Clinical Report-Incorporating Recognition and Management of Perinatal and Postpartum Depression Into Pediatric Practice

 
Guidance for the Clinician in
                                                                                                               Rendering Pediatric Care

Clinical Report—Incorporating Recognition and
Management of Perinatal and Postpartum Depression
Into Pediatric Practice
                                                                           Marian F. Earls, MD, THE COMMITTEE ON PSYCHOSOCIAL
abstract                                                                   ASPECTS OF CHILD AND FAMILY HEALTH
Every year, more than 400 000 infants are born to mothers who are          KEY WORDS
                                                                           postpartum depression, perinatal depression, Edinburgh
depressed, which makes perinatal depression the most underdiag-            Postpartum Depression Scale, medical home, dyad relationship,
nosed obstetric complication in America. Postpartum depression             paternal depression
leads to increased costs of medical care, inappropriate medical care,      ABBREVIATIONS
child abuse and neglect, discontinuation of breastfeeding, and family      AAP—American Academy of Pediatrics
                                                                           PCP—primary care provider
dysfunction and adversely affects early brain development. Pediatric
practices, as medical homes, can establish a system to implement           The guidance in this report does not indicate an exclusive
                                                                           course of treatment or serve as a standard of medical care.
postpartum depression screening and to identify and use community          Variations, taking into account individual circumstances, may be
resources for the treatment and referral of the depressed mother and       appropriate.
support for the mother-child (dyad) relationship. This system would        This document is copyrighted and is property of the American
have a positive effect on the health and well-being of the infant and      Academy of Pediatrics and its Board of Directors. All authors
                                                                           have filed conflict of interest statements with the American
family. State chapters of the American Academy of Pediatrics, working      Academy of Pediatrics. Any conflicts have been resolved through
with state Early Periodic Screening, Diagnosis, and Treatment (EPSDT)      a process approved by the Board of Directors. The American
and maternal and child health programs, can increase awareness of          Academy of Pediatrics has neither solicited nor accepted any
                                                                           commercial involvement in the development of the content of
the need for perinatal depression screening in the obstetric and pedi-
                                                                           this publication.
atric periodicity of care schedules and ensure payment. Pediatricians
must advocate for workforce development for professionals who care
for very young children and for promotion of evidence-based interven-
tions focused on healthy attachment and parent-child relationships.
Pediatrics 2010;126:1032–1039

BACKGROUND
Maternal and paternal depression affect the whole family.1 This report
will specifically focus on the impact of maternal depression on the
young infant and the role of the primary care clinician in recognizing
                                                                           www.pediatrics.org/cgi/doi/10.1542/peds.2010-2348
perinatal depression. Perinatal depression is a major/minor depres-
                                                                           doi:10.1542/peds.2010-2348
sive disorder with an episode occurring during pregnancy or within
                                                                           All clinical reports from the American Academy of Pediatrics
the first year after birth of a child. A family history of depression,      automatically expire 5 years after publication unless
alcohol abuse, and a personal history of depression increase the risk      reaffirmed,revised, or retired at or before that time.
of perinatal depression.2                                                  PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
The incidence of perinatal depression varies with the population sur-      Copyright © 2010 by the American Academy of Pediatrics
veyed, but estimated rates for depression among pregnant and post-
partum women have ranged from 5% to 25%. Studies of low-income
mothers and pregnant and parenting teenagers have reported rates of
depressive symptoms at 40% to 60%. In general, as many as 12% of all
pregnant or postpartum women experience depression in a given year,
and for low-income women, the prevalence is doubled.1 The rate of
major and minor depression varies during pregnancy from 8.5% to
11.0%, and in the first year after birth of a child, the rate ranges from

