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Reducing Maternal Depression and Its Impact on Young Children
Toward a Responsive Early Childhood Policy Framework

Authors: Jane Knitzer, Suzanne Theberge, and Kay Johnson
Publication Date: January 2008

Executive Summary

Maternal depression is a significant risk factor affecting the well-being and school readiness of young children. Low-income mothers of young children experience particularly high levels of depression, often in combination with other risk factors. This policy brief provides an overview of why it is so important to address maternal depression as a central part of the effort to ensure that all young children enter school ready to succeed. It highlights:

  • what research says about the impact of maternal depression on young children, particularly infants and toddlers, and how prevalent maternal depression is;
  • examples of community and programmatic strategies to reduce maternal depression and prevent negative cognitive, social emotional and behavioral impacts on young children;
  • key barriers to focusing more attention to maternal depression in policies to promote healthy early child development and school readiness;
  • state efforts to address policy barriers and craft more appropriate policy responses; and
  • recommendations.

Depression is increasingly recognized as major worldwide public health issue. It has a negative impact on all aspects of an individual’s life – work and family – and can even lead to suicide. Typically, depression is discussed as an adult problem affecting women or men, and increasingly, it is recognized as a significant problem for children.1 But far too rarely is depression, particularly maternal depression, considered through a lens that focuses on how it affects parenting and child outcomes, particularly for young children; how often it occurs in combination with other parental risks, like post-traumatic stress disorder; and what kinds of strategies can prevent negative consequences for parents, for their parenting and for their young children.

Maternal depression, alone, or in combination with other risks, can pose serious but typically unrecognized barriers to healthy early development and school readiness, particularly for low-income young children.

  • The negative effects of maternal depression on children’s health and development can start before birth.2
  • Maternal depression can impair critical early relationships.3
  • Maternal depression can impair parental safety and health management (such as breastfeeding, safety practices, preventive health measures, or managing chronic health conditions).4
  • The cumulative impact of depression in combination with other parental risks to healthy parenting (such as poverty, substance abuse, domestic violence, or prior trauma) is even greater.5
  • Depression in other caregivers (fathers, grandparents, child care providers) can also impact the early development of young children.6

Prevalence Data on Maternal Depression

  • Approximately 12 percent of all women experience depression in a given year.7
  • For low-income women, the estimated prevalence doubles to at least 25 percent.8
  • Estimated rates of depression among pregnant and postpartum and parenting women in general range from 5 to 25 percent.9
  • Low-income mothers of young children, pregnant and parenting teens report depressive symptoms in the 40 to 60 percent range.
  • —  Over half the mothers (52%) in a study of 17 Early Head Start programs reported depressive symptoms.10

    —  Another study found that an average of 40 percent of young mothers at community pediatric health centers screened positive for depressive symptoms (site specific rates ranged from 33% to 59%).11

    —  Studies of women participating in state welfare-to-work programs indicate that depression and elevated levels of depressive symptoms range from 35-58 percent.12

Recommendations

This brief profiles several emerging efforts to target depression in parents of young children, including such strategies as:

  • screening and follow-up for women, typically in ob/gyn or pediatric practices;
  • targeted interventions to reduce maternal depression and improve early parenting in early childhood programs such as home-visiting and Early Head Start Programs; and
  • promoting awareness about the impact of maternal depression and what to do about it for the general public, low-income communities, and early childhood and health practitioners.

This brief also makes a series of policy recommendations for communities, states, and the federal government. Addressing and targeting resources to maternal depression as a barrier to early healthy development and early school success is complex undertaking that will require the involvement of programs, community leaders, state policymakers and legislators and families and researchers at local and state levels, as well as some national leadership. To move this agenda forward, below is a set of strategic actions for those at the local, state and federal levels.

