The mother-baby bond: a systematic review about perinatal depression and child developmental disorders


La relazione madre-figlio: rassegna sulla depressione perinatale e lo sviluppo   del bambino


MELANIA MARTUCCI1, FRANCA ACETI2, NICOLETTA GIACCHETTI2, CARLA SOGOS1

E-mail: melania.martucci@uniroma1.it


1Child Neuropychiatry Unit, Department of Human Neuroscience, Sapienza University of Rome, Italy

2Post-Partum Disorders Unit, Department of Human Neuroscience, Sapienza University of Rome, Italy


SUMMARY. Background. Perinatal depression is a common mental disorder, which has become a significant public health concern, especially in the western developed countries where it has a prevalence of 10-20%. As a mental illness, it does not only concern the affected mother but also the child and family. Aim. The aim of this review is to examine any developmental disorders in children of depressed mothers. Methods. Studies were identified from the following sources: PubMed (Database 2015-2021), Psycarticles (Database 2015-2021), and Psychinfo (Database 2015-2021). Of the 388 studies considered, 32 full-text articles have been analysed, and 22 have been included in the review. Results. Results suggest an increased risk of child emotional dysregulation and socio-emotional problems. Several studies reported an increased risk of cognitive, motor and language delay. Moreover, some studies suggest behaviour problems in preschool-age for the children of depressed mothers. Conclusions. These evidences lead to the importance of including maternal mental health into primary health care and adequately addressing the dyad to treat depressed mothers and prevent consequences for child development.


KEY WORDS: perinatal, depression, child development.


RIASSUNTO. Introduzione. La depressione perinatale è un disturbo mentale di elevato interesse nel contesto della sanità pubblica, soprattutto nei Paesi occidentali, ove si evidenzia una prevalenza del 10-20%. La depressione perinatale non riguarda solo la salute mentale della madre ma ha un impatto considerevole anche per il bambino e la famiglia. Obiettivo. A tal proposito, l’obiettivo di questa revisione sistematica della letteratura è stato quello di esaminare l’associazione tra depressione perinatale e difficoltà nello sviluppo del bambino. Metodi. Sono stati selezionati e revisionati gli articoli pubblicati dal 2015 al 2021 sui siti PubMed, Psycarticles e Psychinfo. Dei 388 titoli selezionati, 32 articoli sono stati analizzati e 22 sono stati inclusi nella sintesi qualitativa degli studi. Risultati. I risultati suggeriscono che i figli di madri depresse hanno un aumentato rischio di disregolazione emotiva e problemi nell’ambito socioemotivo. Le evidenze riportano difficoltà nell’acquisizione delle tappe dello sviluppo cognitivo, motorio e del linguaggio. Si evidenzia, inoltre, un rischio aumentato di insorgenza di disturbi esternalizzanti e internalizzanti in età evolutiva. Conclusioni. Queste evidenze suggeriscono l’importanza di individuare e trattare precocemente le madri depresse mediante un intervento terapeutico che includa la diade madre-bambino, utile a prevenire le conseguenze per lo sviluppo del bambino.


PAROLE CHIAVE: depressione, perinatale, sviluppo del bambino.

BACKGROUND

Pregnancy, postpartum and puerperium are characterised by significant physical, relational, and psychological transformations in mother’s life.

Women can experience feelings of fear, sadness and inadequacy but also anxious-depressive symptoms that should not be underestimated. Perinatal mental health is a topic of growing interest, with distinct clinical conditions that could affect mothers in such a period of high vulnerability. Baby or maternity blues occurs in about 40 to 80 percent of mothers during the first postpartum month, and it is usually mild, self-limiting condition without important consequences to the health of the mother and child1 . Perinatal Depression (PD) is a frequent and debilitating mental disorder, which has become of significant public health concern2 especially in the western developed countries, where it has a prevalence of 10 to 20 percent3.

PD is a non-psychotic depressive episode that occurs in women either in pregnancy or from 4 weeks to 3 months after childbirth4,5.

