Reducing Maternal Depression and Its Impact on Young Children - Toward a Responsive Early Childhood Policy Framework
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Project Thrive
Issue Brief No. 2
Reducing Maternal Depression
and Its Impact on Young Children
Toward a Responsive Early Childhood Policy Framework
Jane Knitzer n Suzanne Theberge n Kay Johnson
January 2008The National Center for Children in Poverty (NCCP) is the nation’s leading public policy center dedicated to promoting the economic security, health, and well-being of America’s low-income families and children. Founded in 1989 as a division of the Mailman School of Public Health at Columbia University, NCCP is a nonpartisan, public interest research organization. Reducing Maternal Depression and Its Impact on Young Children: Toward a Responsive Early Childhood Policy Framework by Jane Knitzer, Suzanne Theberge, and Kay Johnson This issue brief reflects NCCP’s continuing commitment to ensuring that every low-income child enters school with the skills to succeed, and that policymakers have access to the very best research to create policies that use public resources in the most effective, smartest way. It is based on a meeting convened through NCCP’s Project THRIVE to identify and promote solutions to emerging issues that impact young children’s healthy development and school readiness. The brief is being jointly published by Project THRIVE, through which NCCP serves as a resource to the Maternal and Child Health Bureau-funded State Early Childhood Comprehensive Systems (ECCS) systems program and Pathways to Early School Success, NCCP’s on-going project to help policymakers, program administrators and practitioners ad- dress barriers that get in the way of reducing the achievement gap for young low-income children. Authors Jane Knitzer, EdD, is the director at NCCP and Clinical Professor of Population and Family Health at Columbia University’s Mailman School of Public Health. She has contributed many important studies on how public policies can promote the healthy development of low-income children and better support families, particularly those who are most vulnerable. Kay Johnson, MPH, MEd, is a consultant to NCCP and director of Project THRIVE, which links policies for child health, early learning, and family support. She has broad expertise in many areas of maternal and child health and has led numerous studies of maternal and child health and early childhood policy, finance, and infrastructure issues. Suzanne Theberge, MPH, is the research analyst for Project THRIVE. Acknowledgments NCCP is deeply grateful to the participants at the NCCP meeting who shared insights, challenges and ideas so willingly (See Appendix), to our other key informants who shared their programs and experience with us, to Janice Cooper for her comments, and to Mareasa Isaacs whose analysis, Community Care Networks for Low-Income Communities and Communities of Color, guided and inspired this work. We are also especially grateful to Phyllis Stubbs-Wynn, who oversees our Project THRIVE work through the Maternal and Child Health Bureau. Copyright © 2008 by the National Center for Children in Poverty
Project Thrive Issue Brief 2
Reducing Maternal Depression and Its Impact on Young Children:
Toward a Responsive Early Childhood Policy Framework
Jane Knitzer n Suzanne Theberge n Kay Johnson l January 2008
“Dollars invested in moms are dollars that really pay off.”
– Dr. Frank Putnam, Professor of Pediatrics and Psychiatry,
University of Cincinnati. 20061
Introduction Framing the Challenge
Maternal depression is a significant risk factor affecting Depression is increasingly recognized as major world-
the well-being and school readiness of young children. wide public health issue. It has a negative impact on
Low-income mothers of young children experience par- all aspects of an individual’s life – work and family
ticularly high levels of depression, often in combination – and can even lead to suicide. Typically, depression
with other risk factors. This policy brief provides an is discussed as an adult problem affecting women or
overview of why it is so important to address maternal men, and increasingly, it is recognized as a significant
depression as a central part of the effort to ensure that problem for children.2 But far too rarely is depression,
ALL young children enter school ready to succeed. It particularly maternal depression, considered through a
highlights: lens that focuses on how it affects parenting and child
n what research says about the impact of maternal de- outcomes, particularly for young children; how often
pression on young children, particularly infants and it occurs in combination with other parental risks, like
toddlers, and how prevalent maternal depression is; post-traumatic stress disorder; and what kinds of strate-
gies can prevent negative consequences for parents, for
n examples of community and programmatic strategies their parenting and for their young children.
to reduce maternal depression and prevent negative
cognitive, social emotional and behavioral impacts
on young children; Defining Depression through a Parenting Lens
n key barriers to focusing more attention to maternal In the context of parenting, depression can be defined
depression in policies to promote healthy early child as:
development and school readiness; n a combination of symptoms that interfere with the
n state efforts to address policy barriers and craft more ability to work, sleep, eat, enjoy and parent (italics
ours) and that affects all aspects of work and family
appropriate policy responses; and
life;
n recommendations for national, state and local poli- n an illness that frequently starts early in life, that may
cymakers. have a biological component and that produces sub-
stantial disability in functioning (whether it is defined
as Major Depressive Disorder or depressive symptoms);3
n a common but invisible pathway to a cluster of adver-
sities for adults who are parents, and their children,
particularly mothers and their young children;
n a condition that responds to prevention and treatment.4
National Center for Children in Poverty Reducing Maternal Depression and Its Impact on Young Children 1“If Mama ain’t happy, no one is happy.”
– Participant in a focus group for low-income women of color.