At the local level, communities can:

  • conduct a community scan to assess local capacity for screening and following-up for pregnant women and parents of babies and young children and to identify how existing resources are used;
  • engage local funders, including community foundations, to develop a strategic plan and implementation steps to help local early childhood programs test and/or replicate evidence-based, effective family focused practices to address maternal depression and its impact on young children;
  • assess and strengthen community capacity to address depression in fathers as well as mothers, and in others who care for young children on a daily basis, whether in families or in child care settings;
  • engage leaders of low-income communities in designing and evaluating public awareness campaigns and culturally and linguistically responsive outreach and program strategies;
  • document disparities and implement strategies to track and improve access to culturally and linguistically responsive instructions; and
  • combine public and private dollars to support early childhood mental health consultants to work with home-visitors and other caregivers.

At the state level, public officials and advocates can:

  • use ECCS grants to help health care providers and systems implement a developmental multi-generational family health/mental health perspective, including attention to prenatal depression and related risks as part of implementing the medical/dental home vision;
  • dedicate a staff person to coordinating interagency screening, prevention and treatment efforts to address depression through a family lens, paralleling positions that have been created for to coordinate cross-agency activities around women’s health or HIV/AIDS;
  • develop a cross-agency strategic action plan to reduce maternal depression and its impact on young children that identifies what each system will do separately and together, such as:
  • —  build on medical home initiatives and perinatal screening initiatives, making sure there is appropriate follow-up treatment;

    —  support cross-training efforts for primary care providers in health and early care and learning settings;

    —  expand early childhood mental health strategies to include attention to depression in staff and families;

    —  provide support to expand access to screening and follow-up treatment for pregnant and parenting mothers through both health practices and early childhood programs;

    —  train and identify mental health consultants with documented expertise in dealing with depression through a family lens to work with pediatricians, early care and learning programs and women’s health agencies; and

    —  embed attention to depression beyond health and early childhood systems and programs (especially TANF, marriage initiatives, WIC, child welfare, etc.) in developing program initiatives, regulations, etc.

  • Maximize the use of Medicaid to prevent and treat depression and related risk factors in the context of promoting healthy early child development, such as:
  • —  use Medicaid waivers (or if that is prohibited, state funds) to extend health insurance coverage to mothers with young children at least to the eligibility levels that the children are covered for the first two years following birth or use the child’s access to Medicaid to cover parents;

    —  promote public awareness campaigns and educational materials that show the links between early school success and addressing maternal depression.

At the federal level federal officials, including Congress can:

  • ensure that Medicaid facilitates, rather than impedes, states’ ability to pay for depression reduction and prevention strategies that are designed to improve outcomes for young children;
  • provide incentives to the states to cover parents of young children through Medicaid up to 200 percent of the poverty level to ensure access to treatment for depression as well as health conditions that impair parenting;
  • create a federal interagency work group, either through legislation or executive order, including health, mental health and children’s agencies that can develop a strategic action plan, and potentially pool funds to support state efforts to design comprehensive approaches to prevent and reduce parental depression and improve outcomes in young children;
  • embed attention to depression beyond health and early childhood systems and programs (especially TANF, marriage initiatives, child welfare, etc.) in developing program initiatives, regulations, etc.; and
  • develop a strategic NIH research agenda that includes support to develop and test a range of interventions to address maternal depression, promote more effective parenting strategies and improve outcomes for young children, particularly for low income
  • women experiencing depression along with other risk factors.

Conclusion

This issue brief calls for policymakers to include much more serious attention to maternal depression as part of the larger efforts across the country to improve healthy developmental and school-readiness outcomes in young children.

The argument is simple: particularly for low-income children, maternal depression is a known barrier to ensuring that young children experience the kinds of relationships that will facilitate their success in the early school years. Investing in treatment and support for one generation will promote healthy development and school readiness for the next. Addressing maternal depression through a parenting and early childhood lens is in effect a “two-fer”: it can help parents, but importantly, it will also pay off for their children, both in the short term and in the longer term. There are tough barriers, particularly fiscal barriers, to creating family focused interventions. It requires a framework shift that provides public incentives for a family-focused, namely multi-generational, culturally responsive, approach that brings together resources from multiple public systems. There is also a critical role as a catalyst and seeder of initiatives for private philanthropy.

