CHIPRA Connect Maternal Depression & Social-Emotional Development Screening & Referral in Primary Care Marian F. Earls, MD, FAAP

Maternal Depression Of all women, up to 12% may experience depression in a given year. If the woman has low income, the prevalence is doubled. If a woman experiences Post Partum Mood Disorder (PPMD), she is likely to experience it with subsequent pregnancies. PPMD can affect mothers with subsequent pregnancies even without a previous history with earlier births.

Compounding Factors Age and Income – 40% - 60% of parenting teens and other mothers who have low income report depressive symptoms. – 25% of parenting mothers who have low income have depression compared to 12% in all women.

Risk Factors for the Mother The mother can be placed at risk for depression if the child has – Difficult temperament – Hard to read cues – Difficulty managing stress – Insecure attachment – Prematurity; chronic health condition – Birth trauma

Perinatal Depression The experience of minor or major depression 8.5% - 11% of women during pregnancy 6.5% % of women postpartum The experience of major depression 3.1% - 4.9% of women during pregnancy 1% - 6.8% of women in the 1st year postpartum

Peak Occurrence 2-3 months postpartum is the peak for minor depression 6 weeks postpartum is the peak for major depression

Spectrum Encompasses Postpartum (“Maternity” or “Baby”) Blues Postpartum Mood Disorders (PPMD) includes – Postpartum Depression – Postpartum Psychosis

Spectrum of Depressive Symptoms 50% - 80% of all mothers experience “Maternity (Baby) Blues” after birth. Transient depressed mood, irritability, crying, anxious, afraid, confused. Begins a few days after the birth. May last 2 weeks; does not impair function. Treat with reassurance and emotional support. Risk factor for later PPMD.

Spectrum of Depressive Symptoms Postpartum Depression meets DSM IV criteria as a minor/major depressive disorder. Occurs during postpartum or within the 1st year. 13% - 20% of women experience PD after birth.

Spectrum of Depression Symptoms 1-3 of 1,000 women experience Postpartum Psychosis (PPP) after birth. Occurs in the first 4 weeks after birth. Impairment is serious. – Paranoia – Mood shift – Hallucinations, delusions – Suicidal and homicidal thoughts Requires immediate medical attention; hospitalization

Impact of Maternal Depression Early brain development – The migration of neurons, formation of synapses, and pruning are affected by genetics and the environment. – If an infant lives in a an environment of neglect, there can be MRI visible changes in the frontal lobes. – If an infant lives with others who are experiencing depression, there is likely to be impaired social interaction and other developmental delays.

Social-Emotional Development - Why concern? Immediate impact – Maternal depression compromises bonding. – Babies often avoid interaction; attachment is at risk. – The mother-child relationship creates an environment for the infant in which s/he withdraws from daily activities. – Emotional and social development, as well as intellectual, language, and physical development is at risk.

Impact of Maternal Depression – At 2 months, the infant has poor state regulation, looks at the depressed mother less, has less interaction with objects, and has a lower activity level. – Infants are at risk for Attachment Disorder, Failure to Thrive, and to show developmental delay at age 1 on the Bayley Scales of Infant Development.

Impact of Maternal Depression Neonatally – Poor orientation skills, tracking – Decreased tone – Lower activity level – Attribution of negative temperament Infants and toddlers – Sad, lethargic; little interest in exploration; withdrawal – Eating or sleeping problems – Cries a lot; difficult to soothe; little vocalization – Difficulty with comforting self; may self-stimulate – Doesn’t turn to significant adults for comfort – No preferred caregiver; may seek comfort from anyone – Resists touch or clings

Early Response is Urgent If the mother continues to experience depression, and there is no intervention for the dyad (mother-child relationship), the child’s developmental issues are likely to persist and be less responsive to intervention over time

Impact of Maternal Depression Impaired parenting Bonding Emotionally disengaged; less speech Perception of child behavior Less positive attribution; increased irritability & hostility Interaction Less sensitive and attuned; more controlling Apathy to the baby; indifference to caregiving Social factors Impaired social interactions; withdrawn Impaired attention to and judgement for health and safety

Impact of Maternal Depression Long Term Infants are at risk for insecure attachment. Children with insecure attachment are more likely to have behavior problems and conduct disorder. Maternal depression in infancy is predictive of cortisol levels in preschoolers, which is linked with anxiety, social wariness and withdrawal When mothers experienced major depression, then attachment disorders, behavior problems, and depression and other mood disorders can occur in childhood and adolescence

Pending AAP Statement Post Partum Depression leads to – Adverse affects on infant brain development – Family dysfunction – Cessation of breastfeeding – Inappropriate medical treatment of the infant – Increased costs of medical care To have a positive impact on the health of the child and family, Medical Homes can be timely and proactive by – Implementing screening – Supporting the mother-child relationship – Identifying and using community resources for referral and treatment

Impact of Maternal Depression Long Term When mothers experience depression, the children, as they age, often have – Poor self-control – Poor peer relationships – School problems – Aggression. – Special education – Grade retention – Early school exit

Pending AAP Statement Advocate for and support – Awareness of the need for screening in the obstetric and pediatric periodicity of care schedules. – Use of evidence-based interventions focused on healthy attachment and parent-child relationships. – Training for professionals who care for very young children. – Appropriate payment.