Dr. Mareasa Isaacs, Executive Director, NAMBHA. 20045
1) Maternal depression is widespread, particularly but the exact nature of the interaction is unclear. Afri-
among low-income women with young children. can American women have very high rates of depres-
sion; rates among Latino women vary from high to very
Maternal depression is widespread across class and race, low, although rates in Latina adolescents are uniformly
and has been linked to genetic composition, situational high.14 But research also suggests that poverty is a more
risk factors and circumstances, and environmental gene powerful predictor. For poor women, rates of depres-
interaction.6 Disproportionately, it impacts low-income sion are high regardless of ethnicity. One study showed
parents, whose depression is embedded in their life equal rates of depression among African American and
circumstances, poverty, lack of social supports and European American low-income women, and a study of
networks, substance abuse, intimate partner violence, TANF recipients did not find a difference in prevalence
childhood abuse, and stress linked to a life of hardship, between ethnic groups.15 In effect, poverty trumps race
and too often, no hope. (See box.) Research has shown as a factor in maternal depression.16
correlations between race and ethnicity and depression,
2) Maternal depression, alone, or in combination
with other risks can pose serious, but typically un-
Prevalence Data on Maternal Depression recognized barriers to healthy early development
and school readiness, particularly for low-income
n Approximately 12 percent of all women experience
depression in a given year.7
young children.
n For low-income women, the estimated prevalence
doubles to at least 25 percent.8
Maternal depression threatens two core parental func-
tions: fostering healthy relationships and carrying out
• Estimated rates of depression among pregnant and
postpartum and parenting women in general range the management functions of parenting. The result,
from 5 to 25 percent.9 long tracked in child development research, has been
• Low-income mothers of young children, pregnant linked to demonstrable reductions in young children’s
and parenting teens report depressive symptoms in behavioral, cognitive, and social and emotional func-
the 40 to 60 percent range. tioning. The impact of depression varies by its timing
– Over half the mothers (52%) in a study of 17 (maternal depression during infancy has a bigger impact
Early Head Start programs reported depressive on a child’s development than later exposure), its sever-
symptoms.10
ity, and the length of time it persists.17
– Another study found that an average of 40 per-
cent of young mothers at community pediatric
health centers screened positive for depressive Negative effects can start before birth
symptoms (site specific rates ranged from 33% The negative effects of maternal depression on children’s
to 59%).11 health and development can start during pregnancy.18
– Studies of women participating in state welfare- While the biological mechanisms are not clearly under-
to-work programs indicate that depression and stood, research on untreated prenatal depression finds
elevated levels of depressive symptoms range
from 35-58 percent.12
links to poor birth outcomes, including low birth-
weight, prematurity, and obstetric complications.19 The
NOTE: Some studies report clinical depression rates, while others report depressive
symptoms. Some researchers believe that multiple depressive symptoms can be the
biological effects can continue; research has found that
functional equivalent of major depressive disorder as they produce similar functional
pain and impairments.13
maternal depression in infancy predicts a child’s likeli-
hood of increased cortisol levels at preschool age, which
2 Reducing Maternal Depression and Its Impact on Young Children National Center for Children in PovertyIf those treating domestic violence don’t screen for depression and
those treating for depression don’t recognize post-traumatic stress disorder
or social anxiety or if neither recognizes the impact on children,
effective services and important resources are minimized.
– Dr. Mareasa Isaacs, Executive Director, NAMBHA. 200420
in turn has been linked with internalizing problems preventive practices for their children. For example,
such as anxiety, social wariness and withdrawal.21 depressed parents are also less likely to follow preventive
health advice and may have difficulty managing chronic
Maternal depression can impair critical early health conditions such as asthma or disabilities in their
relationships young children.28
Recent neuroscience is clear that the primary ingredi-
ent for healthy early brain development is the quality of The cumulative impact of depression in combina-
the earliest relationships from a baby’s primary caregiver tion with other parental risks to healthy parenting
(which can be either parent, of course, but most often is even greater.
is the mother, especially for low-income children). Depression in women often co-exists with other
Maternal depression can interfere with the early bond- “parental adversities” and life stressors, particularly
ing and attachment process between mother and baby. in low-income communities. These factors include,
Maternal depression has also been linked with nega- along with the hardships associated with not having
tive relationships in early childhood, and with reduced enough money, substance abuse, domestic violence,
language ability, which is key to early school success.22 and prior trauma. A recent analysis of a birth cohort
Three year old children whose mothers were depressed from 1998-2000 that followed children from infancy
in their infancy perform more poorly on cognitive and up to age 3 years in 18 cities provides important data.
behavioral tasks.23 Mothers who are depressed lack the On the positive side, half of the mothers in the sample
energy to carry out consistent routines, to read to their had no risks. But of the half who did, one-third of
children, or simply, most importantly, to have fun with those had more than one risk,* and as the number of
them, singing, playing, and cuddling them.24 Children risks increased, so too did the likelihood of behavioral
of mothers with major depression are known to be at problems related to aggression, anxiety and depression
risk for behavior problems, and are also at high risk for and inattention and hyperactivity in the children.29 At
depression or other mood disorders in later childhood age three, of young children of parents who experienced
and adolescence.25 no risk factors, 7 percent were aggressive, 9 percent
anxious and depressed, and 7 percent hyperactive. The
Maternal depression can impair parental safety comparable figures for young children whose moms ex-
and health management perienced three risk factors were 19 percent, 27 percent
The impact of depression in mothers has also been and 19 percent. The study also found that maternal
linked with health and safety concerns. Depressed depression and anxiety is associated with a stronger risk
mothers are less likely to breastfeed, and when they do of child behavior problems than four other risks tracked
breastfeed, they do so for shorter periods of time than (smoking, binge drinking, emotional domestic violence
non-depressed mothers.26 Mothers who are depressed and physical domestic violence).30
are less likely to follow the back-to-sleep guidelines
for prevention of SIDS or to engage in age appropri-
ate safety practices, such as car seats and socket cov-
ers.27 Depression also affects the health services use and
__________
* Risks measured included major depressive episode (14%); generalized anxiety disorder (3.6%); smoking (28%); binge drinking or illicit drug
use (5%); emotional domestic violence (21%); and physical domestic violence (9%).