1032   FROM THE AMERICAN ACADEMY OF PEDIATRICS
FROM THE AMERICAN ACADEMY OF PEDIATRICS

6.5% to 12.9%; the rate of major de-             substance abuse.5 The rate of paternal        Infants who live in a setting of depres-
pression during pregnancy ranges                 depression is higher when the mother          sion are likely to show impaired social
from 3.1% to 4.9%, and in the first year          has postpartum depression, which              interaction and delays in development.
after birth of a child, the rate ranges          compounds the effect on children.5,6 A        If the maternal depression persists un-
from 1.0% to 6.8%. The timing shows a            nondepressed father has a protective          treated and there is not intervention
peak of 6 weeks after birth of a child           effect on children of depressed moth-         for the mother and the dyadic relation-
for major depression and 2 to 3                  ers and is a factor in resilience.7–9         ship, the developmental issues (partic-
months for minor depression.2 There                                                            ularly attachment) for the infant also
is another peak of depression 6                  Family                                        persist and are likely to be less respon-
months after birth of a child.                   Perinatal depression may be comorbid          sive to intervention over time.17 Ad-
The spectrum of depressive symptoms              with marital discord, divorce, family vi-     dressing maternal depression in a
in the postpartum period ranges from             olence (verbal and/or physical), sub-         timely and proactive fashion is essen-
“maternity blues” to postpartum de-              stance use and abuse, child abuse and         tial to ensure healthy early brain and
pression and postpartum psychosis.               neglect, failure to implement the             child development and readiness to
Maternity blues affects 50% to 80% of            injury-prevention components from             succeed.18
new mothers and occurs during the                anticipatory guidance (eg, car safety
                                                                                               In their evidence report, “Breastfeed-
first few days after delivery. Symptoms           seats and electrical plug covers),10 fail-
                                                                                               ing and Maternal and Infant Health Out-
include crying, worrying, sadness, anx-          ure to implement preventive health
                                                                                               comes in Developed Countries,”19 the
iety, and mood swings. Symptoms are              practices for the child (eg, Back to
                                                                                               Agency for Healthcare Research and
usually gone after a few days or within          Sleep),10–13 and difficulty managing
                                                                                               Quality reviewed 6 prospective cohort
1 to 2 weeks. It does not impair func-           chronic health conditions such as
                                                                                               studies regarding postpartum depres-
tion and can be treated with reassur-            asthma or disabilities in the young
                                                                                               sion and breastfeeding. It revealed an
ance and emotional support. Postpar-             child.11,14 Families with a depressed
                                                                                               association between not breastfeed-
tum depression occurs in 13% to 20%              parent (ie, any parental depression)
                                                                                               ing, or early cessation of breastfeed-
of women after birth. It meets the cri-          overutilize health care and emergency
                                                                                               ing, and postpartum depression. The
teria of the Diagnostic and Statistical          facilities.14 Studies of families of a per-
                                                                                               report noted that “it is plausible that
Manual of Mental Disorders, Fourth               son with major depression that began
                                                                                               postpartum depression led to early
Edition (DSM-IV) for depression and is           before 30 years of age demonstrate
                                                                                               cessation of breastfeeding as opposed
distinct from maternity blues.3                  that the parent, siblings, and children
                                                                                               to breastfeeding altering the risk of de-
                                                 are 3 to 5 times more likely to have
Postpartum psychosis affects approxi-                                                          pression.” It also noted that both ef-
                                                 major depression themselves. It is
mately 1 to 3 mothers of 1000 deliver-                                                         fects might occur and that further in-
                                                 likely that some types of depression
ies and most often occurs in the first 4                                                        vestigation is needed to assess the
                                                 have genetic determinants.
weeks after delivery. Mothers with                                                             nature of this association.
postpartum psychosis are severely im-            THE IMPACT OF MATERNAL                        The consequences of maternal depres-
paired and may have paranoia, mood               DEPRESSION ON THE INFANT                      sion include negative effects on cogni-
shifts, hallucinations, delusions, and                                                         tive development, social-emotional de-
                                                 Maternal postpartum depression
suicidal and homicidal thoughts. This                                                          velopment, and behavior of the child.
                                                 threatens the mother-child (dyad) re-
is a serious condition that requires im-
                                                 lationship (attachment and bonding)           Language acquisition depends on the
mediate medical attention and usually
                                                 and, as such, creates an environment          number of words used by the family,
hospitalization. Preexisting bipolar
                                                 for the infant that adversely affects the     playing, and having fun and cuddling
disorder is a risk factor for developing
                                                 infant’s development. The processes           with the infant and child,20 which are
postpartum psychosis.
                                                 for early brain development—                  likely to occur less frequently in the
Depression: A Family Issue                       neuronal migration, synapse forma-            family of a depressed mother. As early
                                                 tion, and pruning—are responsive to           as 2 months of age, the infant looks at
Fathers                                          and directed by environment as well as        the depressed mother less often,
Paternal depression is estimated at              genetics. For example, it is known that       shows less engagement with objects,
6%.4 Eighteen percent of fathers of              an infant living in a neglectful environ-     has a lower activity level, and has poor
children in Early Head Start had symp-           ment, which is common with de-                state regulation. Infants are at risk for
toms of depression. In an 18-city study,         pressed mothers, can have adverse             failure to thrive, attachment disorder
depressed fathers had higher rates of            changes visible on MRI of the brain.15,16     (deprivation/maltreatment disorder