AAP Mental Health Competencies The “primary care advantage” Longitudinal, trusting relationship Family centeredness Unique opportunities for prevention & anticipatory guidance Understanding of common social-emotional & learning issues in context of development Experience in coordinating with specialists in the care of CSHCN Familiarity with chronic care principles & practice improvement

Mental Health Competencies Systems-based practice – MH advocacy, collaborative relationships Patient Care – build resilience, identify risk, partner with family Medical Knowledge – DSM-PC, evidence base for screening and interventions Practice-based Learning & Improvement Interpersonal &Communication Skills – common factors approaches Professionalism

Bright Futures Health Promotion Themes include: Promoting Family Support: Bright Futures now includes parental social-emotional well- being surveillance. Promoting Child Development Promoting Mental Health

Opportunities for Prevention and Promotion in Primary Care Psychosocial and maternal depression screening Developmental & behavioral screening and surveillance in pediatric and family practice offices Social/emotional screening for children identified “at risk” Prenatal Visits Psycho-social screening and surveillance for risk and protective factors is an integral part of routine care and the relationship with the child and family. Implementation requires a QI approach to office process

Use of a Preventive Services Prompting Sheet to increase reliability of process

Edinburgh Postpartum Depression Scale – Completed by the mother – At 2 month, 4 month, 6 month visits – Simple 10 multiple choice questions – Score of 10 or greater indicates possible depression – English and Spanish – Sensitivity – 86%; Specificity – 78% – Free download

USPSTF – PHQ-2 – Not specific to postpartum; can be used during pregnancy and for surveillance and to indicate risk of depression in adults in general. – “Over the past 2 weeks, (1) have you ever felt down, depressed, or hopeless? and (2) have you felt little interest or pleasure in doing things?”

ASQ -SE Parent/caregiver completes in minutes English and Spanish 1-3 minutes to score Handouts on social-emotional milestones and activities Used in conjunction with the ASQ or another validated screening tool that provides information on overall development

ASQ -SE Use the 6 month tool for ages 3 – 8 months Completed by mother Single cutoff score Provides information about infant caregiver interaction Screens affect, self-regulation, adaptive functioning, autonomy, compliance, communication, and interaction

Infant Attachment DC 0 – 3 206: Reactive Attachment Deprivation / Maltreatment Disorder of Infancy Observed in the context of evidence of deprivation or maltreatment manifested by: 1. Persistent parental neglect or abuse of a physical or psychological nature, of sufficient intensity and duration to undermine the child’s basic sense of security and attachment; 2. Frequent changes in, or inconsistent availability of, the primary caregiver, making an attachment to an individual caregiver impossible; or 3. Other environmental compromises and situations beyond the control of the parent & child which are prolonged, interfere with the appropriate care of the child, and prevent stable attachments.

Coding for Screening AAP recognizes the Edinburgh as a measure of risk in the infant’s environment. Billing is appropriate at the infant’s visit. CPT code (final AAP code recommendation pending) for the Edinburgh CPT code for ASQ-SE or 99420

When Screening Shows a Concern Communication Demystification Support Resources – family, community Referrals: – Integrated/Co-located Mental Health Provider – For mom – For dyad – For child for targeted prevention and early intervention

Demystification and Emotional Reassurance Remove the mystery about maternal depression. – PPD happens with many women to varying degrees. – It is not her fault; doesn’t mean she is a bad mom. – She will feel better; depression is treatable. – You are a resource. Other helps are available. Having a baby is a time of transition for every family. – The transition time can be difficult when there are more stressors; The transition time can be easier when there are more supports.

Intervention For Mom – Ranges from support, to therapy, to therapy plus medication, to emergency mental health services/hospitalization. For Dyad Relationship – Includes therapy with child mental health professional re attachment and bonding; follow-up ASQ SE, and if Attachment Disorder of Infancy, referral to Part C.

Immediate Action If the Edinburgh Score is 20 or greater, or If the mother expresses concern about her or her baby’s safety, or If the PCP suspects the mother is suicidal, homicidal, severely depressed/manic or psychotic, – Refer for emergency mental health services – Be sure she leaves with a support person (not alone) and has a safety plan

Brief Intervention Strengthen the mother-child relationship. Understand and respond to baby’s cues. Encourage routines for predictability and security. Focus on wellness: sleep, diet, exercise, stress relief. Acknowledge, accept and heal personal experiences. Realistic expectations; prioritize important things. Encourage social connections

Role of Fathers Paternal depression is estimated at 6%; 20% of fathers in Early Head Start. Incidence of depression is higher when the mother has PPD. If both parents experience depression, the effect on the children is compounded. A father who is not depressed can be a protective factor.

With Integrated MH Provider Immediate triage for positive screens Secondary screens Support and follow-up Referral Coordination with PCP

Referral for Mom Who? – Mother’s PCP – Mother’s obstetrician – Mental health provider For – Individual and/or couple’s therapy – Medication management

Referral for the Dyad The mother and child need to be referred to a professional with expertise in the treatment of very young children. Evidenced based treatments Circle of Security ( Child-Parent Psychotherapy ABC (Attachment & Biobehavioral Catch up) Part C services can provide modeling for interaction and play with the infant to promote healthy development

Other Community Resources Public Health Nurses Lactation Specialists Parent Educators Family Support Groups Parent-child groups Mother’s morning out Early Head Start Mentoring and Home Visitation – Parents as Teachers Program – Healthy Families America Program – Faith based and other volunteers

Summary Early brain development research highlights the importance of a healthy parent-child relationship. The non-stigmatizing longitudinal pediatric relationship lends itself to identifying maternal depression and supporting parental and child mental health. Universal early routine structured psycho-social screening opens the door to broader communication within families, and between families and the medical staff about mental health related concerns. Medical providers show they are concerned with all aspects of a patient’s health and well-being, including their mental health.