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Maternal Mental Health_Hurley_5.4.12

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Maternal Mental Health_Hurley_5.4.12

  1. 1. MATERNAL DEPRESSION ANDCHILD GROWTH & DEVELOPMENT Evidence from LAMI Countries Kristen M. Hurley, Ph.D. Maureen M. Black, PhD. University of Maryland School of Medicine Pamela J. Surkan, Ph.D. Johns Hopkins Bloomberg School of Public Health
  2. 2. AGENDA• Prevalence• Assessment strategies• Risk factors for women• Consequences to children – Poor maternal functioning/caregiving – Poor child growth and development
  3. 3. PREVALENCE
  4. 4. PREVALENCE IN LAMI COUNTRIES• Africa and Asia (Husain, Creed, & Tomenson, 2000) – 15%-28%• Pakistan (Kazi et al., 2006) – 28%-57%• Latin America (Wolf, DeAndraca, & Lozoff, 2002) – 35%-50%• WHO estimates that by 2020 depression will be the second largest cause of DALYs Wachs, et al, child development perspectives, 2009
  5. 5. ASSESSMENT IN LAMI COUNTRIES
  6. 6. ASSESSING MATERNAL DEPRESSION• Depression can diagnosed – Diagnostic and Statistical Manual of Mental Disorders (APA, 1994) – Schedules for Clinical Assessment in Neuropsychiatry (Wing, 1990) OR• Depressive Symptoms can be assessed via a questionnaires: – Edinburgh Postnatal Depression Scale (Cox, 1987) – Center for Epidemiologic Studies–Depression(Radloff,1977) – WHO Self-Reporting Questionnaire (WHO, 1994) – Adult Psychiatric Morbidity Questionnaire (Harrington, 1990)
  7. 7. RISK FACTORS ASSOCIATED WITHMATERNAL DEPRESSION IN LAMI COUNTRIES• Poverty/ Economic Stress (6)• Low social support (7)• Domestic violence (1)• Maternal anemia (2) Wachs et al, child development perspectives, 2009
  8. 8. RISK FACTORS ASSOCIATED WITHMATERNAL DEPRESSION IN LAMI COUNTRIES• Lack of mental health resources/services (2)• Social stigma (1)• Families with large #’s of young children (3)• Having preterm or LBW infant (1) Wachs et al, child development perspectives, 2009
  9. 9. RISK FACTORS ASSOCIATED WITHMATERNAL DEPRESSION IN LAMI COUNTRIES• Having a child with developmental disabilities (1)• Having unplanned or unwanted infant (1)• Female child in culture with strong preference for male (2)• Lack of control over resources & reproductive health (1) Wachs et al, child development perspectives, 2009
  10. 10. CONSEQUENCES
  11. 11. INTERGENERATIONAL CONSEQUENCES OFMATERNAL DEPRESSION IN LAMI COUNTRIES• Maternal Consequences – Impaired parenting/caregiving – Child perceived as having a difficult temperament – Problems in breastfeeding Wachs et al, child development perspectives, 2009
  12. 12. INTERGENERATIONAL CONSEQUENCES OFMATERNAL DEPRESSION IN LAMI COUNTRIES• Child Consequences – Behavior problems – Childhood depression – Motor delay and low academic achievement – Undernutrition – Diarrhea Wachs et al, child development perspectives, 2009
  13. 13. Maternal Depressive Symptoms &Infant Development in Bangladesh Black et al, Journal of Child Psychology and Psychiatry, 2007
  14. 14. PURPOSE• To examine how maternal depressive symptoms are related to infant development among 221 low-income infants in rural Bangladesh• To examine how the relationship is affected by maternal perceptions of infant irritability and observation of caregiving practices Black et al, Journal of Child Psychology and Psychiatry, 2007