PEDIATRICS Volume 126, Number 5, November 2010                                                                                     1033
of infancy as defined the Diagnostic              toms and improved functioning in the        ternal depression on behavior out-
Classification of Mental Health and De-           offspring.”24,25                            comes for children at the ages of 3 and
velopmental Disorders of Infancy and                                                         4 years. The researchers concluded
Early Childhood: DC0-3R21), and devel-           THE ROLE OF THE PRIMARY CARE                that “reductions in maternal depres-
opmental delay on the Bayley Scales of           PROVIDER                                    sion mediated improvements in both
Infant Development at 1 year of age.             Many experts see a role for primary         child externalizing and internalizing
Such infants are at risk for insecure            care practices in screening for de-         problem behavior.”23
attachment, which is associated with             pression, in general, and specifically       The majority of pediatricians agree
later conduct disorders and behavior             for postpartum depression. The 1999         that screening for perinatal depres-
problems. Maternal depression im-                report of the Surgeon General on men-       sion is in the scope of pediatric prac-
pairs parenting skills and can affect            tal health,26 the 2000 report of the Sur-   tice.34 In a survey by Olson et al,35 few of
attention to and judgment regarding              geon General’s Conference on Chil-          the pediatricians felt that they were re-
child supervision for safety and health          dren’s Mental Health,27 and Bright          sponsible for diagnosis and manage-
management. The presence of other                Futures guidelines28 call for early iden-   ment, but the majority reported that
risks to healthy parenting, such as pov-         tification and treatment of mental           they had provided brief interventions.
erty, substance abuse, domestic vio-             health problems and disorders. In a re-     Most of the pediatricians indicated
lence, and previous trauma, in addi-             cent policy statement, “The Future of       that they had insufficient training to di-
tion to depression, creates an                   Pediatrics: Mental Health Competen-         agnose and treat maternal depres-
increased cumulative risk. The infant’s          cies for Pediatric Primary Care,” the       sion. The Parental Well-being Project of
temperament is another factor, which             American Academy of Pediatrics (AAP)        Dartmouth Medical School, which in-
may increase parental stress (difficult           also recognized the unique advantage        cluded 6 community pediatric prac-
temperament) or impart resilience for            of the primary care clinician for sur-      tices in New Hampshire and Vermont,
the infant (easy temperament). Mater-            veillance, screening, and working with      showed that pediatricians, using a
nal depression in infancy predicts a             families to improve mental health out-      simple 2-question screen, could effec-
child’s likelihood of increased cortisol         comes.29 The AAP Medical Home Initia-       tively screen for perinatal depression.
levels at preschool age, which in turn           tive30 and the AAP policy statement on      In the 6 months of the pilot, screening
has been linked with internalizing               the family31 addressed family-centered      was performed at 67% of well-child
problems such as anxiety, social wari-           pediatric care. The President’s New         visits.
ness, and withdrawal.22 Behavior prob-           Freedom Act of 2004 states that early       As with other screening (developmen-
lems, attachment disorders, depres-              screening, assessment, and treatment        tal and behavioral, psychosocial) initi-
sion, and other mood disorders in                of mental health problems must be-          atives in practice, there have been per-
childhood and adolescence can occur              come a national goal.32 Using data          ceived barriers to implementation,
more frequently in children of mothers           from the National Evaluation of Healthy     including lack of time, incomplete
with major depression.                           Steps for Young Children (in the            training to diagnose/counsel, lack of
Treating a mother’s depression is as-            Healthy Steps practices, mothers were       adequate mental health referral
sociated with improvement of depres-             assessed for depression), the effect of     sources, fear that screening means
sion and other disorders in her child.24         maternal depressive symptoms on the         ownership of the problem, and lack
The STAR*D–Child (Sequenced Treat-               children’s receipt of well-child care       of reimbursement.36 However, since
ment Alternatives to Relieve Depres-             was assessed. Minkovitz et al con-          2000, there have been many successful
sion–Child) project is a study that be-          cluded that “Increased provider train-      models of screening in primary care
gan in December 2001 and followed                ing for recognizing maternal depres-        practices, including developmental
151 mother-child pairs in 8 primary              sive symptoms in office settings, more       and behavioral screening, maternal
care and 11 psychiatric outpatient clin-         effective systems of referral, and de-      depression screening, and psychoso-
ics across 7 regional centers in the             velopment of partnerships between           cial screening. In these projects, strat-
United States. The children were as-             adult and pediatric providers could         egies have been implemented to inte-
sessed every 3 months. The research-             contribute to enhanced receipt of care      grate screening into office flow, to
ers concluded that “continued efforts            among young children.”33                    improve reimbursement, and to assist
to treat maternal depression until               A recent study from the University of       practices with identifying and collabo-
remission is achieved are associated             Pittsburgh followed 731 families to ex-     rating with community resources, in-
with decreased psychiatric symp-                 amine the effect of intervention for ma-    cluding mental health resources.37 The

