, & Kramer, 2016). Similarly, low social support, recent intimate partner violence (IPV) and unplanned pregnancy have been associated with increased maternal depressive symptoms during pregnancy (Bayrampour et al., 2015; Nylen, O’Hara, & Engeldinger, 2013; Valentine, Rodriguez, Lapeyrouse, & Zhang, 2011). As there is significant comorbidity between anxiety and depressive symptoms, these risk factors are likely to be shared (Field, 2017).
Traditionally the focus of interventions for maternal mood disorders has been on postpartum depression (Leach, Poyser, & Fairweather‐Schmidt, 2017). However, some evidence suggests that mood disorders are more highly elevated during pregnancy. In Andersson et al.’s study depression or anxiety were prevalent in 16% of women post-delivery compared to 29% of pregnant women (2006). However, unique effects on child outcomes from the antenatal and postnatal period are difficult to untangle given the tendency for symptom continuity across the two periods. For example, Grant, McMahon, and Austin (2008) found that 71% of those diagnosed with an antenatal mood disorder continued to meet criteria during the postnatal period. Similarly, longitudinal birth cohort studies examining symptoms rather than the disorder in the Netherlands and Australia have identified distinct patterns of maternal depressive symptoms over time emphasising the tendency for these symptoms to persist across the prenatal and the early parenting period (Giallo, Woolhouse, Gartland, Hiscock, & Brown, 2015; Van der Waerden et al., 2015). For these reasons longitudinal modelling of repeated measurement of depressive and anxiety symptoms over both pregnancy and the postpartum is required.
There is substantial evidence that perinatal maternal emotional distress carries important and enduring adverse effects on offspring. Literature reviews report increased risk for poorer cognitive functioning (Hay et al., 2008), poorer physical health and central adiposity (Gentile, 2017), and internalising and externalising behaviour problems in offspring of mothers with mood disorders from infancy through to adolescence (Gentile, 2017; Giallo et al., 2015; Kingston, Tough, & Whitfield, 2012). As summarised in Gentile and Galbally’s review (2011), in many but not all studies maternal perinatal depression is associated with adverse neurodevelopmental outcomes for children, such as developmental delay (Deave, Heron, Evans, & Emond, 2008), impaired language development (Sohr-Preston & Scaramella, 2006) and reduced cognitive functioning in childhood (Bjørnebekk et al., 2015; Gentile & Galbally, 2011). In addition to the findings for depressive and anxiety symptoms, high levels of perceived stress and greater number of stressful life events during pregnancy have also been correlated with difficult infant temperament (Austin, Hadzi-Pavlovic, Leader, Saint, & Parker, 2005; Huizink, De Medina, Mulder, Visser, & Buitelaar, 2002) and lower birthweight (Rice et al., 2010).
Several studies have reported effects of maternal mood problems on children’s social and emotional functioning. For the current study, social and emotional functioning is defined as a young child’s capacity to form a close and secure relationship with peers and adults; allowing that child to experience, regulate and express emotions appropriate to the social circumstances, to explore their environment and to learn (Yates et al., 2008). Through this paradigm, social ability, behaviour problems, and emotional regulation are important components of social-emotional development (Halle & Darling-Churchill, 2016). As such, studies which aim to measure social-emotional functioning often include measures of characteristics which could be framed as internalising symptoms such as anxious/depressive behaviours, somatic complaints and withdrawn behaviours, and externalising symptoms (Achenbach, 2001).
Significant associations between maternal perinatal distress and child social-emotional functioning have been summarised in several systematic and meta-analytic reviews (e.g. Korja, Nolvi, Grant, & McMahon, 2017; Goodman et al., 2011; Rees, Channon, & Waters, 2018), all of which suggest a small portion of variance in social and emotional development scores in offspring can be explained by prenatal and postnatal maternal depressive, anxiety and stress symptoms. In a range of studies the variance in child social-emotional problems accounted for by maternal mental health remained significant after controlling for socio-demographic variables (Bagner, Pettit, Lewinsohn, & Seeley, 2010; Barker, Jaffee, Uher, & Maughan, 2011; Fredriksen et al., 2018; Van den Bergh & Marcoen, 2004). As a result of these findings, there is now an appreciation that perinatal mood disorders are emerging as potentially modifiable factors which if addressed may play an important role in the prevention of poor outcomes in child development and mental health (Goodman & Gotlib, 1999; Grote et al., 2010).
