Disclosure SAVING THE NEXT GENERATION: Objective 1a. Objective 1b. The Role of the Perinatal Team. Call:
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1 SAVING THE NEXT GENERATION: The Role of the Perinatal Team Terri Hargrave, MD, MPH Associate Professor Emeritus of Psychiatry SUNYUpstate October 12, 2018 Disclosure I receive grant funding from NYS OMH to consult to clinicians who see individuals under age 22 regarding mental health assessment and management issues including Obstetricians: Call: Objective 1a Recognize the importance of maternal and paternal experience to the next generation of brains Preconception Adverse Experiences and Resiliency Social Determinants of Health Objective 1b Recognize the importance of maternal and paternal experience to the next generation of brains Beginning at Conception Brain growth Number of neurons Interconnectivity Genetics and Epigenetics Social Determinants of Health
2 Objective 2 Consider how a Perinatal team can foster resiliency experiences for every new baby, recognize risk at each and every visit! Objective 3 Recognize that fathers are also at risk for perinatal mood and anxiety disorders as a consequence of becoming a father Up to 50% if mother is depressed Also correlates with risk to next generation behavior Presents somewhat differently from maternal perinatal depression Epidemic: Child Psychiatric Disorders Prevalence:16 22% (14 million) (Shaffer et al. 1996) Severe Functional Impairment: 5 9% (Costello et al.1996, 58 Fed Reg 1993) 80% receive no treatment (Burns et al.1995) Associations/Outcomes Adult Psychiatric Disorders Substance Abuse School failure/poorly qualified work force Unemployment Increased rates of incarceration Difficulty parenting/perpetration of the cycle
3 A Public Health Approach to Prevention of Childhood MHI Primary Prevention efforts applied to the whole population Secondary Prevention efforts applied to the at risk population Tertiary Prevention efforts applied to the already ill population, preventing worsening Headlines: August 2018 Parents Adverse Childhood Experiences and Their Children s Behavioral Health Problems A. Schickedanz MD,PHD, et. al. PEDIATRICS 142(2), August 2018.e The story of the child Begins in the experience of its parents during their childhoods ACES Adverse Childhood Experiences Scale (before age 18) 10 Items Yes/no answers
4 ACES, What are They? The Abuse Cluster Verbal abuse Physical abuse Sexual abuse ACES, What are They? The Neglect Cluster Emotional neglect Physical neglect ACES, What are They? The Household Dysfunction Cluster Parents separated/divorced Domestic violence ACES, What are They? The Household Dysfunction Cluster Lived with substance abuser Lived with mentally ill household member Household member in prison
5 ACE Score 4 or more: Correlations Adult Alcoholism/Liver Disease Chronic Depression/Suicide Attempts Perpetrating Domestic Violence/Being raped Difficulty Parenting ACE Score 4 or more: Correlations Smoking as an Adult/COPD Impaired Work Performance Et. Al. Difficulty Parenting Stress Science: Allostatic Load Resiliency Scale Resiliency Promoting Factors ACES 14 items 5 possible responses for each item Higher scores better Not validated as predictive, but useful in scaffolding
6 Resiliency Factors The Nuclear Family Cluster Mother loved me Father loved me We had rules and were expected to keep them My family cared how I did in school Resiliency Factors The Extended Family Cluster Other people loved me Someone enjoyed playing with me When I was upset, a relative could calm me When I felt bad, I could find someone to talk to Resiliency Factors The Community Cluster Neighbors/parents friends liked me Teachers, coaches, ministers, etc. helped me Folks around me talked about making life better Resiliency Factors Self Efficacy Cluster People noticed I was capable and could get things done I was an independent gogetter I believed life is what you make it
7 Saving the Next Generation Know and Care for their Parents Objective 1b Recognize the importance of maternal and paternal experience to the next generation of brains Beginning at Conception Brain growth Number of neurons Interconnectivity Genetics and Epigenetics Social Determinants of Health Brain growth trajectory The Brain by Dan Siegel 4Oxw A40