1034   FROM THE AMERICAN ACADEMY OF PEDIATRICS
FROM THE AMERICAN ACADEMY OF PEDIATRICS

ABCD (Assuring Better Child Health and           ing the mother and facilitating her ac-      ship. Perinatal/postpartum depres-
Development) Project, funded by the              cess to resources to optimize the child’s    sion is an early risk to the infant, to the
Commonwealth Fund and adminis-                   healthy development and the healthy          mother-infant bond, and to the family
tered by the National Academy for                functioning of the family. For the mother,   unit. Surveillance and screening for
State Health Policy, now involves 28             the infant’s PCP provides information for    perinatal/postpartum depression is
states and their AAP chapters. The               family support, therapy resources,           part of family-centered well-child care.
Medicaid agency in Illinois, one of the          and/or emergency services as indicated.      Including postpartum depression
ABCD states, pays pediatricians who              The PCP does provide guidance, support,      screening in the practice’s preventive
use the Edinburgh Postpartum Depres-             referrals, and follow-up for the infant      services prompting system can help
sion Scale. Details of the various state         and the dyad relationship.                   ensure a reliable process for address-
initiatives and practice and parent                                                           ing risk.
materials are available at www.                  IMPLEMENTATION
                                                                                              The new Bright Futures guidelines in-
abcdresources.org and www.nashp.                 Over the course of routine well-child        clude surveillance regarding parental
org. Heneghan et al,38 in their discus-          care, the PCP and the family are devel-      social-emotional well-being. The US
sion of factors associated with manage-          oping a longitudinal relationship. Com-      Preventive Services Task Force has en-
ment of maternal depression by pedia-            munication at each visit is tailored to      dorsed the Edinburgh Postnatal De-
tricians, reported that in their sample,         the developmental process for the            pression Scale as well as the general
511 of 662 pediatricians reported identi-        child and for the family. Anticipatory       2-question screen for depression.2,41
fying maternal depression and address-           guidance addresses this dynamic de-          Given the peak times for postpartum
ing it in practice. They discussed the           velopmental process. A crucial part of       depression specifically, the Edinburgh
practice characteristics and attitudes           this communication is eliciting parent/      scale would be appropriately inte-
related to this and the need for changes         family/child strengths and risks. Both
in attitude and practice to improve iden-                                                     grated at the 1-, 2-, 4-, and 6-month vis-
                                                 parental and provider concerns
tification and management. In their arti-                                                      its. The Current Procedural Terminol-
                                                 determine the anticipatory guidance
cle about the legal and ethical consider-                                                     ogy (CPT) code 99420 is recommended
                                                 discussion.
ations of postpartum depression                                                               for this screening, recognizing the Ed-
                                                 Screening and surveillance for risk          inburgh scale as a measure for risk in
screening at well-child visits, Chaudron
                                                 and protective factors are an integral       the infant’s environment, to be appro-
et al concluded: “We believe that from the
                                                 part of routine care and the relation-       priately billed at the infant’s visit.
perspective of feasibility, and now from
                                                 ship with the child and family. This
the legal and ethical standpoints, the                                                        The Edinburgh Postpartum Depression
                                                 communication includes discussion of
benefits of screening outweigh the                                                             Scale is a simple, 10-question screen
                                                 family support systems and other psy-
risks.”39                                                                                     that is completed by the mother. A
                                                 chosocial factors such as poverty, pa-
The primary care provider (PCP) has a                                                         score of ⱖ10 indicates risk that de-
                                                 rental mental health, and substance
particularly important role in the early                                                      pression is present. An affirmative re-
                                                 use. It begins as early as the prenatal
identification of maternal depression             visit. According to a recent AAP state-      sponse on question 10 (suicidality indi-
and facilitation of intervention to pre-         ment, a prenatal visit allows for getting    cator) also constitutes a positive
vent adverse outcomes for the infant,            to know the parent(s) and is an oppor-       screen result. The screen is in the pub-
the mother, and the family. The PCP              tunity to identify any high-risk condi-      lic domain and is freely downloadable.
may be the first clinician to see the in-         tions to anticipate special care             It is available in English and Spanish.
fant and mother after the infant is              needs.40 In this statement, the AAP also     The 2-question screen for depres-
born; therefore, the PCP has very early          recommended that pediatricians com-          sion41 is:
access. In addition, it is the PCP who           municate with obstetricians in their         Over the past 2 weeks:
has continuity with the infant and fam-          community to inform them of their pre-
ily, and by the nature of this relation-                                                      1. Have you ever felt down, depressed,
                                                 natal visit policies so that obstetri-
ship, the PCP practices with a family                                                            or hopeless?
                                                 cians might refer patients for the pre-
perspective.                                     natal visit. This would also provide an      2. Have you felt little interest or plea-
Screening for postpartum depression              opportunity for the pediatrician to be-         sure in doing things?
does not require that the PCP treat the          come aware of depression during the          One yes answer is a positive screening
mother. The infant is the PCP’s patient.         pregnancy and to plan for support and        result. This screen is suitable to indi-
However, the PCP has a role in support-          follow-up of the mother-infant relation-     cate risk of depression for adults in