National Center for Children in Poverty Reducing Maternal Depression and Its Impact on Young Children 33) Depression in other caregivers can also impact
Depression in child care providers exacerbates problems
the early development of young children. in early childhood programs and is related to the high
levels of expulsion from child care.
Fathers
n Research shows that caregivers in low-income and
Overall, depression in fathers is estimated at 6 percent,31
non-subsidized care centers were more likely to suffer
with community sample prevalence rates ranging from from depression than the average female U.S. popula-
1.2 to 25 percent.32 Eighteen percent of fathers in Early tion.38
Head Start report depressive symptoms.33 In the 18-city n Child care center directors and caregivers with depres-
study highlighted above, fathers had lower rates of sion symptoms were more likely to leave the profes-
major depression and anxiety disorder, but higher rates sion than those without depression, leading to a less
experienced workforce, compounding the problem.39
of substance abuse (including smoking, binge drinking
and illicit drug use). In families where both parents are n A study of 1,217 non-familial caregivers found care-
givers who were depressed were less sensitive, more
depressed, the effects on children are compounded. It
withdrawn, and interacted less frequently with the
is also noteworthy that some studies show that depres- children than those who were not depressed, particu-
sion in fathers is strongly related to maternal depression: larly for caregivers in family child-care settings and
rates of paternal depression are higher when mothers caregivers with less education.40
suffer from post partum depression, ranging from 24 n In a study of young children being expelled from child
to 50 percent.34 Further, non-depressed fathers offer a care centers, depressed caregivers were more likely to
protective effect on children of depressed mothers.35 expel children than non-depressed caregivers.41
Grandparents
4) Much is known about how to treat depression
While there is little research on depression in grandpar-
in women but too often women, especially low-
ents raising children, even the scant data that we have
suggest that as states expand strategies to address ma-
income women, do not get appropriate help.
ternal depression, they should take a family and indeed
Depression is in general, a highly treatable disease. It
intergenerational perspective. Over a quarter of Head
is responsive to combinations of traditional cognitive
Start grandparents who are primary caregivers were
and interpersonal treatment strategies, to medication,
mildly depressed (26.8%) and another quarter were ei-
and to creating peer-to-peer support groups.42 Studies
ther moderately depressed (9.8%) or severely depressed
examining the efficacy of standardized treatment for
(17.2%); in effect, half of the sample.36 Thus these
low-income populations, particularly with respect to the
rates are comparable to those of mothers. A study by
use of cognitive-behavioral therapies suggest that core
Chapin Hall Center for Children of grandparents who
treatment strategies need to be adapted, for example,
are the full-time caregivers of their grandchildren found
with more emphasis on engagement strategies, or using
that over a third (36.8%) scored above the CES-D (a
phone, rather than face-to-face interventions.43 But even
depression screening tool) cutoff for depression, and an
with adaptations, there is another limitation of tradi-
additional group reported occasional or past depression.
tional treatment for parents.
The higher CES-D scores were significantly associated
to parental incarceration; grandchildren with emotional
Most interventions for depression address only the
behavior issues; and grandparents’ perceptions of their
adult; they do not address the adult as a parent, and
own physical health and well-being.37
they do not actively include strategies to prevent or
repair damage to the early parent-child relationship,
Other caregivers
which, as we know from early brain science, is critical to
Not surprisingly, since many who provide child care
healthy early development.44 Further, there is very little
and work in early learning programs are themselves
research that tests the efficacy of strategies that address
low-income women, emerging research also highlights
maternal depression in low-income women with mul-
the impact of depression on other caregivers and on the
tiple risks. In fact, women with multiple risks are often
child care system in general. (See box.)
excluded from research. But even when treatment strat-
egies are linguistically and culturally appropriate and
4 Reducing Maternal Depression and Its Impact on Young Children National Center for Children in Poverty“The gap between the availability of good treatment for parents and the
utilization of treatment is enormous—what we tolerate for depression,
we would not tolerate for diabetes.”
– Dr. William Beardslee, Academic Chair, Department of Psychiatry,
Children's Hospital Boston. 200645
research-informed, often there are too few appropriately
Parental Access to Mental Health Services through
trained providers, particularly providers of color.46 Medicaid49
Even more significant is that many low-income women States make choices about parental eligibility levels for
lack access to health insurance in general, or mental access to Medicaid/SCHIP, which means they can, in
theory, have access to mental health services.
health insurance in particular, creating an additional
set of hurdles for them. Medicaid does allow the states For pregnant woman,
to cover parents of eligible children, but in most states, n 16 states set eligibility levels at 200 percent or more
eligibility levels are very low. (See box.) of the federal poverty level ($20,650 for a family of
four in 2007), the remainder, between 133 percent
Focus groups with low-income women from multiple and 200 percent of the poverty level.
ethnic groups also make it clear that often the women
For working parents,
are reluctant to seek treatment because of how they per-
n 5 states set eligibility levels at 200 percent of the
ceive depression, and what acknowledging the need for
federal poverty level; 14 states set eligibility levels at
treatment might mean for them and their family.47 less than 50 percent of the federal poverty level.
n 35 states set eligibility at or below 100 percent of the
For example, many women think how they feel is just poverty level; 14 of them at or below 50 percent of
“the way it is;” that depression comes with the reality the poverty level.
of their life situations. Secondly, they are very leery of
the stigma involved in admitting they have a prob- For nonworking parents,
lem. There is great distrust of mental health agencies, n 35 states set eligibility levels at less than 100 percent
of the federal poverty level; 30 of them at 50 percent
including community mental health centers. And, most
or less than the poverty level.
important of all, women are fearful of what admitting
to depression will mean for their children. Many are Note: See also 50 state profiles of early childhood policies: .