8 Programmed already by birth Stress Response System Autonomic Nervous System Reactivity Cortisol Response System Set Point Brain size & richness of connections Genetics and Epigenetics The Placenta as Translator of Mother s Experience 11 beta Hydroxysteroid Dehydrogenase Type II
9 Headlines August 27, 2018 Depression in Pregnancy May Alter Babies Brains Lisa Rapaport, reporter health prenatal depressionanxiety/depression in pregn... Headlines September 2018 A Meta Analysis of Maternal Prenatal Depression and Anxiety on Child Socioemotional Development Sheri Madigan PhD, et. al. Journal of the American Academy of Child and Adolescent Psychiatry 57(9) Headlines September 2018 Parental Psychiatric Symptoms and Children s Outcomes: Toward Understanding and Responding to Intergenerational Risk in Child Psychiatry Matthew Biel, MD, MSc Journal of the American Academy of Child and Adolescent Psychiatry 57(9) Headlines 8/2/18 Perinatal Maternal Depressive Symptoms as an Issue for Population Health Michael Meaney, PhD
10 Headlines August 16, 2018 Prenatal Exposure to Violence Increases Toddlers Aggressive Behavior to their Mothers L. Miller Graff & J. Burke Lefever medical.net/news/ /prenatal exposure... Maternal Stressors leading to Epigenetic Changes Manifest at Birth Depression/anxiety/other mental illness in mom/dad Alcohol/ drug and/or other toxin exposure Domestic violence The Baby s Own (Prenatal ) ACES Maternal Stressors leading to Epigenetic Changes Manifest at Birth Poverty Poor nutrition/food Insecurity War Unsafe neighborhood Refugee/immigrant/illegal alien Et. al. The Baby s Own (Prenatal) Adverse Social Determinants of Health Stress Science: Allostatic Load Resiliency Promoting Factors ACES
11 Protective Maternal Experiences leading to Epigenetic Changes Manifest at Birth Father consistently present and caring Financial stability Early consistent nurturing prenatal care The Baby s own (Prenatal) Resiliency Factors Protective Maternal Experiences leading to Epigenetic Changes Manifest at Birth Extended family available Safe neighborhood Community involvement (Church, etc.) Et. al. The Baby s own (Prenatal) Resiliency Factors Objective 2 Consider how a Perinatal team can foster resiliency experiences for every new baby, recognize risk at each and every visit! Ob/Peds Primary prevention: Fostering resiliency and preventing ACES for every baby Build caring relationship with parents
12 Ob/Peds Primary prevention: Fostering resiliency and preventing ACES for every baby At every visit With every member of the Ob/Peds practice team Include fathers as much and as often as possible Ob/Peds Primary prevention: Fostering resiliency and preventing ACES for every baby Ask and address mom s and dad s concerns first before your own agenda Saving the Next Generation: Fostering resiliency and preventing ACES for every baby Identify support systems for every pregnant woman Significant other Extended family Friends Saving the Next Generation: Fostering resiliency and preventing ACES for every baby Identify support systems for every pregnant woman Community resources/services Project 62 Moms on Call peer support line: Yourself/Your Practice
13 Saving the Next Generation: Fostering resiliency and preventing ACES for every baby Stress SELF CARE: sleep nutrition exercise meditation yoga time for self Ob/Peds Saving the Next Generation: Fostering Resiliency Parents Universal screening to define the high risk babies Remember to screen mothers AND fathers ACES Less reluctance to complete scale when reported as total score rather than by individual item Other Mental Health Screening Tools Depression Anxiety Mood Disorders Psychosis
14 Objective 3 Recognize that fathers are also at risk for perinatal mood and anxiety disorders as a consequence of becoming a father Up to 50% if mother is depressed Also correlates with risk to next generation behavior Presents somewhat differently from maternal perinatal depression Remember the fathers Paternal peripartum depression is: Common: may be as common as maternal peripartum depression More likely when: Mother also depressed Low relationship satisfaction Poor social supports Remember the fathers! Paternal peripartum depression is: More likely when: Young (< 25 years old) Personal past history of depression Low Socioeconomic Status Premature baby Paternal Perinatal Depression Characteristics More likely: Irritable, cynical, angry, Self critical, Indecisive, Reclusive Avoids interaction with family