The presence of depressive symptoms during the period of pregnancy and postpartum is evaluated using the Edinburgh Postnatal Depression Scale (EPDS)6.

Several studies report that children of depressed mothers have increased risk of socio-emotional development delay, neuropsychological, and cognitive deficit, externalising and internalising behaviour problems, in comparison with children of healthy mothers7.

Relevant findings of Schore’s studies suggest some considerations regarding mother-child interaction and its role in child development8. These evidences underlines the importance of a tuning and responsive mother in childhood. Infact, through a series of non-verbal, tactile and gestural visual-facial modulations and a prosodic and auditory preverbal communication, the child and the caregiver can learn to have adequate interactions8.

The tuning is not continuous, but breaking moments are characterised by “interactive repair” or by a “break and repair” mechanism and the role of the caregiver, as an external regulator, should be in time to restore sufficiently and adequate regulation to prevent the negative arousal in the child8. The restoration of quiet corresponds to the production of neuropeptides (oxytocin), neuromodulators (catecholamines) and neurosteroids (cortisol)8. These neurotransmitters are fundamental in the development of the social and emotional brain with long-term effects on the hypothalamic-pituitary-adrenocortical axis8.

Depressed mothers, instead, present withdrawn and inhibited or intrusive and hyper-controlling behaviour; a show of poor physical and visual contact and difficulty in interpreting the child’s needs9.

These events have an important correlation with the psychological and emotional development in the first eighteen months of life, because in this period myelination of the limbic system takes place and right hemisphere matures, with impact on the cortical areas10.

Hence, maternal depression can affect organ development (e.g., pre-frontal cortex) and the hypothalamic-pituitary-adrenal axis (HPA axis; the system responsible for regulating stress hormone production, e.g., cortisol) such that the fetus becomes overly sensitive to environmental stressors11,12. Indeed, studies have shown that chronically elevated levels of cortisol in depressed mothers during pregnancy can lead to slower fetal growth, premature birth, infant brain cell damage, and over-reactive infant biological stress responses, which can cause long-term cognitive and emotional defcits later in childhood12,13.

All those studies suggest the seriousness of maternal depression as a mental illness concerning not only the affected mother but also the fetus and child10-13.

Early diagnosis is important to prevent consequences on child development and to investigate the correlation between maternal depression and child outcomes.

This review is a part of a larger clinical project-intervention conducted by the Perinatal Psychiatry Unit in collaboration with the Child Neuropsychiatry Unit of the Human Neuroscience and Mental Health Department of Umberto I Hospital14-23. The goal of the project is to evaluate primary and secondary prevention and treat maternal depression to sustain a child-mother relationship in the first years after childbirth. The aim of this review is to examine perinatal depression influences on child development.

METHODS

Criteria for considering studies for this review

Types of studies: Prospective longitudinal studies, cohort and retrospective studies that analyse the consequences of perinatal depression on child development.

Types of participants: mothers with a diagnosis of perinatal depression and their children in infancy and preschool age.

Type of intervention: any type of intervention to evaluate the correlation between maternal depression and child outcomes (comparison between children of depressed and healthy mothers, longitudinal observation with periodic assessments of maternal depression and child development).

Types of outcome: measures of socio-emotional, cognitive and motor child development, effects of maternal depression on externalising and internalising behaviours of children.

Selection of trials

The titles and abstracts were screened against the inclusion criteria by the second author to identify relevant articles. If it was unclear whether an article met the inclusion criteria, then the full-text version was obtained, and the article assessed more thoroughly. Once all potentially relevant studies had been obtained, each study was evaluated for inclusion independently by two reviewers. If there was a question about the inclusion of any study, the final decision was made by both authors. If the primary reviewers could not come to a consensus regarding the inclusion or exclusion of a study, the full article was submitted to the third reviewer. Reviewers were not blinded to the name(s) of the author(s), institution(s) or publication source.

The reviewers independently extracted the data from the articles using a form covering the following:

• Methods: any type of method to evaluate depressive symptoms and consequent child development outcomes (e.g. questionnaires and scales of child development).

