- Authors: Alan Stein et al
- The Lancet (2018)
As well as the debilitating impact on the mother, PND is associated with a range of negative child outcomes, including impaired cognitive development, behavioural issues and insecure attachment. These issues have been shown to persist in to adolescence.
Given the impact on mother and child, and estimated related economic costs of £8.1bn per year in the UK, there is a strong imperative to act to tackle the effects of perinatal mental disorders.
Stein and colleagues' study explores the limitations of much of the research into treatment for PND and its impact on children. They point out that the impact of PND on child development is most pronounced when the depression persists beyond the first few months, but that most research relates to relatively brief forms of interventions in the early post-natal period, rather than more intensive and long-term therapies.
They tested whether a parenting intervention could improve children's, cognitive, language, behaviour and attachment outcomes by age two when provided alongside an intensive form of treatment for maternal depression in cognitive behavioural therapy (CBT).
Parenting has long been established as a crucial link between maternal depression and child outcomes, with low levels of maternal contingent responsiveness impacting on children's cognitive development and poor support for emotional self-regulation linked to behavioural issues. So there is good reason to think that a parenting intervention such as video feedback therapy (VFT) - which been shown to be effective in a number of contexts - could lead to better developmental outcomes when provided alongside effective treatment for PND. VFT aims to improve the quality of the mother-child interaction by enhancing attention to infant cues, emotional scaffolding, and sensitivity to treating the child as an agent with attachment needs. To achieve this, therapists record interactions between parents and children in the home and discuss various aspects of that interaction at the next visit, with the aim of helping mothers to better understand infant communication signals and enhancing maternal responsiveness.
The researchers used a randomised control trial to compare this approach to one involving CBT delivered alongside progressive muscle relaxation (PMR), which is commonly used to treat stress but does not actively target parenting. The study involved 152 women living in the Oxford area who had a child aged between four and a half and nine months old and met the diagnostic criteria for a major depressive diagnosis which had persisted for at least three months. They received 11 intensive home visits from a clinical psychologist before the child's first birthday, with two booster sessions in the second year. Child outcomes were measured at aged two.
The study demonstrated very encouraging findings, with significant improvements in maternal depression such that at least 80 per cent of participants no longer met the diagnostic criteria, and child outcomes at age two were in the normal range for a non-clinical population. However, the researchers found no difference between the groups receiving VFT and those receiving PMR. In other words, both groups improved by a similar amount, and VFT did not show any additional benefit in terms of parent or child outcomes.
Implications for practice
- As the authors point out, the findings have significant implication for how we approach the treatment of PND and its effects on children's development in the first 1,000 days.
- They suggest that the strong and sustained impact on maternal depression can be explained by the intensive and tailored nature of the intervention, alongside the inclusion of booster sessions and the fact that the intervention was delivered in the mothers' homes.
- They note that the finding that child outcomes were the same in both groups - despite only one receiving a parenting intervention - is at odds with the view that treating maternal depression alone is not sufficient to mitigate the impact on child development. They suggest that this may be due to the marked and sustained improvement in maternal mood meant that most children were not exposed to maternal depression for the entirety of their second year - a period in which the association between PND and negative child outcomes is strong. PND impacts on child outcomes by lowering parent's ability to meet their children's needs. The study provides good evidence that it is possible to effectively treat PND in high-risk mothers with persistent post-natal depression and that this can largely mitigate the adverse impact on child development.
- However, this was a high-intensity home visiting intervention delivered by skilled practitioners, which will be very costly and logistically challenging to deliver at scale. So if we are serious about supporting women experiencing PND, and about breaking the link between this debilitating condition and negative consequences for children's development, then we need to invest properly in high-quality treatment. We also need more high-quality studies like this that rigorously evaluate the impact of treatment.
Mitigating the Effect of Persistent Post-natal Depression on Child Outcomes Through an Intervention to Treat Depression and Improve Parenting: A Randomised Controlled Trial, A Stein, E Nesti, P Lawrence, C Granger, C Kempton, M Graske, The Lancet (2018)
What Works to Enhance the Effectiveness of the Healthy Child Programme: An Evidence Update, Early Intervention Foundation, K Asmussen, L Brims (2018)
- The Early Intervention Foundation is a What Works Centre that champions and supports the use of effective early intervention to improve the lives of children and young people at risk of experiencing poor outcomes