PERINATAL MENTAL HEALTH: CHILDREN S LONG-TERM OUTCOMES How the South London Child Development Study & work at the Channi Kumar Mother & Baby Unit has informed the need for perinatal mental health services Improving Perinatal Mental Health London : February 2017 susan.pawlby@kcl.ac.uk gertrude.seneviratne@slam.nhs.uk
South London Child Development Study (SLCDS) (1986-2013) Collaborators Debbie Sharp, Professor of Primary Medicine, University of Bristol Dale Hay, Professor of Social Psychology, Cardiff University Dominic Plant, Research Associate, IoPPN, King s College London Cerith Waters, Lecturer, School of Psychology, Cardiff University Professor Carmine Pariante, IoPPN, King s College London Community-based study 252 pregnant women recruited into the study from the antenatal clinics of 2 General Practices in SE London, 204 of whom agreed to follow-up 85-90% families participated at 20 and 36 weeks gestation, 3 and 12 months post partum, 4, 11, 16 and 25 years. Interviewer-based study face-to-face contact interviews in the home, unless otherwise requested observation of mother and child multi-informant primary caregiver, child, teacher biological measures at 25 years
Lambeth Road Group Practice
Gallions Reach Health Centre, Thamesmead
Aims of the SLCDS A prospective, longitudinal, community study from pregnancy through the next 25 years: Examine the prevalence of emotional disorders in the perinatal period Trace the course of maternal depression throughout the child bearing and child rearing years Identify associations between maternal depression and offspring outcome Examine the role of maltreatment in predicting offspring outcome Ascertain the optimal time for detecting maternal depression in order to offer treatment with possible beneficial consequences for the child
Initial results Demography Mean age 25.9 (16-43) Married 60%, regular partner 32%, single 8% White British 78%, West Indian 6% Asian 2% African 5% Middle class 14%, working class 86% A levels 13%, O levels/cse 57%, none 30% Depressed on CIS-R 20w 25%; 36w 26%; 3m 24%; 12m 20% Associations Unplanned pregnancy (considered TOP) Past psychiatric history Poor social support/marital relationship Childhood maltreatment/abuse
Prevalence rates of maternal depression Pregnancy 33.6% 1 st year postpartum 31.2% Years 1 to 4 35.2% Years 4 to 11 22.6% Years 11 to 16 29.5% Pregnancy to 16 years 66.7%
Mother s depression: Timing of offspring 1 st exposure Pregnancy N = 42 (34.4%) 1 st year postpartum N = 17 (13.9%) Years 1 to 4 N = 15 (12.3%) Years 4 to 11 N = 1 (0.8%) Years 11 to 16 N = 6 (4.9%) No exposure N = 41 (33.6%)
Performance of Children at 11 years (SLCDS) 1 z-scores 0.5 0-0.5-1 IQ Reading Maths Conduct Effect of mother's postnatal depression Hyperactivity Attention Emotional Mother well Mother ill
Antenatal depression (AND) Research/services focussed on PND for a long time Increasing interest in AND possibly more prevalent than PND Of particular relevance is the basic science research looking at the role of stress and hormones e.g. cortisol i.e. the possible intrauterine insult to the fetus Of equal importance is antenatal anxiety very often co-morbid with depression May be associated with pre term labour and low birth weight Treating AND might be the best prevention for PND
Antenatal depression (AND) and By age 16 children s antisocial outcomes 33% children been arrested and/or had a diagnosis of conduct disorder of these 45% had committed violent acts AND places children at 2 x risk for antisocial behaviour 4 x risk for violent acts not explained by depression later in mother s life, social class, ethnicity, smoking or alcohol in pregnancy etc not explained by father s antisocial behaviour Mother s own conduct problems in childhood predicted depression in pregnancy
Case 1 Mother was depressed in pregnancy Reported not feeling good connection with fetus Felt it was her! She had poor relationship with her mother, abused Black sheep of family Pregnancy unplanned Child at 11 Behaviour difficulties at school Inattentive in class Few friends Social anxiety
Case 1 At 16 years Living on her own IQ 65 Electronically tagged Been living on street, suicide attempts, drugs, attacking people on buses, 20+ court appearances, co-morbid social anxiety and depression At 25 years Highest educational level - NVQs child care Employment - volunteer on youth projects Number of children - 0 Residence - Supported accommodation Psychopathology - PTSD Past psychopathology - MDD, cocaine dependence, alcohol abuse
Antenatal depression (AND) predicts depression in 16-year-old offspring 2/3 women depressed at least once over the 17 years majority more than once 1/3 depressed in pregnancy more than ½ had seen GP about mental health before the pregnancy nearly all had another episode in child s lifetime 14% children depressed at 16 all exposed to maternal depression 60% first exposed in utero risk if exposed to AND 4.7 x those not exposed Conclusion AND can identify a group of women at risk of further depressive episodes and adolescents at risk of depression
Adolescent depression at 16 years and first exposure to mother s depression