15 Paternal Perinatal Depression Characteristics Loses self in work, hobbies, exercise Risk taking behaviors Somatic symptoms Comorbid substance abuse Paternal Perinatal Depression Characteristics May present later postpartum If using Edinburgh, use lower cut off score (10 11) Usually fathers do not seek care unless prompted by someone to do so Paternal Perinatal Depression Common Themes: Perceived pressure to provide for the family with feeling unable to adequately do so Unprepared for role of infant parenting Emotional disconnect father and mother Interaction between paternal and maternal mood symptoms and psychosocial stressors Paternal Perinatal Depression? Related to decreased testosterone levels during pregnancy and postpartum
16 Why does it matter? Paternal perinatal depression correlates with: more family stress lessinfant father bonding more spanking Saving the next generation and correlates with: poor reading scores, more ADHD, ODD, conduct, anxiety and depression in offspring from early childhood When is fetal/child mental health risk present? When a parent is at risk for mental illness or is already ill, this creates risk for the fetus/child. When is fetal/child mental health risk present? ACES >4, either parent if both are involved Low resiliency score, either parent Multiple current psychosocial stressors Parental body language: Your gut feeling
17 What to do when there is risk: Build relationship Establish support system Continue screening Stress self care Empathic recognition of difficult past Psychoeducation re: Impact of ACES What to do when there is risk: Closer monitoring Care management What help does the parent want? What is available that might decrease risk? Help connecting with services When a parent is already ill Relationship Establish support system Psychoeducation Risk to fetus/baby Self care plan Care management Already ill Therapy Medication
18 For Dads: Paternal Depression Resources referral to therapist/pcp for meds Phone consult Dr. Will Courtenny: Sad Dad: An exploration of postnatal depression in men Spencer (2014) Already ill Consider Consulting Project TEACH How Project TEACH can help you For moms or dads under age 22 Phone consult: M Th 8 7; F 8 5; Help with referrals Website One time Face to face Assessment Coming October 16, 2018 Consults to you for any age mom: info@projectteachny.org
19 In Summary, Maternal and paternal experiences in childhood and in the perinatal period have tremendous impact on the brains of their children. In Summary, Paternal peripartum depression is common, presents somewhat differently in fathers, and is similarly associated with long term adverse outcomes in their children. In Summary, Using universal screening and preventive relationshipbased interventions in perinatal settings is called for to address the epidemic of childhood mental illness. Sources Objective 1: ACES and the Brain Science Van der Kolk, B The Body Keeps the Score : Brain, Mind, and Body in the Healing of Trauma (2014) Penguin Books 445pp. Burke Harris, N The Deepest Well: Healing the Long Term Effects of Childhood Adversity (2018) Houghton Mifflin Harcourt 251pp Journal of Zero to Three:National Center for Infants, Toddlers and Families (2014) Prenatal Influences on Child Development 34(4) pp6 59
20 Sources Objective 3: Paternal Depression Serrano VJ et.al. (2018) Zero to Three Focusing on Fathers: Recognizing the Role of Paternal Mental Health in Family Well Being During the Postpartum Period 38(6): Smith H et.al. (2013) Infant and Child Development Paternal Postnatal and Subsequent Mental Health Symptoms and Child Socio Emotional and Behavioral Problems at School Entry 22: Top ED et.al. (2016) Archives of Psychiatric Nursing Paternal Depression Rates in Prenatal and Postpartum Periods and Affecting Factors 30: Sources: Objective 2: Practice Evolution Raney LE (2015) Integrated Care: Working at the Interface of Primary Care and Behavioral Science American Psychiatric Publishing 276pp Langley GJ (2009) the Improvement Guide: a Practical Approach to Enhancing Organizational Performance Jossey Bass 490pp The Community Technical Assistance Center of New York Questions, Comments? Thank you
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