  15. 15. METHODS• Maternal Depressive Symptoms – Center for Epidemiologic Studies–Depression(CESD; Radloff, 1977)• Infant mental, motor, and behavioral development – Bayley Scales of Infant Development (Bayley, 1993)• Maternal perception of infant temperament – Infant Characteristics Questionnaire (ICQ; Bates et al, 1979) – Toddler Behavior Assessment Questionnaire (TBAQ; 1996)• Stimulation and support in the home – HOME observation scale (Caldwell et al, 1984) Black et al, Journal of Child Psychology and Psychiatry, 2007
  16. 16. RESULTS• Half (52%) the mothers reported depressive symptoms above the clinical cut-off of 16• Depressive symptoms were associated with – Lower family income – Lower maternal/parental education – Larger household size – Lower scores on the HOME inventory – Maternal perceptions of infant irritability – Poor infant development Black et al, Journal of Child Psychology and Psychiatry, 2007
  17. 17. Depressive symptoms among rural Bangladeshi mothers: implications for infant development MOTOR SKILLS ORIENTATION/ENGAGEMENT SKILLS Black et al, Journal of Child Psychology and Psychiatry, 2007
  18. 18. Depressive symptoms among rural Bangladeshi mothers: implications for infant development MOTOR SKILLS ORIENTATION/ENGAGEMENT SKILLS Black et al, Journal of Child Psychology and Psychiatry, 2007
  19. 19. CONCLUSION• Infants whose mothers reported depressive symptoms & infant fussiness acquired fewer skills: – Cognition – Motor – Orientation /Engagement
  20. 20. CONCLUSION• Infants whose mothers reported depressive symptoms & infant fussiness acquired fewer skills: – Cognition – Motor – Orientation /Engagement• This relation was partially explained via: – Parental responsiveness & opportunities for play in the home, suggesting that caregiving behavior is influenced by both depression & perceptions of infant temperament
  21. 21. Meta-analysis of maternal depressive symptoms and child growth in developing countries Surkan et al. Bull WHO 287:607-615D, 2011
  22. 22. PURPOSE• To investigate the relationship between maternal depression and child growth in developing countries through a systematic literature review & meta-analysis Surkan et al. Bull WHO 287:607-615D, 2011
  23. 23. METHODS• 6 databases were used: • Pubmed, PsychInfo, CINAHL Plus, Web of Science, SCOPUS, EMBASE• Search terms: • “mother” OR “maternal” • “depression” OR “depressive disorder” OR “mental health” • “child” OR “infant” • “nutritional disorders” OR “growth disorders” OR “nutritional status” OR “body size” Surkan et al. Bull WHO 287:607-615D, 2011
  24. 24. METHODS• Meta-Analysis – Estimates were converted to odds ratios – We reanlayzed original data from two studies Surkan et al. Bull WHO 287:607-615D, 2011
  25. 25. RESULTS• Articles included – 17 studies• Regions – Africa (4), South America/Caribbean (6), Asia (7)• Study Design – Cross-sectional (7), Case-control (6), Longitudinal (4)• Definitions – Short stature and underweight (9 used <-2 z-scores) – Depression (measures varied – most assessed depressive symptoms) Surkan et al. Bull WHO 287:607-615D, 2011
