The Integrated Child and Adolescent Psychiatrist: Perinatal Mental Health Care to Improve Maternal-Infant Outcomes Disclosures of Potential Conflicts Source Research Funding Advisor/ Consultant Employee Honorarium or expenses for this presentation or meeting UNM Anilla Del Fabbro, MD Associate Professor Vice Chair Division Chief UNM Child and Adolescent Psychiatry adelfabbro@salud.unm.edu 1 2 3 4 Objectives Discuss why perinatal psychiatry is a priority for child and adolescent psychiatrists Discuss a system of collaborative care at UNM between pediatrics, nursing, midwifery, psychosomatic and child psychiatry Discuss the development of the UNM perinatal psychiatry clinics List opportunities and challenges that may emerge as a result of an integrated, collaborative approach Mother-Infant Communication The Work of Beatrice Beebe Why Is Perinatal Mental Health Important? Depression Lifelong and Intergenerational Impacts on Mothers, Infants/Children and Family Systems Significant Adverse Childhood Event starting during pregnancy and impacting fetal, infant and child development Common and Treatable Most common obstetrical complication 14-23% of women have depression during pregnancy 15% of women take an antidepressant during pregnancy 50% of Postpartum Major Depressive Episodes begin prior to delivery Postpartum depression across populations: 10%-25% Some prevalence rates are estimated to increase to as high as: 40-50% in women with previous history of PPD 56% in urban, low-income women Only 8% of mothers Approximately 10% of new fathers receive experience depression treatment 1
Maternal Depression impairs parenting capacity and impacts child development Perinatal depression is associated with anxiety, childhood abuse, increased alcohol and drug use, pre-term delivery, low-birth weights, and impacts child development: Attachment insecurity Emotional dysregulation Poor cognitive development (Claire 2012, Melchior 2012) Not Just PPD Perinatal Mood and Anxiety Disorders Pregnancy Related Depression Encompasses Range of Symptoms with onset in the first year postpartum: Depression Anxiety PTSD Bipolar Psychosis OCD Anxiety Severe Mental Illness May Arise or Recur During Pregnancy 8.5-18% of mothers experience significant anxiety 9% of mothers have PTSD due to traumatic birth experience +/- previous trauma history 3%-9% of mothers have OCD in postpartum period Bipolar Disorder affects 2.9% of mothers In Women with Bipolar Disorder: 60-70% experience a mood episode during pregnancy or the post-partum period Postpartum Psychosis is rare 1-2 per 1000 births, but is a medical emergency Infant at low risk of harm if OCD or Intrusive Thoughts related to Depression, vs. true psychosis with thoughts of harm to infant Lifelong and Intergenerational Impacts Keeping the peace Prenatal Consequences Inadequate prenatal care poor nutrition Preeclampsia spontaneous abortion higher preterm birth rates lower birth weights Relationship Consequences Less sensitive caregiving Less responsive caregiving Negative feedback loop Insecure attachments Maternal Consequences Suffering Lack of joy in child Missed work Suicide attempts Social impairment Marital discord / divorce Risk for substance abuse Health Care Consequences Less frequent health visits More Urgent Care /ER Ineffective anticipatory guidance Behind on immunizations Avoiding the ire of the adult 2
Infant and Early Childhood Development Impact on Child and Adolescent Development Infant: Heightened arousal Poor self-regulation Dysregulation Passivity Lower cognitive performance Attentional weaknesses Toddler: Less mature expression of autonomy Internalizing and externalizing problems Lower rates of social interaction Delayed speech Less creative play Lower cognitive performance Attentional weaknesses Impaired adaptive functioning Internalizing and externalizing problems Depression Anxiety disorders Conduct disorders Socialization difficulties Conduct disorders Increased substance abuse and alcohol dependence Learning disorders ADHD Lower academic achievement A Journey Initiated by pediatrics-epds Consult requests and the need evolved Why did it start in pediatrics? 1 in 5 children and adolescents in the U.S. experience mental health problems Up to one half of all lifetime cases of mental illness begin by age fourteen Nearly 2/3 of these children do not get the help they need Early identification, diagnosis and treatment can help children reach their full potential Maternal depression impairs parenting capacity and impacts child development Perinatal depression is associated with anxiety, childhood abuse, increased alcohol and drug use, pre-term delivery, low-birth weights, and impacts child development: Attachment insecurity Emotional dysregulation Poor cognitive development (Claire 2012, Melchior 2012) 3