PEDIATRICS Volume 126, Number 5, November 2010                                                                                      1035
general and is not specific to postpar-           When the mother needs specific               symptoms who need support, it may be
tum depression. Beyond the postpar-              follow-up for herself, there are often      enough to refer them to a parent sup-
tum period, incorporating surveillance           access issues because of uninsured          port organization.
for parental mental health is war-               or underinsured status. Community           There are research-based programs
ranted as well and might be accom-               mental health programs may also             for treatment of the dyad to promote
plished by use of this 2-question                provide limited services for these          healthy attachment and relationship.
screen.                                          mothers. Care for the mother is an          These programs include the Circle
Responses to a positive postpartum               advocacy issue for all who serve chil-      of Security, parent-child interactive
depression screening result range                dren and their families, and it is an       therapy, and child-parent psycho-
from reassurance (maternity blues)               issue for state AAP chapters to ad-         therapy.44,45 The Circle of Security is a
to supportive strategies (maternity              dress in states where access for            parent education and psychotherapy
blues, minor depression) and refer-              mothers is limited because of state         program. It is an individualized
ral for specific interventions (minor             policy and service and payment              video-based intervention based on
and major depression). In the situa-             structure.                                  attachment theory to strengthen the
tion of milder symptoms, demystifi-               If suicidality or psychosis is a concern,   parents’ ability to observe and
cation and parent education may be               or the score on the Edinburgh scale is      improve their caregiving capacity.
effective in addressing concerns. De-            greater than 20, accessing crisis inter-    Child-parent psychotherapy is a ther-
mystification lets the mother know                vention services for the mother is nec-     apeutic treatment for mothers and
that (1) she is not alone (postpartum            essary. In this instance and for other      young children to increase attach-
depression happens to many women                 mental health emergencies, the prac-        ment security.45
to varying degrees), (2) she is not to           tice should know and use the referral
                                                                                             Referral to early intervention (Part C of
blame (hormonal changes play a big               process for local public mental health
                                                                                             the Individuals With Disabilities Educa-
role), and (3) she will get better. Pro-         crisis/emergency services.
                                                                                             tion Act) services can provide general
vision of extra return visits for sup-           Treatment must address the mother-          developmental intervention (educa-
port may be all the family needs and             child dyad relationship. For the child      tion), which, if performed in the home,
can build a strong foundation for the            and mother together, there are gener-       also provides mentoring for healthy in-
ongoing relationship between physi-              ally more referral options. If the child    teraction. If the infant exhibits specific
cian and family. Given the associa-              is in an environment of maternal de-        delays, specific therapies can also be
tion with cessation of breastfeeding,            pression, he or she is at risk for          provided. (To identify lead agencies
particular promotion and encour-                 attachment issues, failure to thrive,       and contacts according to state, see
agement of breastfeeding is indi-                abuse/neglect, and, ultimately, devel-      www.nectac.org and www.nichcy.
cated. When concerns are significant              opmental delay. At the very least, close    org.)
enough to warrant referral, there                follow-up of the child in the medical
are several options and consider-                                                            For many families, referral to Early
                                                 home is warranted. Specific screening
ations. For the mother, particularly if          for social-emotional development, as        Head Start, Mother’s Morning Out pro-
the depression is more than mild, re-            well as for general development and         grams, or child care is an effective
ferral for therapy and/or medication             behavior, should be included. Pilowsky      option as well. Mothers may receive
may be needed. In some models,                   et al, in the STAR*D–Child (Sequenced       services through Healthy Families
mothers have been referred to their              Treatment Alternatives to Relieve           America, a Nurse-Family Partnership
obstetricians for follow-up; in oth-             Depression–Child) study described           (if the referral occurs prenatally),
ers, mothers have been referred to               above, recommended that children of         other evidence-based home-visiting
mental health providers or their                 depressed mothers be followed and           programs, or local volunteer organiza-
PCPs. It is important for pediatri-              assessed.42,43 The infant (with the         tions. (To locate Head Start programs,
cians to communicate with the moth-              mother) can be referred to a mental         see http://eclkc.ohs.acf.hhs.gov/hslc/
ers’ obstetricians and/or PCPs when              health clinician (with expertise for        HeadStartOffices.)
these situations arise, because the              treatment of very young children) to        Whatever the treatment and referral
obstetricians/PCPs will want to know             address the dyad relationship. (Note        options implemented, follow-up of the
about the mother’s depression and                that, depending on the family situation,    infant and mother by the PCP (to mon-
may have a better understanding of               this referral might be for the father or    itor progress and to support the fam-
the mental health system for adults.             both parents.) For women with mild          ily) is necessary.