• Participants: include women defined as depressed in the antenatal or postpartum period and their children in infancy and preschool age.

• Depression must be measured by a valid assessment tool (Edinburgh Postnatal Depression Scale)6 or diagnosed by a physician and could range from mild to severe symptoms.

• Outcomes: child developmental outcomes are selected considering the main indicators of a typical developmental profile in infancy and preschool age (cognitive, language, motor and socioemotional development, emotive-behavioral skills). Hence, we have considered indicators of child develepomental disorders: the emotional dysregulation and socioemotional problems, cognitive, language, motor, socioemotional developmental delay and early child behaviour problems.


Uncertainty and disagreement were resolved through discussion and consultation among the reviewers.

Studies were identified from the following sources: PubMed (Database: 2015-2021), Psycarticles (Database: 2015-2021), Psychinfo (Database: 2015-2021).

The following search terms were used to identify articles: “Perinatal”, “Postnatal”, “Maternal”, “Depression” And “Child”, “Children”, “Developmental”, “Disorders”.

RESULTS

We identified 388 articles and analysed 58 abstracts. We excluded 26 articles because 7 studies were systematic reviews, and 19 articles did not report measures about developmental disorders or perinatal depression (Figure 1).




We analysed 32 full articles, included 22 articles, and we report the list of excluded full articles along with the reason for their exclusion (Table 1)24-33.




Included articles

Child emotional dysregulation and socioemotional problems (N=7)

We have selected three different groups of studies that point out different child outcomes. The first group includes seven studies demonstrating that maternal depression is correlated with high levels of emotional reactivity, child emotional dysregulation and increased irritability in infancy and preschool age (Table 2).







We found that, in a multivariate analysis, prenatal depression symptoms [odds ratio(OR)=1.19, 95% confidence interval (CI) 1.15-1.25], postnatal depression symptoms (OR=1.17, 95% CI 1.12-1.23), unhealthy diet in pregnancy (OR=1.12,95% CI 1.06-1.19) and at child age of 3 years (OR=1.34, 95% CI 1.26-1.42) and 4.5 years (OR=0.79, 95% CI 0.73-0.85), as well as child dysregulation at the age of 4 years (OR=1.17, 95% CI 1.10-1.24) are all significantly associated34. Hence, maternal depression symptoms and unhealthy diet show important developmental associations but they are also independent risk factors for atypical child development34. 

Another study presents evidence regarding two distinct developmental pathways to adolescent depressive symptoms that involve specific early and mid-childhood features. The first links prenatal maternal depressive symptoms, toddler temperament (high perceived intensity b=.11 and low perceived adaptability b=.11), childhood irritability symptoms, and adolescent depressive symptoms.

The second one links prenatal maternal depressive symptoms, toddler temperament (negative perceived mood b=.15), childhood anxiety/depressive symptoms, and adolescent depressive symptoms. This study suggests that distinct developmental pathways lead to adolescent depressive symptoms and are important targets and windows of opportunity for their prevention35.

Relevant findings suggest that the maternal depression is significantly related to the negative emotional tone and negative emotional reactivity of the child at 24 months postpartum, such that increase of the major depressive disorder trait invokes more negativity of the child during the interaction tasks and negative reactivity to the frustration36. Higher maternal prenatal mood entropy is predictive of increased child negative affectivity at 6 and 12 month, with increased child report of anxiety symptoms at age 10 (r=.24; p<01;) and with adolescent reports of depressive symptoms at age 13 (r=.29; p<.01), suggesting the long-term consequences of perinatal depression on people mental health37. In this study, predictability of maternal mood is calculated by applying Shannon’s entropy to the distribution of responses on mood questionnaires. This application involves a quantification of unpredictability of the item-by-item responses to assessments of mood states37. In this sense, mood entropy quantifies the degree of predictability of the item-specific response37.

Moreover, we included a study that focuses on the comparison between children of depressed mothers and healthy mothers.