The real message from this brief is clear. While there is much more to be known, we already have enough evidence about effective approaches to address a damaging condition that ripples throughout a family and a community, with lifelong implications for everyone it touches. We simply cannot afford not to respond with resources and commitment.

Endnotes

1. Putnam, Frank. Reducing Maternal Depression and Its Impact on Young Children: Building a Policy Framework 6/22/06.

2. Bonari, Lori; Pinto, Natasha; Ahn, Eric; Einarson, Adrienne; Steiner, Meir; Koren, Gideon. 2004. Perinatal Risks of Untreated Depression During Pregnancy. Canadian Journal of Psychiatry 49 (11):726-735.

3. Essex, Marilyn J.; Klein, Marjorie H.; Cho, Eunsuk; Kalin, Ned H. 2002. Maternal Stress Beginning in Infancy May Sensitize Children to Later Stress Exposure: Effects on Cortisol and Behavior. Biological Psychiatry 52 (8):776-784.

Huang, Larke N., & Freed, Rachel. 2006. The Spiraling Effects of Maternal Depression on Mothers, Children, Families and Communities. Issue Brief #2. Annie E. Casey Foundation

Lyons-Ruth, K.; Connell, D. B.; Grunebaum, H. U.; Botein, S. 1990. Infants at Social Risk: Maternal Depression and Family Support Services as Mediators of Infant Development and Security of Attachment. Child Development 61 (1):85-98. Network, NICHD Early Child Care Research. 1999. Chronicity of Maternal Depressive Symptoms, Maternal Sensitivity, and Child Functioning at 36 Months. Developmental Psychology 35 (5):1297-1310.

Paulson, James F.; Dauber, Sarah; Leiferman, Jenn A. 2006. Individual and Combined Effects of Postpartum Depression in Mothers and Fathers on Parenting Behavior. Pediatrics 118 (2):659-668.

4. Chung, Esther K.; McCollum, Kelly F.; Elo, Irma T.; Lee, Helen J.; Culhane, Jennifer F. 2004. Maternal Depressive Symptoms and Infant Health Practices among Low-Income Women. Pediatrics 113 (6):e523-529.

Henderson, Jennifer J.; Evans, Sharon F.; Straton, Judith A. Y.; Priest, Susan R.; Hagan, Ronald. 2003. Impact of Postnatal Depression on Breastfeeding Duration. Birth 30 (3):175-180.

Kavanaugh, Megan; Halterman, Jill S.; Montes, Guillermo; Epstein, Mike; Hightower, A. Dirk; Weitzman, Michael. 2006. Maternal Depressive Symptoms Are Adversely Associated with Prevention Practices and Parenting Behaviors for Preschool Children. Ambulatory Pediatrics 6 (1):32-37.

Paulson, James F.; Dauber, Sarah; Leiferman, Jenn A. 2006. Individual and Combined Effects of Postpartum Depression in Mothers and Fathers on Parenting Behavior. Pediatrics 118 (2):659-668.

Sills, Marion R.; Shetterly, Susan; Xu, Stanley; Magid, David; Kempe, Allison. 2007. Association between Parental Depression and Children’s Health Care Use. Pediatrics 119 (4):e829-836.

5. Whitaker, Robert C.; Orzol, Sean M.; Kahn, Robert S. 2006. Maternal Mental Health, Substance Use, and Domestic Violence in the Year after Delivery and Subsequent Behavior Problems in Children at Age 3 Years. Archives of General Psychiatry 63 (5):551-560.

6. Gilliam, Walter S.; Shabar, Golan. 2006. Preschool and Child Care Expulsion and Suspension: Rates and Predictors in One State. Infants & Young Children: An Interdisciplinary Journal of Special Care Practices 19 (3):228-245.

Goodman, Janice H. 2004. Paternal Postpartum Depression, Its Relationship to Maternal Postpartum Depression, and Implications for Family Health. Journal of Advanced Nursing 45 (1):26-35.