1036   FROM THE AMERICAN ACADEMY OF PEDIATRICS
FROM THE AMERICAN ACADEMY OF PEDIATRICS

The AAP Task Force on Mental Health                the Virginia chapter of the AAP, the         Children” (January 2008) that is an
and the Committee on the Psychoso-                 state Early Periodic Screening, Diag-        excellent source for pediatricians
cial Aspects of Child and Family Health            nosis, and Treatment (EPSDT), Re-            and AAP state chapters.
have promoted collaborative, colo-                 source Mothers, and Healthy Fami-         ● Bright Futures (http://brightfutures.
cated, and integrated models for men-              lies Virginia47 and recommends               aap.org).
tal health services within primary care            adopting perinatal depression
                                                                                             ● The American College of Obstetri-
medical homes. In such settings, social            screening guidelines in the state
                                                                                                cians and Gynecologists recom-
work staff or mental health providers,             budget.
                                                                                                mends psychosocial screening of
who are colocated in the practice as             ● Parental Depression Screening for            pregnant women at least once per
part of the care team, can provide im-             Pediatric Clinicians: An Implementa-         trimester (or 3 times during pre-
mediate triage for positive screening              tion Manual, by Ardis Olson, MD              natal care) by using a simple
results, support and follow-up for                 (available on the Commonwealth               2-question screen and further
mothers, and linkage and referral for              Fund Web site at (www.cmwf.org):             screening if the preliminary
more specialized services. Colocated               In her studies, Olson has found that         screen result indicates possible
and integrated mental health provid-               a 2-question paper-based screen,             depression.49
ers can perform secondary screen-                  followed by a brief discussion with       ● The National Women’s Health Infor-
ings and collaborate with the PCP for              the mother and the pediatrician,             mation Center (www.4women.gov)
ongoing care.                                      was both feasible and effective in           is a federal government source for
Concurrent with the implementation of              identifying women who needed                 women’s health information.
screening, the practice needs to iden-             follow-ups or referrals. One of the
tify support and intervention re-                  studies examined the difference be-       SUMMARY AND CONCLUSIONS
sources, both within the practice and              tween a verbal interview and a pa-        The primary care pediatrician, by vir-
in the community. Although it is often             per form; the paper screen was            tue of having a longitudinal relation-
the case that PCPs do not perceive that            found to be far more effective.35,47,48   ship with families, has a unique oppor-
there are resources in the community,            ● Depression During and After Preg-         tunity to identify maternal depression
many public and private resources                  nancy: A Resource for Women, Their        and help prevent untoward develop-
may be discovered in the process of                Families, and Friends (www.mchb.          mental and mental health outcomes
engaging community partners. Net-                  hrsa.gov/pregnancyandbeyond/              for the infant and family. Screening