  26. 26. Underweight: Results from 17 studiesStudy Location Time point Statistics for each study O ratio and 95%CI dds Odds Lower Upper ratio limit limit p-ValueAdewuya et al. 2008 Nigeria 9 months 2.840 0.979 8.235 0.055Anoop et al. 2004 India 6-12 months 7.400 1.509 36.300 0.014Baker-Henningham et al. 2003 Jamaica 9-30 months 1.385 1.081 1.773 0.010Black et al. 2009 Bangladesh 12 months 0.723 0.412 1.269 0.259Carvalheas et al. 2002 Brazil 12-23 months 3.100 0.966 9.949 0.057de Miranda et al. 1996 Brazil <24 months 2.900 1.268 6.633 0.012Harpham et al. 2005 Ethiopia 6-18 months 1.100 0.872 1.387 0.421Harpham et al. 2005 India 6-18 months 1.100 0.872 1.387 0.421Harpham et al. 2005 Peru 6-18 months 0.900 0.667 1.214 0.490Harpham et al. 2005 Vietnam 6-18 months 1.400 1.094 1.791 0.007Patel et al. 2003 India 6 months 2.800 1.087 7.213 0.033Rahman et al. 2004 (urban) Pakistan 12 months 2.800 1.176 6.665 0.020Rahman et al. 2004 (rural) Pakistan 12 months 3.000 1.500 6.000 0.002Santos et al. 2010 Brazil 48 months 1.500 0.802 2.806 0.205Stewart et al. 2008 Malawi 9.9 months (median) 1.313 0.804 2.145 0.277Surkan et al. 2008 Brazil 6-24 months 1.800 0.595 5.450 0.298Tomilson et al. 2006 South Africa 18 months 2.320 0.899 5.990 0.082 Combined Estimate 1.472 1.215 1.782 0.000 0.1 0.2 0.5 1 2 5 10 Reduced risk Increased riskM Analysis etaSurkan et al. Bull WHO 287:607-615D, 2011
  27. 27. Short Stature: Results from 15 studiesStudy Location Time point Statistics for each study Odds ratio and 95% CI Odds Lower Upper ratio limit limit p-ValueAdewuya et al. 2008 Nigeria 9m onths 2.840 0.979 8.235 0.055Black et al. 2009 Bangladesh 12 months 2.317 1.147 4.681 0.019Harphamet al. 2005 Ethiopia 6-18 months 0.900 0.682 1.187 0.455Harphamet al. 2005 India 6-18 months 1.400 1.217 1.610 0.000Harphamet al. 2005 Peru 6-18 months 1.100 0.872 1.387 0.421Harphamet al. 2005 Vietnam 6-18 months 1.300 0.982 1.721 0.067Patel et al. 2003 India 6m onths 3.200 1.125 9.102 0.029Rahm et al. 2004 an Pakistan 12 months 2.800 1.293 6.065 0.009Santos et al 2010 Brazil 48 months 1.000 0.658 1.519 1.000Stewart et al. 2008 Malawi 9.9 months (median) 1.628 0.924 2.869 0.092Surkan et al. 2008 Brazil 6-24 months 1.800 1.109 2.923 0.017Tom ilson et al. 2006 South Africa 18 months Combined estimate 2.520 0.981 6.475 0.055 1.416 1.177 1.704 0.000 0.1 0.2 0.5 1 2 5 10 Reduced risk Increased risk Surkan et al. Bull WHO 287:607-615D, 2011
  28. 28. SUMMARY• Findings • In developing countries, children of mothers with depressive symptoms presented higher risk of o Underweight (OR=1.47, p<0.01) o Short stature (OR=1.41, p<0.01) • Population Attributable Risk Calculation o If the infants were entirely unexposed to maternal depressive symptoms, 23% to 29% fewer children would be underweight or stunted Surkan et al. Bull WHO 287:607-615D, 2011
  29. 29. TREATMENT
  30. 30. EFFECTIVE PSYCHOSOCIAL APPROACHES• Brief screening methods have been effective, but still not commonly used• In LAMI counties, women treated by primary health care workers – limited training in the recognition & treatment of depression• Critical need for frontline staff to be trained to identify mental health problems – training need not be restricted to primary health care workers. Wachs et al, child development perspectives, 2009
  31. 31. EFFECTIVE PSYCHOSOCIAL APPROACHES• Social support – Taiwan (support groups led by nurses) – Pakistan (support groups led by trained community women)• Group therapy – Uganda (group therapy led by trained group leaders)• Use of existing health mechanism – Jamaica (home-visit by community health workers) • Parenting issues discussed • Mother/child play activities introduced• Enhance mother-infant interactions – South Africa (improvement in interactions/infant growth) Wachs et al, child development perspectives, 2009
  32. 32. THANK YOU!khurley@peds.umaryland.edu

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