reluctant to take medications because they fear what the
side effects will do to their parenting (such as not being
able to get their children ready for school). Others fear
that if they are not seen as good parents, child welfare
will come and take their children away. On the other
hand, researchers have successfully adapted traditional
treatments to be more responsive to women by address-
ing trauma, using outreach and strengthening the focus
on educational and support approaches.48
National Center for Children in Poverty Reducing Maternal Depression and Its Impact on Young Children 5Themes from Focus Groups with Low-Income Women50 What Can Help Parents With or
At Risk of Depression and Their
Many low-income women and women of color have
Young Children?
n
difficulty recognizing depression, because they see
symptoms as naturally occurring events that are part
of every-day life. Parental depression can pose a serious risk to young
n Uniformly, women value their children; recognize the children, but it is not a sentence either for a mom or
impact of depression on them; and are fearful of los- for her young children. Promoting early identification
ing their children, or have already experienced loss and screening and, for low-income women, adapting
through immigration, child welfare etc.
and making traditional treatments more accessible will
n Most women need and crave support for their mother- help. Both research and reports from the field suggest
ing role, and value greatly support from others when
they get it.
that educating parents about the effects of their depres-
sion on their children may also encourage mothers to
n Trusting relationships with providers who understand
their daily life and cultural realities is key to women seek treatment. Some practitioners have found that
following through on treatment. presenting maternal depression treatment as a “gift for
n Concerns about the use of medications as the treat- your child” to be highly effective to mothers who may
ment of choice in primary health care and mental otherwise be resistant to treatment.55 Other important
health settings are a deterrent to treatment. strategies are also emerging that center around offering
Note: Isaacs based this analysis on data from three separate sets of focus groups of
family-focused services in settings that parents trust,
low-income women of color. such as doctors’ offices or early childhood programs.
A family approach to treatment for all women with
young children, but particularly for low-income wom-
Low-income Women, Access to and Use of Traditional
en, in settings that they trust represents an opportunity
Treatment
for interventions that can help both young children and
n Estimates are that 80 percent of all who receive treat- their parents.56 It is, in other words a “two-fer.” Treat-
ment for depression are helped. Estimates about what ment for the mom becomes prevention or early inter-
percentage of those who need help get it range from a vention for the child (and for the parent-child relation-
high of 57 percent to a low of 20 percent, not control-
ship). Early childhood programs can also provide such
ling for income.51
supportive experiences for parents that they may also
n Low-income women and women of color consistently
have less access to, or are less likely to seek treat-
prevent depression or reduce the need for more formal
ment. treatment in some families.
– A study of women receiving public assistance found
43 to 50 percent of TANF recipients had experi- Below we highlight examples of emerging efforts across
enced depression for more than short periods of the country to address depression in the context of par-
time in the last year,* yet only 11 to 13 percent enting young children. In general, these efforts involve
were receiving treatment for depression.52
three types of strategies:
– A study comparing access to treatment among
white women, African American women, and Latino n screening and follow-up for women, typically in
women found that of those who reported moderate ob/gyn or pediatric practices;
to severe depressive symptoms, 58 percent of the
white women reported a mental health visit, com- n targeted interventions to reduce maternal depression
pared to 36 percent of African American women and improve early parenting in early childhood pro-
and 11 percent of Latino women.53 grams such as home-visiting and Early Head Start
– Low income women are also more likely to be given Programs; and
older medications than non-poor women.54
__________
n promoting awareness about the impact of maternal
* When broken down by age, rates were highest among the 40+ age group, with depression and what to do about it for the general
57 to 60 percent reporting depression in the last year, and rates were lowest in the
18-24 age group, with 35 to 38 percent reporting depression in the last year. Rates public, low-income communities, and early child-
vary by state, but range within about four percentage points.
hood and health practitioners.
6 Reducing Maternal Depression and Its Impact on Young Children National Center for Children in Poverty“A focus on maternal depression as a “family” intervention can support
strengthening families, attachment to work and employment, and
greater assurance that young children will enter school ready to learn.”
– Dr. Mareasa Isaacs, Executive Director, NAMBHA57
Screening and Follow-up Tools for Screening
Early detection leading to treatment can be important n The most common validated screening tools used to
in reducing the impact of depression on women and detect maternal depression are the Edinburgh Postnatal
Depression Scale (EPDS), the Postpartum Depression
young children. One strategy that states and communi-
Screen (PPDS), the Beck Depression Inventory-II
ties are implementing is to identify, through the use of (BDI-II), and the Center for Epidemiological Studies-
standardized screening instruments, women who are Depression Scale (CES-D). All are more sensitive to
experiencing depression who are pregnant or parenting identifying major depressive disorder, but can accu-
young children. Screening is being done in a variety of rately identify minor depressive disorders as well.60*
settings including pediatricians’ offices, women’s health n ACOG recommends a simple two question screen for
clinics, and obstetrics/gynecology practices. When the all pregnant women (1. Over the past two weeks, have
you ever felt down, depressed, or hopeless? 2. Over
screening is implemented in pediatric practices, it is the past two weeks, have you felt little interest or plea-
often part of a child-focused effort to increase develop- sure in doing things?), with further screening for those
mental screening. women whose answers indicate possible depression.61
n Studies found that a two-question paper-based
The American College of Obstetricians and Gynecolo- screen, followed by a brief discussion with the mother
gists (ACOG) recommends psychosocial screening of by a pediatrician, was both feasible and effective in
identifying women who needed follow-ups or referrals.
pregnant women at least once per trimester (or three
One of the studies examined the difference between
times during prenatal care), using a simple two question a verbal interview and a paper form, and the paper
screen and further screening if the preliminary screen screen was found to be far more effective.62
indicates possible depression.58 Others support the use __________
* Some research suggests that due to typical changes in normal pregnancy and
of standardized, validated tools. But there is research postpartum recovery, general depression screening tools may show high rates of false
showing that even asking parents questions about how positives, indicating that postpartum-specific depression screening tools may be
more effective. (Holden, Jeni; Cox, John. 2003. Perinatal Mental Health: A Guide to
they are feeling and what they are facing makes it pos- the Edinburgh Postnatal Depression Scale (EPDS). London: RCPsych Publications.)
sible to discuss otherwise seemingly off-limits issues.