From this study, it emerges that 37% of infants born from mothers with persistent preconception mental health problems are categorised as high in emotional reactivity as compared to 23% born from mothers without preconception history (adjusted OR: 2.1, 95% CI: 1.4-3.1)38. Ante and postnatal maternal depressive symptoms are similarly associated with infant emotional reactivity, but these perinatal associations reduce somewhat after adjustment for prior exposure. 

 These results suggest that maternal depression is related to a characteristic temperament in toddlerhood. In this regard, Wall-Wieler et al.39, report that children exposed to maternal depression before age 5 have a 17% higher risk of having at least 1 developmental vulnerability at school entry than children not exposed to maternal depression before age 5. Exposure to maternal depression is most strongly associated with difficulties in social competence (adjusted relative risk [aRR]=1.28; 95% confidence interval [CI]: 1.20-1.38, 1.36), and emotional maturity (aRR=1.27; 95% CI: 1.18-1.37)39. Another recent study suggests depressed mothers display lower regulatory caregiving at 9 months, 6 years, and 10 years, evaluated by mother-child interactions assessment (6 minutes of free play at 9 months and 10 min of play with age-appropriate toys that elicit creative-symbolic play at 6 years. At 10 years, mothers and children engaged in two well-validated discussion paradigms for 7 min each). Children of depressed mothers show significantly less social collaboration and lower emotion recognition, but there are no differences between the groups in children’s executive function40.

Child Developmental Delay (N=8)

Eight studies suggest the difficulty of children of depressed mothers in acquiring different competences (motricity, cognitive development, problem-solving, communication) (Table 3).







Hence, in preschool age, children of mothers with depressive symptoms have reduced scores at cognitive assessment41. This result is in line with prior studies demonstrating experiences with insensitive maternal interactions and insecure mother-child attachment appear to be predictive of impaired cognitive functioning42. Moreover, chronic maternal depression could influence the child’s cognitive development through maladaptive parenting behaviours; it is difficult for depressed mothers to propose stimulating activities, books or objects.

Relevant findings from another study suggest the women with current depression and those with both postpartum depression and current depression are significantly more likely to have a child with developmental disabilities in communication, gross motor and personal-social domains assessed four years after childbirth (OR=2.59, 95% CI=1.16-5.78; OR=4.34, 95% CI=2.10-8.96 and OR=5.66, 95% CI=1.94-16.54, respectively)43.

Tuovinen et al.44 suggest similar results underlying that higher mean maternal depressive symptoms predict lower total developmental milestones, fine and gross motor, communication, problem-solving, and personal/social skills scores in children (p<0.001).

Wang et al.45, demonstrated an increased risk of psycho-motor developmental delay in preterm children of depressive mothers; these data were collected when the children were eight months old, according to the concept that early maternal depression and environmental risk factors directly affect the cognitive and social functioning of children.

Relevant findings from two studies demonstrate the poorer performance of babies exposed to antenatal or prenatal depression by in the first week after birth46,47.

The lack of effect of antenatal depression on developmental outcomes at 12 months demonstrated in the first study of these46 is potentially surprising.

It can be explained considering that cognitive and language scores are numerically lower in infants of depressed mothers.

However, the differences do not reach statistical significance. Further follow-up studies are required for better clarification of the antenatal depression’s effect on infant development46. In a recent study data about maternal depressive symptoms and child development was collected before pregnancy, during pregnancy, 4 months postpartum, and at 2.5 years postpartum. Results suggest that compared to mothers with no maternal depressive symptoms (MDS), the mothers reporting cumulative MDS at all four time points are 2.19 (95% CI 1.55-3.11), 2.67 (95% CI 1.71-4.16), 2.79 (95% CI 1.59-4.92) and 3.25 (95% CI 1.30-8.15) times significantly more likely to have children with social- emotional developmental delay. Mothern with MDS at one and two time points are 3.67 (95% CI 1.29-10.47) and 3.68 (95% CI 1.83-7.41) times more likely to report child motor and cognitive/adaptive delay. Mothers reporting MDS at all four time points are 1.82 (95% CI 1.34-2.48), 2.60 (95% CI 1.78-3.80), 2.53 (95% CI 1.54-4.17) and 2.42 (95% CI 1.02-5.77) times significantly more likely to report any child developmental delay48. Gül et al.49 2020 found that higher scores of “maternal depression” increase the risk of having total development delay for infants (OR=1,59, 95% CI: 1,24-2,04, p<.001).These studies report a specific effect of prenatal depressive symptoms on newborn’s outcomes, and they highlight the crucial necessity for antenatal screening and adjusted treatments of maternal depressive symptoms.