Does child maltreatment moderate the effect of AND on child psychopathology? We were able to look at antenatal depression child maltreatment at age 11 child psychopathology at 11 and 16 21% children at 11 reported some form of abuse AND increased risk of maltreatment 4x 30% children had psychiatric diagnosis at 11 and/or 16 highly correlated with AND Children exposed to AND and maltreatment had 12x risk of psychopathology Conclusion Relationship between AND and child psychopathology is moderated by maltreatment
Case 2 Mother was abused as a child in and out of care Mother was depressed in pregnancy During childhood Gary was physically abused by his biological father. father held his fingers over the gas flame until it hurt and he called out in pain hit with a belt forced to sit on the floor at night, with his hands on his head and his father s feet holding him down, and to watch adult TV programmes. He had problems with his teachers. defiant, restless and disruptive in class. bullied by his peers. anxious about going to school. IQ of 76 Interviewer describes Gary as crushed
. Case 2 At 16 years old Gary has a conduct disorder Been in trouble with the police for breaking into a telephone box and stealing the money, for vandalism and for low-level fire-setting. Been in trouble for fighting, breaking his parents curfew, and running away from home. At 25 years Highest educational level - GCSEs Employment - Yes park cleaner Number of children - 0 Residence - With mother and step father Psychopathology - Social phobia
Intergenerational transmission of maltreatment and psychopathology: the role of antenatal depression Mother s own childhood maltreatment is single biggest predictor of AND 10 x as likely to suffer from AND as those not maltreated Childhood maltreatment or AND alone did not increase children s risk of maltreatment by 11 or psychopathology at 16 Childhood maltreatment and AND together greatly increased risk of child s maltreatment by 11 and adolescent antisocial behaviour at 16 did not increase risk of depression in child at 11 or 16 Conclusion women at risk of AND could be identified by brief childhood social history target AND therapeutically
AND, child maltreatment and adult offspring depression Now looking at young adult offspring at 25 years Offspring exposed to AND 3.4 x as likely to have depression than non-exposed Offspring exposed to AND 2.4 x more likely to experience child maltreatment than non-exposed Exposure to maltreatment mediated the relationship between AND and offspring depression in adulthood Maternal depression after pregnancy did not mediate this pathway Conclusion Clinical practice and health policy development should focus on treatment of maternal depression in pregnancy as a means of reducing child maltreatment and depression in the young adult population
Context Maternal mental health is a major public health issue The costs of perinatal mental health LSE Report (2014) Cost to UK is 8.1 billion annually 72% of cost due to adverse impacts on the child BUT.. The good news is that the perinatal period is a window of opportunity Women are highly motivated to mitigate the effects of their own mental health problems on their babies Desire to break the cycle Motivated to be the best parent they can be New life = new hope
Channi Kumar Mother and Baby Unit 13 bedded acute psychiatric unit for local, regional and national referrals Full MDT assessment and treatment of all mental health problems presenting during pregnancy or up to one year post birth Staff include psychiatrists, psychologists, RMNs, OTs, nursery nurses, social workers and health care assistants Treatment is individualised and reflects the input of whole MDT
Psychological Issues Presenting problems often reflect difficulties in parenting role Lack of connection with baby: my baby feels like he belongs to someone else Perfectionism: I must be a perfect mother and never make a mistake Negative thinking: I am a complete failure as a mother Unusual beliefs about baby: my unborn baby hates me, and I hate her Unwanted intrusive thoughts: I am worried that I might be a paedophile Difficulties coping with emotions: I am worried that I will hurt my baby if she does not go to sleep
Psychological Interventions Individual assessment and formulation Psychological support and coping strategies Direct treatment of mental health disorder, e.g. CBT for OCD Interventions focussed on childhood abuse and trauma issues, experiences of being parented Couple and family work Interventions focussed on mother-infant relationship
Intervention based on mind-mindedness Concept developed by Elizabeth Meins Mother s ability to see her baby as a person, with a mind, thoughts, feelings Baby-centred what might my baby be feeling, thinking? What would my baby be saying if s/he could talk? Sometimes difficult to know attuned/non-attuned Focus on what the baby brings to the interaction
Admitted perinatal mental health care: Mother& Baby Units
Take home messages Mental illness in childbearing women is very common Its adverse impact on the developing fetus and child is severe and long lasting All women should have their mental health assessed at the start of pregnancy and a psycho-social history taken Specialist perinatal mental health teams should be universally available More training of MWs and HVs in perinatal mental health Training in infant development and the relationship between parents and infant should be a mandatory part of perinatal mental health training