Although there has been concern that families would
find screening intrusive, some evidence suggests that Screening for Maternal Depression in Action
most seem to welcome it.59
n In North Carolina, a project funded by The Com-
Experience also suggests that screening should be readily monwealth Fund supported through its ABCD I
available in settings where mothers are, should be easy project (described below) piloted a project to increase
for both the provider and the client, and should involve formal developmental screening and surveillance for
building the infrastructure to support follow-up. The Medicaid-eligible children receiving Early Periodic
screeners must be trained, and a referral/follow-up sys- Screening, Diagnosis, and Treatment (EPSDT)
tem should be in place before screening is implemented services in pediatric and family practices. Beginning
so that those doing the screening know how to respond in one county in 2000, the project assisted pediatric
and where they can turn if a problem is identified. practices in implementing an efficient, practical pro-
cess for young children for screening, promoted early
identification and referral, and facilitated the prac-
tice’s ability to link to early intervention and other
National Center for Children in Poverty Reducing Maternal Depression and Its Impact on Young Children 7community services. Once the approach took hold, health workers have begun screening newly regis-
the designers began to embed maternal screening tered clients at all eight sites for perinatal depression
into the project. The approach is now used statewide using EPDS, totaling about 1,500 women each year
in North Carolina and has spurred similar initiatives (previously, clients at some of the eight programs
elsewhere.63 It has also been the catalyst for a state- were screened). The overall program has served over
wide policy change in North Carolina’s Medicaid 50,000 families since its founding in 1989.65
program that is discussed below.
n In Chicago, spurred by the deaths of several women Targeted Interventions in Early Childhood
who were suffering from maternal depression, the Programs to Address Depression*
UIC Perinatal Mental Health Project was founded
to enhance the health care system's early recognition A potentially powerful, but still underutilized strategy
and treatment of perinatal depression. The project is to embed explicit interventions designed to prevent,
has trained over 3,000 providers in specific tools to or reduce depression and its harmful impacts on young
aid screening assessment and treatment. Technical children into early childhood programs, especially
assistance on implementation of these procedures is home-visiting and Early Head Start programs. In these
available for clinics and providers. A key component programs addressing maternal depression is an invest-
of the intervention is telephone-based consulta- ment in improved outcomes for the children. Typically,
tion for the primary care providers to ensure they the interventions involve a focus on improved parent-
have access to additional information and guidance child relationships and parenting practices. But it is
when necessary. In addition, a medications chart was important to underscore that family-focused interven-
developed and widely disseminated to assist primary tions are not mental health as usual, where the adult
care providers in treating perinatal depression. This is treated, and sometimes the child is either treated or
work is funded in part by a HRSA-MCHB Perinatal screened, but they are not treated together.
Depression Grant. With support from the Michael
Reese Health Trust and Healthcare and Family Home-visiting programs, whether they are stand-alone,
Services, UIC is also working on two alternative or a component of Early Head Start or through feder-
approaches to treatment of perinatal depression for ally funded Healthy Start programs, are available in
HFS-enrolled providers and women. A “stepped many communities across this country and represent an
care” model provides training and tools to primary important, but underutilized opportunity to prevent and
care providers to assess, treat and refer women address maternal depression and its consequences for
with perinatal depression. A self-care tool provides young children.
women with suggestions for dealing with cognitive
behavioral issues and help them emerge from perina- Research on Early Head Start, which is a nationwide,
tal depression.64 comprehensive family support and child development
program that seeks to enhance all aspects of develop-
n The MOMobile program, based in eight sites in
ment for infants and toddlers at the poverty level, has
southeastern Pennsylvania, under the auspices of the
paid special attention to maternal depression. An initial
Maternity Care Coalition, sends community health
study found that depressed parents participating in Ear-
workers around neighborhoods to support pregnant
ly Head Start were more likely than the control group
women, new parents, and families with infants.
to improve their parenting practices and have children
The advocates link families with services and sup-
who were less aggressive or negative when interacting
ports, provide parenting education, provide service
with peers; had more positive parent-child interactions;
referrals, and distribute baby supplies and food in
were less likely to receive harsh discipline strategies; and
emergency situations. Through a Pew Charitable
overall, were more engaged and attentive.66 The follow-
Trusts grant, MCC’s social workers and community
up study, two years after the program, shows fewer
__________
* There are also powerful individual therapeutic strategies that engage parents and children. The dyadic therapy model teaches a mother how to read,
interpret, and respond to her infant’s cues, and assists the mother in dealing with her emotions and needs related to motherhood. The model improves
attachment, increases both maternal and child sensitivity, and reduces incidence of abuse and neglect, and is effective even when the mother is de-
pressed. (Parent-Child Mental Health Interventions, Zero to Three Fact Sheet. Zero to Three, National Center for Infants, Toddlers, and Families.)