Hamre, Bridget K.; Pianta, Robert C. 2004. Self-Reported Depression in Nonfamilial Caregivers: Prevalence and Associations with Caregiver Behavior in Child-Care Settings. Early Childhood Research Quarterly 19 (2):297-318, Isaacs, Maresa R. 2006. Maternal Depression: The Silent Epidemic in Poor Communities. Casey Foundation.

Kahn, Robert S.; Brandt, Dominique; Whitaker, Robert C. 2004. Combined Effect of Mothers’ and Fathers’ Mental Health Symptoms on Children’s Behavioral and Emotional Well-Being. Archives of Pediatric Adolescent Medicine 158 (8):721-729.

O’Brien, R. W.; D’Elio, M. A.; Vaden-Kiernan, M.; Magee, C.; Younoszai, T.; Keane, M.J.; Connell, D. C.; Hailey, L. 2002. A Descriptive Study of Head Start Families: Faces Technical Report I. U.S. Administration on Children, Youth, and Families. Department of Health and Human Services.

Ramchandani, Paul; Stein, Alan; Evans, Jonathan; O’Connor, Thomas G. 2005. Paternal Depression in the Postnatal Period and Child Development: A Prospective Population Study. Lancet 365 (9478):2201-2205.

7. Isaacs, Maresa. 2004. Community Care Networks for Depression in Low-Income Communities and Communities of Color: A Review of the Literature. Submitted to Annie E. Casey Foundation. Washington, DC: Howard University School of Social Work and the National Alliance of Multiethnic Behavioral Health Associations.

8. Lanzi, R. G.; Pascoe, J. M.; Keltner, B.; Ramey, S. L. 1999. Correlates of Maternal Depressive Symptoms in a National Head Start Program Sample. Archives of Pediatric Adolescent Medicine 153 (8):801-807.

Miranda, Jeanne; Green, Bonnie L. 1999. The Need for Mental Health Services Research Focusing on Poor Young Women. The Journal of Mental Health Policy and Economics 2 (2):73-80.

Onunaku, Ngozi. 2005. Improving Maternal and Infant Mental Health: Focus on Maternal Depression. National Center for Infant and Early Childhood Health Policy at UCLA.

Riley, A. W.; Broitman, M. 2003. The Effects of Maternal Depression on the School Readiness of Low-Income Children. Baltimore, MD: Report for the Annie E. Casey Foundation, Johns Hopkins Bloomberg School of Public Health.

Siefert, K.; Bowman, P. J.; Heflin, C. M.; Danziger, S.; Williams, D. R. 2000. Social and Environmental Predictors of Maternal Depression in Current and Recent Welfare Recipients. American Journal of Orthopsychiatry 70 (4):510-522.

9. Gaynes, B.N.; Gavin, N.; Meltzer-Brody, S.; Lohr, K.N.; Swinson, T.; Gartlehner, G.; Brody, S.; Miller, W. C. 2005. Perinatal Depression: Prevalence, Screening Accuracy, and Screening Outcomes. Rockville, MD:: Prepared by the RTI-University of North Carolina Evidencebased Practice Center, under Contract No. 290-02-0016.

10. Research to Practice: Depression in the Lives of Early Head Start Families. April 2006. Administration for Children and Families, U.S. Department of Health and Human Services.

11. Kahn, Robert S.; Wise, Paul H.; Finkelstein, Jonathan A.; Bernstein, Henry H.; Lowe, Janice A.; Homer, Charles J. 1999. The Scope of Unmet Maternal Health Needs in Pediatric Settings. Pediatrics 103 (3):576-581.

12. Siefert, K.; Bowman, P. J.; Heflin, C. M.; Danziger, S.; Williams, D. R. 2000. Social and Environmental Predictors of Maternal Depression in Current and Recent Welfare Recipients. American Journal of Orthopsychiatry 70 (4):510-522.