Early child behaviour problems (N=5)

We included five articles about the association of perinatal depression with early child behaviour problems (Table 4).







Narayanan et al.50 compared the associations between maternal and paternal depressive symptoms and early child behaviour problems. Higher levels of maternal symptoms at six months predict emotionally reactive (p=0.01), anxious/depressed (p<0.001),withdrawn (p=0.03), attention problems (p=0.02) and aggressive child behaviour (p=0.01) at 48 months, while higher levels of paternal symptoms do not predict child behaviour. The results confirm that mothers’ mental health status shortly following childbirth seems to need the most attention, as it is most often the case today.

In a study, in particular, negative child affectivity in toddlerhood is associated with internalising and externalising behaviours at the age of seven. More specifically, the high maternal depressive symptom trajectory is associated with 7-year maternal depressive symptoms (b=5.52, SE 1.65, p<0.01), child internalising problems (b=7.60, SE= 3.12, p=0.02) and externalising problems (b=6.23, SE=3.22, p=0.05). Caregiving engagement among high depressive symptom trajectory mothers is significantly associated with observed child affect (b=-0.21, SE=0.11, p=0.05). Parental nurturance in toddlerhood mediates the association between high maternal depressive symptom trajectory and child internalising problems at seven years (indirect effect b=2.33, 95% CI: 0.32-5.88).

These findings demonstrate the continuity of behavioral problems from toddlerhood to early school age, suggesting the long term effects of postpartum maternal depressive symptoms on child behaviour51.

Relevant findings report that all maternal depressive time-points (1.5, 3, 5 years postpartum) are significantly and positively associated with child internalising and externalising problems. Analyses are repeated using a sibling comparison design to adjust for familial confounding. After sibling comparison, however, only concurrent maternal depression is significantly associated with internalizing [estimate=2.82 (1.91-3.73, 95% CI)] and externalizing problems [estimate=2.40 (1.56-3.23, 95% CI)].

A potential explanation for these findings is that after toddlerhood, the child may need more behaviorally engaged mothers. Hence, it may also take a few years before the effects are expressed as children behaviour problems.

Instead, effects may be reflected in other developmental domains52. Moreover, two recents studies report that maternal depression during toddlerhood has a stronger effect on child internalizing (SE=0.21) and externalizing (SE=0.22) symptoms and social skills (SE=-0,08) at age 5, than either prenatal or postnatal depression53. Rotheram-Fuller et al.54 recruited a clinical sample of Pregnant women and their children in 24 periurban township neighborhoods in Cape Town, South Africa (N=1,238 mothers). This study found that at 36 months the pattern of maternal depressed mood is significantly associated with Child Behavior Checklist Internalizing Problems Scale Score (F=7.8, p=.01), Externalizing Problems Scale Score (F=7.8, p<.01), and Total Problems Score (F=8.4, p<.01)54.

No significant association between maternal depression and child development (N=2)

Finally, two studies demonstrated no significant association between maternal depression and child development (Table 5).




The first study, conducted in South Africa, demonstrates that growth and developmental delays, motor, speech milestones through 24 months post-birth are similar for mothers with and without perinatal depressed mood55.

The second of such studies underlies a correlation between developmental delay in children at psychosocial risk and low quality of mother-child interaction. However, there is not a direct correlation with depressive symptoms56.