Mechanisms of risk transmission between maternal emotional distress and adverse outcomes for cognitive, social and emotional child development are likely to occur through a number of complex developmental, genetic and epigenetic pathways. One possible pathway is through the impact of maternal mood disorders on parenting behaviour, the parent-child relationship and general family functioning (Galbally & Lewis, 2017). Parenting practices that are potentially altered by depression include breastfeeding (Cooper, Murray, & Stein, 1993; Galbally, Watson, Ball, & Lewis, 2018), child and adolescent diet and nutrition, influences on the development of early sleep patterns (Galbally, Watson, Teti, & Lewis, 2018) and reduced capacity to provide stimulating and enriching experiences (Gentile, 2017; Lewis, Galbally, Gannon, & Symeonides, 2014). Secondly, risks are conferred through genetic pathways. Recent findings have confirmed a small genetic contribution to major depression which is differentially inherited by all humans (Wray et al., 2018), and the degree of inheritance of such risk is likely to interact in a multiplicative or additive manner with environmental factors in a manner which is of considerable current research interest.
Thirdly, according to the fetal programming hypothesis, critical periods of fetal development are influenced through the timing, type and duration of environmental exposures in utero and across early post-natal development (Van den Bergh & Marcoen, 2004). Exposures such as changes in diet, chemical exposures from smoking, alcohol use or from pharmaceutical medications, or physiological changes which accompany mental health conditions, may directly influence sensitive periods of fetal development (O’Connor et al., 2003). These can exert long term programming effects on numerous biological systems, including the metabolic, endocrine and cardiovascular systems (O’Connor et al., 2003). In mental health research there has been a focus on the impact of such exposures on the functions of the stress response system along the hypothalamic-pituitary-adrenal (HPA) axis, which is linked to maturation and regulation of circadian rhythms, physical growth and the neurodevelopmental integration of limbic-cortical processes which regulate emotion and the cognitive appraisal and regulation of emotion (Lupien, McEwen, Gunnar, & Heim, 2009).
In previous literature the relative contributions of prenatal and postnatal environmental factors on offspring outcomes remain unclear, as does the influence of the type and timing of mental health exposure on child outcome (Galbally et al., 2016). Equally, associations between child social-emotional development and maternal mood may be the result of indirect factors for which maternal mental health disorders act as a proxy, such as lifestyle factors (e.g., alcohol use, diet and smoking) which often co-occur with certain mood disorders (DiPietro et al., 2002; Galbally et al., 2016).
Maternal psychological attributes may also influence perceptions of child temperament (Atella, DiPietro, Smith, & St James-Roberts, 2003). A number of studies have not accounted for the effects of confounding variables (McLean, Cobham, & Simcock, 2018). Additionally, the findings are mixed - some studies have suggested that maternal mental health trajectories characterised by persistently high symptoms identified from pregnancy to early childhood are especially harmful for children’s outcomes (Cents et al., 2013; Van der Waerden et al., 2015), while others have found that adverse effects are only present in cases where the exposure occurs during pregnancy (Betts, Williams, Najman, & Alati, 2014). Few studies have examined the relationship between maternal mental health and subsequent child social and emotional outcomes across different time points in pregnancy in order to more closely examine the timings of exposure, and how these relationships change over time.
The current study aimed to examine relationships between maternal anxiety and depression symptoms in early pregnancy (<20 weeks gestation), change across pregnancy (>20 weeks gestation) and the postnatal period (at six and 12 months postpartum) in association with children’s social and emotional development at 12 months of age. It was hypothesised that infants of mothers with higher levels of depressive and anxious symptoms in early pregnancy would have significantly more difficulties with social-emotional functioning at 12 months of age. Secondly, infants of mothers with increasing symptoms of depression and anxiety across the time points would have significantly more difficulties with social-emotional functioning at 12 months of age. Thirdly, changes in maternal mental health symptoms over time, measured through growth curves, would also account for a significant portion of variance in social-emotional functioning at 12 months of age.
Section snippets
Study design
Data for this study were drawn from the Mercy Pregnancy and Emotional Wellbeing Study (MPEWS), a prospective cohort study based at Mercy Hospital for Women in Melbourne, which aimed to investigate the early developmental mechanisms and modifiers for maternal, fetal and child emotional wellbeing (Galbally et al., 2016). MPEWS uses a selected cohort design in which the criteria for recruitment of the two selected groups were: women diagnosed with depression (past and current) using the Structured
Results
Data for 282 participants were available at Wave 1. Of these, 257 completed at least one Wave 5 measure, reflecting 91% of the original cohort. Of the 257 active participants at Wave 5, 191 participants completed the BITSEA at Wave 5 (74.3%). Demographic information for participants recruited at Wave 1 and active at Wave 5, (N = 257) is summarised in Table 1.
Of those who remained in the study at Wave 5, the mean age of women at recruitment was 31.32 years (SD = 4.76). Most women were married,
Discussion
In this longitudinal study of 282 pregnant women and their children, both initial maternal mental health symptoms, and the changes in these symptoms over time, predicted socio-emotional problems in 12 month old infants. Mothers who reported experiencing higher depressive or anxious symptoms in the first trimester of pregnancy, and who reported stable or increasing symptoms over the perinatal period, tended to rate their children as having more social and emotional problems. This suggests that
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