Perinatal Psychiatry-An unmet need Referrals from: Start Clinic, inpatient and outpatient UNM Nurse Midwifery and OB/GYN, Neurology, Family Medicine and Pediatrics Initially established at UPC, now integrated into UNM OB/GYN outpatient clinic Provide assessment, psychotherapy, medication management, social work services, referrals for additional outpatient services (home visiting) UNM Journeys/Perinatal Psychiatry Clinic -Anilla Del Fabbro, MD-director -Kimothi Cain, MD, MPH -Dr. Mary Shapiro, PhD-inpatient CL -Child and adolescent psychiatry fellows -General psychiatry residents -Dr. Katzman, MD-fathers -UNM Nurse Midwives and OB/GYN providers -UNM Pediatrics -NM Highlands social work interns Screening tools used -EPDS -GAD-7 -PTSD-CL -Psychosocial assessment Treatments -Psychopharmacology -Individual therapy, group (incl grief), couples, and parenting -Focus, Milagro ACE Study Adverse childhood events are common Almost 2/3 reported at least one ACE, >1 in 5 reported 3 or more ACE Short- and long-term outcomes of these childhood exposures include a multitude of health and social problems As the # of ACE increase, the risk for health problems increases in a strong and graded fashion Abuse and Neglect are rampant Children are suffering from a hidden epidemic of child abuse and neglect 3.3 million reports of child abuse made in the U.S. every year, involving 6 million children In the U.S. we lose 5 children every day to abuse-related deaths Approximately 80% of children that die from abuse are under the age of 4 More than 90% of juvenile sexual abuse victims know their perpetrator in some way 4
Children under 3 at high risk in NM. There can be no keener revelation of a society's soul than the way in which it treats its children. Nelson Mandela http://www.nccp.org/ Case study 1 Why focus on the parent? -18 year old postpartum x 4 weeks -living with FOB -disorganized, concern re care of baby, recent odd behaviors and talk -history of bipolar disorder -hospitalized -DC home on antipsychotic -F/U with perinatal psychiatry Ed Tronick's Still Face I fear What the past will do to me In the future Toxic Stress Derails Healthy Development -Yehuda Amichai, Concrete Poem http://www.youtube.com/watch?v=rvw FkcOZHJw 5
Might depression be a normal response to abnormal life experiences? Child s Perspective Growing up under the shadow of a caregiver with depression The infant of a depressed mother is at risk for developing insecure attachment, negative affect and dysregulated attention and arousal. Stark Tree in Storm Wynn Bullock Toddlers and preschoolers of depressed mothers are at risk for developing poor self-control, internalizing and externalizing problems, and difficulties in cognitive functioning and in social interactions with parents and peers. Child s Perspective Growing up under the shadow of a caregiver with depression School-age and adolescent children are at risk for impaired adaptive functioning and psychopathology, including conduct disorders, affective disorders and anxiety disorders. They are also at risk for ADHD and learning disabilities. Child s Perspective Growing up under the shadow of a caregiver with depression Contextual risk factors such as poverty, marital conflict and stressful life events may exacerbate parental depression and child behavior problems. On the other hand, some children develop resiliency through an easy-going temperament, good social cognitive skills and understanding of the parent s illness. What to do? Always remember the baby, intergenerational trauma Babies experience stress, trauma Ask about stressors, birth control, DV and SA Educate and normalize Refer early when family is THINKING about having a child Work with dyad, triad, family system-therapy Work as part of a collaborative team A Word from James Heckman PhD James Heckman Nobel Laureate 2000 His research has given policy makers insights on econometric methods applied to education, job training. Recently his emphasis has been on human development and lifecycle skill formation. 6
How to make a difference? Prevention Early intervention Targeting the parents/caregivers After climbing a great hill, one only finds that there are many more hills to climb. Nelson Mandela Education Interdisciplinary teams Time What do we do in perinatal psychiatry? What do we do in perinatal psychiatry? Look at patient through different perspectives and lenses History is important (EPDS-Lifetime) What happened to you? Trauma It requires constant communication and collaboration with other disciplines (and colleagues) It requires consistent communication with patient and family Careful review of past psychiatric history and medications Case study 2 Winnicott -33 year old married mother of a toddler -considering a second pregnancy -history of depression and anxiety -history of eating disorder -counseled by pharmacist and psychiatrist that being on SSRI was irresponsible and detrimental to her potential pregnancy -tearful, labile, dysregulated with poor sleep and appetite since she had stopped all medications When I look I am seen, so I exist. 7
Conclusions Maternal distress is common. Peripartum de novo and/or exacerbation of mental health issues can negatively impact children cognitively, emotionally and behaviorally. As a result of this multidisciplinary collaboration, early identification and treatment of perinatal women with mental health issues is been addressed, resulting in better outcomes for infants, toddlers, children and their families. 8