8 Reducing Maternal Depression and Its Impact on Young Children National Center for Children in Povertydepression symptoms among women who participated that embeds cognitive behavioral therapy into three
in Early Head Start than in the control group.69 A different home visiting models. Pilot results show
combination of child factors such as improved cogni- that the two-generational approach resulted in
tion, vocabulary at ages two and three; and improved significant decreases in parental depression and im-
child engagement at age three; and family factors, such proved language and cognitive functioning in infants
as improved parenting skills, reduced parenting distress, and toddlers.72 ECS therapists provide an adapted
seems to account for the reduction in depression.68 form of cognitive behavior therapy to mothers in
their homes, working to treat depression and prevent
Augmenting Early Childhood Programs69 relapses, as well as maximize the effectiveness of the
home visiting program. The program’s success rates
n Family Connections in Head Start: Taking are comparative to antidepressants or typical cogni-
Prevention Seriously tive behavior therapy.73 The early results show that
In Boston, the Family Connections project is a of the 29 percent of mothers who enter ECS with
strength-based prevention model that is being imple- clinically significant levels of depression, half are no
mented across six Head Start and Early Head Start longer depressed after nine months in the program.74
sites. The core elements of the program are to: A randomized control trial is now in progress that
will also track child outcomes.
– build competence and resilience in HS/EHS staff
in order to strengthen staff ’s ability to engage Every Child Succeeds is a collaborative regional
around issues of depression and adversity; program that has three founding partners: Cincin-
nati Children’s Hospital Medical Center, Cincinnati-
– provide hope, to enhance parent engagement and
Hamilton County Community Action Agency/Head
parenting skills;
Start, and the United Way of Greater Cincinnati.
– strengthen meaningful teacher-child interactions Funding comes from a public-private partnership
related to emotional expression and adversity; and that includes Medicaid, state and county funding,
– better identify and plan for needed services for United Way of Greater Cincinnati agencies, corpo-
children and families in emotional distress. rate and individual sponsorships.
Family Connections (which is part of a major pre-
ventive intervention study) is based on lessons from Two other strategies reflecting practice and experiential
several intervention models including an empirically wisdom should also be noted: peer-to-peer support/
tested family-focused intervention developed for to recovery groups for depressed women in low-income
help older, middle class children and parents cope communities, and expanding access to mental health
with depression.70 consultants in both early childhood programs (includ-
ing home-visiting programs) and health care settings,
Reports by Head Start parents, teachers, and director such as pediatric practices.
showed that it is feasible to deliver training sessions
linked to consultation and to develop and sustain par- Peer-to-peer support groups, frequently called Sister
ent and teacher activities. Most strikingly, staff turn- Circles, have been shown to reduce depression in black
over and sick days decreased markedly in more than and Latino women.75 The groups provide support and
one center in response to the program. Staff also report social networks, and they may particularly appeal to
increase in skills. Positive change in teacher attitudes women who fear the stigma of traditional mental health
and practices relating to mental health and related services.76 Most groups do not focus on young children;
adversities were evident in all centers. Findings varied however, we did identify one program that focuses on
by center, based on site organization and readiness.71 parents with infants and toddlers.
n Every Child Succeeds (Cincinnati): Addressing n In New York City, the Caribbean Women’s Health
Depression Directly Association organizes the Community Mom’s Pro-
Recognizing that the challenges of helping depressed gram, a program for immigrant women who are
moms cuts across different home-visiting models, pregnant and parenting children, birth to age two.
Every Child Succeeds has developed and approach The program provides health education workshops,
National Center for Children in Poverty Reducing Maternal Depression and Its Impact on Young Children 9Policymakers should focus serious attention on maternal depression
as part of the larger efforts across the country to improve healthy
developmental and school-readiness outcomes in young children.
support services, home visiting, and screening and the home visiting program strengthened the team
referrals for maternal depression.77 Active, older com- approach of the Nurse-Family Partnership, increased
munity members were recruited to provide direct ser- the skills of both the nurses and the clinicians to deal
vices, such as home visiting and community engage- with maternal and infant mental health issues, and
ment. The Health Workers build strong connections allowed the consultants to reach a greater number of
with mothers to both build social support networks families than would otherwise be possible.79
and to provide education about maternal depression
at the one-on-one and community level. Because These “on-the-ground” examples suggest that core com-
the Health Workers come from the communities ponents of successful efforts to address maternal and
in which they work, they are uniquely equipped to other risks in early childhood settings:
understand the roles of racism, cultural gender roles, n link services and supports for parents and children,
and stress of the daily lives of the women.78 through formal and informal strategies;
Linking mental health consultants to home-visiting n provide training and support to home visitors, teach-
programs is another approach to strengthening the ca- ers and child care providers to help families and to
pacity to respond to families with depression and other get support for their own depression;
risks. The consultants’ role is to help the home-visitors n help parents address specific parenting challenges
identify and respond effectively to relationship based related to depression and other adversities;
problems, including depression, to help home-visitors n ensure that children in higher-risk families have ac-
decide if referrals are needed and in some programs, to cess to high-quality child development programs like
work directly with the family alongside the home-visi- Early Head Start to reinforce social and emotional
tor. Below is an example of embedding a mental health skills and early learning opportunities; and
consultant in the Nurse Family Partnership Program.
n provide clinical treatment when it is needed in set-
n Louisiana Nurse-Family Partnership Program: tings families trust.
Adding Mental Health Consultants
The Louisiana Nurse-Family Partnership Program
augmented the standard nurse intervention with
extra training and with mental health profession-
als in order to deal with the increased infant and
maternal mental health risks they knew to be pres-
ent in the Louisiana population, including maternal
depression. In a preliminary trial, the nurses and the
mental health consultants received intensive training
in infant mental health issues and child development
and then worked together in an extremely high-risk
population, with one consultant per site nursing team
(typically eight nurses and one nurse supervisor for
160 families). While the study was small, it indicated
that incorporating mental health consultants into
10 Reducing Maternal Depression and Its Impact on Young Children National Center for Children in PovertyBuilding the Policy Framework highlight policy activities related to, or including mater-
nal depression in two states.