working with community providers                   depression): This Web site has infor-     can be integrated, as recommended by
may be a new activity for a primary                mation for the woman and/or her           Bright Futures and the AAP Mental
care practice. It can be accomplished              family about the definition and            Health Task Force, into the well-child
by invitation to a lunch meeting at the            symptoms of postpartum depres-            care schedule and included in the pre-
practice to discuss the planned                    sion and when to seek treatment.          natal visit. This screening has proven
screening and referral activities, or a          ● National Center for Children in Pov-      successful in practice in several initia-
larger meeting called by a group of                erty, Project Thrive (www.nccp.org):      tives and locations and is a best prac-
practices may be possible. Sending out             The Public Policy Analysis and Edu-       tice for PCPs caring for infants and
a brief inquiry or survey to local men-            cation Center for Infants and Young       their families. Intervention and refer-
tal health providers or family support             Children at the National Center for       ral are optimized by collaborative rela-
groups may yield additional contacts.              Children in Poverty has as its core       tionships with community resources
Partnering with parents in finding                  mission increasing knowledge and          and/or by colocated/integrated primary
community resources is the essence                 providing policy analysis that will       care and mental health practices.
of the medical home.                               help states build and strengthen          LEAD AUTHOR
                                                   comprehensive early childhood sys-        Marian F. Earls, MD
MODELS AND RESOURCES                               tems and link policies to ensure ac-      COMMITTEE ON PSYCHOSOCIAL
● Virginia Bright Futures has a train-             cess to high-quality health care,         ASPECTS OF CHILD AND FAMILY
  ing Web site and has developed a                 early care and learning, and family       HEALTH, 2009 –2010
  new parent kit that includes infor-              support. The National Center for          Benjamin S. Siegel, MD, Chairperson
  mation on perinatal depression and               Children in Poverty has a document        Mary I. Dobbins, MD
                                                                                             Marian F. Earls, MD
  is given to 70% of new parents. Vir-             entitled “Reducing Maternal De-           Andrew S. Garner, MD
  ginia Bright Futures partnered with              pression and Its Impact on Young          Laura McGuinn, MD

PEDIATRICS Volume 126, Number 5, November 2010                                                                                     1037
John Pascoe, MD                                     Mary Jo Kupst, PhD – Society of Pediatric              CONSULTANT
David L. Wood, MD                                      Psychology                                          George J. Cohen, MD
                                                    D. Richard Martini, MD – American Academy of
LIAISONS                                               Child and Adolescent Psychiatry                     STAFF
Robert T. Brown, PhD – Society of Pediatric         Mary Sheppard, MS, RN, PNP, BC – National              Karen S. Smith
  Psychology                                           Association of Pediatric Nurse Practitioners        ksmith@aap.org

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1038     FROM THE AMERICAN ACADEMY OF PEDIATRICS
FROM THE AMERICAN ACADEMY OF PEDIATRICS

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