DISCUSSION AND CONCLUSIONS

Maternal depression is a global public health issue that must be addressed early in order to protect the mother-child relationship and to prevent negative consequences on child development. The reviewed studies and our daily clinic observations suggest that maternal depression is a significant risk factor for child psycho-motor and socio-emotional development delay. Moreover, Laucht et al.57 report that social-emotional outcomes of children of postnatally depressed mothers is significantly poorer than in the healthy mothers’group. We found seven studies that report an association between maternal mental healh and early child emotional dysregulation as well as socioemotional troubles34-40.

These data suggest negative emotional reactivity and irritability could be predictive factors of increased risk in childhood and adolescent mental health, and longitudinal studies allow us to analyse this risk of serious consequences on people mental health.

 Our systematic review suggests that maternal depression is associated to global developmental delay. Eight studies report that maternal depression increases the risk of cognitive, language, motor and socioemotional developmental delay assessed form childbirth to three years after childbirth. Our selected studies demonstrated lower scores at cognitive assessment, personal-social domains and problem solving skills of children exposed to maternal depression, in preschool age, compared with children of undepressed mothers41,43-49.

These data suggest the possibility to early recognize the risk of child developmental disorders and the importance to detect them in the first years after childbirth.

Most of the cases described can evolve differently58. The persistence of an insufficient stimulation can transform a reversible functional fact into an irreversible alteration, due to failure in activating and organising specific functional activities, with development delay involving multiple areas58.

Literature suggests that initial difficulties in the cognitive use of the motor act and of the perceptive act can interfere with the development of praxic, symbolic and communicative skills58.

We included five studies that report maternal depression as a risk factor for early child behavior problems (internalizing and externalizing problems), assessed in preschool age and at school entry50-54.

Finally, two studies demonstrated no significant association between maternal depression and child development55,56.

The first study is conducted in South Africa and the results could be explained considering that deficits in caregiving may be mitigated by the social connections that rural living demands, and more intact social structures, as compared to peri-urban townships. The rural environment may offer social protective factors in managing depression and other difficulties faced by women so that we can reflect on socio-cultural differences in maternal mental health55.

The second of such studies underlies a correlation between developmental delay in children at psychosocial risk and low quality of mother-child interaction56, but there is not a correlation with depressive symptoms. It is important to consider that the factors of care and context are interrelated. A mother who has a supportive social context in child caring is exposed to less stress and as a consequence is less likely to depressive symptoms. In this way, the mother is more likely to have good quality interactions with her child that are stimulating for his or her deve­lopment.

Therefore, an early intervention on mother-child relationship to encourage the creation of a facilitating environment for the child is essential in the first years after childbirth, when a tuned and responsive mother can facilitate the development of the potential and hereditary tendencies of the infant.

Hence, it emerges the importance of including maternal mental health into primary health care and adequately address the dyad to treat depressed mothers with psychotherapy and psychopharmacology. Moreover, it’s important to sustain an intervention on the mother-child relationship through baby observation and psychotherapy for the dyad. Through these measures, it could be identified as the early situation of dysfunctional parenting styles.

Therefore, if the risk of a delay in socio-emotional and psychomotor development is recognized early, immediate planning of the most appropriate intervention becomes possible, while accounting for social context and general resources that influence maternity experience.

Maternal-child interaction guidance and psychotherapeutic group support produce significant effects on parenting (e.g. sense of competence) and child development59.

Interpersonal psychotherapy (IPT), cognitive behavioural therapy (CBT) and psychotherapeutic group support show promising results for improving specific parental styles and/or child development outcomes59. In a very well designed study of CBT interventions for antenatal depression, the treatment group showed improved infant outcomes, including developmental progress (specifically, problem-solving), child self-regulation, infant temperament and behaviour variables such as high-intensity pleasure, reactivity and negative affectivity60.

Literature and clinic experience suggest that it is essential to consider perinatal depression as a pathology of the relationship. Hence, it’s important to focus therapy on the mother-child relationship as well as an essential project of primary prevention in mental health.


Conflict of interests: the authors have no conflict of interests to declare.

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