State Efforts n North Carolina, the North Carolina ABCD I ini-
tiative. The North Carolina effort to promote paren-
The lesson from research is clear: adult depression is tal screening for depression is part of a larger effort
not only bad for adults, it is bad for children, especially to promote and pay for developmental screening for
young children. Yet crafting a coherent policy response all young children. After the project to test strategies
beyond demonstration programs is very difficult. A to increase screening in pediatric offices was success-
basic issue is that most low-income women, as noted fully replicated in nine counties (see earlier descrip-
above, lack access to health insurance, of if they have tion), it was expanded to cover the state, backed by
it, coverage for mental health. Policy mechanisms to formal changes in the state Medicaid policy in 2004.
pay for screening and follow-up are limited. Even more The policy requires that practices to use a formal,
challenging is sustaining family-focused interventions in standardized developmental screening tool at 6, 12,
the context of early childhood programs such as home- 18, or 24 months and 3, 4, and 5 years of age, and
visiting and Early Head Start. In fact, most of the initia- as of 2006, more than 70 percent of children were
tives highlighted above are either foundation funded, or being screened at well-child visits, compared to an
time-limited research and demonstration programs. Few average of only 15.3 percent prior to implementa-
states have the capacity, nor are there federal incentives, tion.81 Parents are screened for depression by their
to take research-informed practices to scale. At the same children’s primary care providers. North Carolina
time, states are trying to respond. has also provided for parental access to treatment.
They have expanded coverage to reimburse for up to
Using ABCD as a Catalyst 26 mental health visits for covered children. Parents
can be seen under their child’s Medicaid benefits for
The major strategy that is emerging across the country, the first six visits, and providers can include PCPs,
largely as the result of an on-going project developed LCSWs, and psychologists. The project has worked
by the Commonwealth Fund’s Assuring Better Child to co-locate mental health providers within primary
Health and Development (ABCD) program, is screen- care practices, which both makes it easier for fami-
ing for maternal depression, either in context of pedi- lies to access care and reduces stigma by delivering
atric practice or prenatal care. The ABCD program, services within locations and communities where
administered by the National Academy for State Health parents are already comfortable.82
Policy (NASHP) is designed to assist states in improv- n Great Start Minnesota, the Minnesota ABCD II ini-
ing the delivery of early child development services tiative, integrates mental health screening into pedi-
for low-income children and their families. The first atric care. The clinic systems co-locate mental health
ABCD consortium (ABCD I) was created in 2000 and professionals into pediatric clinics. While the focus is
provided grants to four states (NC, UT, VT, WA) to on children’s mental health, parents are screened for
develop or expand service delivery and financing strate- mental health issues during the prenatal and perinatal
gies aimed at enhancing healthy child development for periods, and for postpartum depression. In addition,
low-income children and their families. the project assisted with passing the 2005 Postpartum
Depression Education legislation in 2005, which
The ABCD II Initiative, launched in 2003, is designed requires physicians, traditional midwives, and other
to assist states in building the capacity of Medicaid licensed health care professionals providing prenatal
programs to deliver care that supports children’s healthy care to have information about postpartum depres-
mental development. The initiative is funding work sion (PPD) available, and hospitals to hand out writ-
in five states (CA, IL, IA, MN, UT).80 An additional ten information about postpartum depression to new
20 states currently receive support through the ABCD parents as they leave the hospital after birth.83 The
Screening Academy. Some of the ABCD II sites have legislation also requires the Minnesota Department
integrated maternal depression screening and pediatric of Health to work with a broad array of health care
social-emotional screening into primary care. Below we providers, consumers, mental health advocates, and
National Center for Children in Poverty Reducing Maternal Depression and Its Impact on Young Children 11families to develop materials and information about
Speak Up When You’re Down in Washington State
postpartum depression.
Washington State funds a public awareness campaign to
The efforts just described generally involve multiple educate women and their families about the symptoms
stakeholders coming together to figure out how to and treatment of postpartum depression. The Speak Up
When You’re Down campaign, first developed by New
use existing resources in ways that will maximize their
Jersey, is led by the Washington Council for Prevention
impact for mothers with depression and their young of Child Abuse and Neglect, along with partner organiza-
children. In particular, they are embedding screen- tions, including community members, educational in-
ing for treatment across settings (in ob/gyn as well as stitutions, and professional organizations in Washington
pediatric practices) and they are finding ways to extend State. The campaign, which started in 2005 through
the HRSA grants, provides educational materials and
parental eligibility through Medicaid. However, the runs a warm line for mothers suffering from post partum
recent regulations proposed by the Center for Medicare depression.85 The program had no funding for a year
and Medicaid Studies pose serious threats to many of but was refunded by a line item in the budget (through
these strategies. a champion within the state legislature) for $250,000
for two more years, starting July 1, 2007. The pro-
gram’s new goals include expanding the campaign to
Enacting State Legislation five languages (English, Spanish, Vietnamese, Russian,
and Somali); ensuring that the materials are culturally
At least one state, New Jersey, has enacted legislation competent; and creating a public service announcement
campaign for television, print, and radio. The Campaign
requiring screening for depression and strengthening
also partnered with the University of Washington School
the capacity to respond to the identified need. of Nursing to support a Web-based provider training that
n New Jersey enacted the Postpartum Depression was developed by the School on a grant.86
Law in April, 2006, that requires physicians, nurse
midwives, and other licensed health care profession-
als to screen new mothers and to educate pregnant n As part of Iowa’s ECCS activities, Maternal Depres-
women and their families about post partum depres- sion Screening: Train the Trainer workshops are
sion.84 New Jersey has long been at the forefront of offered in partnership with the Iowa departments of
postpartum depression action and legislation, due Public Health, Human Rights, Management, Educa-
in part to the advocacy work of Mary Jo Codey, the tion, Human Services, Prevent Child Abuse Iowa,
wife of the former governor Richard Codey, and this Head Start Collaboration Office, and the University
was the first law in the country to require health care of Iowa’s Depression and Clinical Research Center.
providers to screen all women who have recently As of the end of fiscal year 2007, 34 trainers were
given birth, and to educate women and families. trained at the Maternal Depression Screening: Train
The bill provides $4.5 million for a comprehensive the Trainer workshops, and these trainers held 15 lo-
program, including the establishment of a statewide cal trainings for providers in Iowa. Preliminary results
perinatal mental health referral network. New Jersey from two demonstration sites indicate a 70 percent
is also the original developer of the Speak Up When increase in rates of screening for maternal depres-
You’re Down campaign, which is now used in Wash- sion.87
ington State. (See box.) n Rhode Island’s ECCS project includes supporting
screening in child care and primary care settings, and
Using the State Early Childhood Comprehensive increasing the capacity of service providers to address
Systems (ECCS) grants to leverage change parent and family behavioral health issues, through
treatment and referral as objectives. Watch Me Grow
In a number of states the ECCS coordinators and the RI trains participating pediatric and family prac-
ECCS grant itself have been the catalyst for focused, tices to screen parents using the Early Childhood
cross-system attention to maternal depression and Screening Assessment, which has four questions that
how it impacts the broader early childhood goals. directly screen for maternal depression. Providers are
For example: also trained in how and where to refer parents who
screen positive for depression.88
12 Reducing Maternal Depression and Its Impact on Young Children National Center for Children in Povertyn In Connecticut, the ECCS Director also facilitates Efforts to assure the healthy mental development of
the Statewide Perinatal Depression Screening Work- young children are many:
group. The Department of Public Health convened n In July 2006, Governor Blagojevich implemented
a “Perinatal Depression Screening: Implications for All Kids, which provides uninsured children access
Consumers and Providers” summit in May 2006, to comprehensive health care with a rich benefit
and has launched a perinatal depression screening package (similar to that under Medicaid EPSDT).
public awareness campaign. A pilot perinatal depres- In December 2007, FamilyCare eligibility (afford-
sion screening project has been started in two com- able coverage for parents and caretaker relatives) was
munity health clinics, and efforts are underway to raised to 400 percent of the poverty level, thereby
institutionalize perinatal screening in DPH funded assuring health benefits for many more Illinoisans.
perinatal case management programs.
– To assure that beneficiaries have access to care
and a “medical home,” the Illinois Department of
Putting It All Together
Healthcare and Family Services (HFS), the single
state agency responsible for the administration of
Over the past several years, Illinois has focused major
Title XIX and Title XXI of the Social Security Act,
energy on improving and linking its efforts on behalf of
FamilyCare, and the All Kids program, imple-
young children. Illinois has a strong state policy frame-
mented a mandatory statewide Primary Care Case
work that includes legislation that calls for preschool for
Management (PCCM) program, with a strong
all young children and includes a set-aside for infants
quality assurance process that includes ongoing
and toddlers. In addition, the state has a strong leader-
tracking and monitoring. Feedback to providers on
ship group, built on solid relationships among advocates
key indicators and ongoing provider training are
and state officials, that has made a special effort to focus
among the strategies incorporated in the program.
on the importance of promoting healthy early relation-
ships. Illinois’ success is based on public/private part- – HFS’ contract with its Managed Care Organiza-
nerships, strong advocacy, and state agencies working tions (MCO) was strengthened to specifically
together to assure the service delivery system meets the require objective developmental screening of
needs of young children. young children and perinatal depression screening,
referral and treatment, with ongoing monitoring
The focus on maternal depression builds on earlier and tracking. Enrollment in an MCO is voluntary
work to promote healthy social and emotional develop- and available in seven counties, including Cook
ment in young children, for example, by expanding ac- County.
cess to early childhood mental health consultation and n Public Act 93-0536 (305 ILCS 5/5-5.23) was passed
the Children’s Mental Health Partnership. The partner- with the goal of improving birth outcomes for over
ship brings together a broad-based strategy to address 80,000 babies whose births are covered each year by
the mental health and social/emotional development HFS. The law requires HFS to develop a plan to im-
of children and adolescents, including young children. prove birth outcomes. Addressing perinatal depres-
Recognizing the importance of maternal depression and sion is among the strategies outlined in the plan.89
particularly its impact on infants and toddlers, Illinois
n Illinois participated in the ABCD II project with
has taken a number of steps across multiple agencies
support from The Commonwealth Fund, the Na-
and communities to develop a “putting it all together”
tional Academy for State Health Policy, the Michael
strategy. Largely driven through public-private collabo-
Reese Health Trust, The Chicago Community Trust,
rations, the work has grown out of the state’s Birth-to-
the Centers for Medicare & Medicaid Services, The
Five early childhood systems development initiative,
Ounce of Prevention Fund, provider organizations
convened by Illinois’ Ounce of Prevention Fund and
(Illinois Chapter of the American Academy of Pe-
through state agency work to address the health needs
diatrics and the Academy of Family Physicians) and
of young children. The effort can be linked to the state’s
many other partners.
ECCS grant work and the governor’s initiatives to im-
prove health outcomes of children and assure they are n Public Act 095-0469, Perinatal Mental Health
ready to learn. Disorders Prevention and Treatment Act, effective
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