Louise Marryat discusses the impact of maternal mental health on parenting behaviour and hopes that introducing a universal health check in the early years will allow health professionals to identify more women who need extra help to allow them to become the best parents they can be.*
A woman is more likely to be admitted to a psychiatric hospital in the three-month period following childbirth than at any other time in her life (Kumar 1982). While only a very small number of women - approximately one or two per thousand - experience a severe postpartum psychosis (Kendall et al. 1981), evidence suggests that 10-17% of all deliveries, that is around 11,000 deliveries a year in Scotland, are followed by a depressive episode that would be regarded as indicative of clinical depression, although this may never come to the attention of health professionals (SeeMeScotland 2012; Cox et al. 1982; Kumar and Robson 1984). In addition, research from the Growing Up in Scotland (GUS) study birth cohort, which follows around 5,000 Scottish children from infancy, suggests that around 12-16% of women in Scotland suffer from depression, anxiety or stress at any one point during the first four years following the birth of a child, accounting for 33% of mothers overall. Furthermore, 17% of mothers experienced repeated spells of poor mental health (Marryat and Martin 2010).
Although distressing for the mother in itself, poor maternal mental health has also been found to have long-term effects on child development and future outcomes, which raises concerns among health professionals and policy-makers alike, particularly when such problems are often left unchecked. Exposure of children to maternal mental health problems has been linked to lower academic achievement, higher rates of early school drop-out and increased adolescent sexual activity (Bohon et al. 2007). In addition, there is evidence of an association between maternal mental health and social, emotional and behavioural outcomes. GUS found that children who had mothers with either brief or repeatedly poor mental health in the early years were more likely to be experiencing social, emotional or behavioural problems at age four. GUS also found evidence of a link between maternal mental health and cognitive outcomes at age three, though at this stage, results were not statistically significant (Marryat and Martin 2010).
There is also evidence to suggest that there may be different developmental outcomes for children exposed briefly to a mother with poor mental health compared with those exposed over a prolonged period. While brief exposure to a mother with poor mental health has been associated with adverse emotional and cognitive outcomes for the child (Murray et al. 1996 and Wachs et al. 2009), long-term exposure may also be associated with adverse behavioural outcomes (Lyons-Ruth et al. 1993 and Chang et al. 2007). However, maternal mental health problems rarely occur in isolation, and are often combined with multiple other factors, the effects of which can be difficult to untangle. GUS data found that mothers were more likely to suffer from poor mental health, and suffer over a longer period of time if they were a lone parent (27% having repeatedly poor mental health, in contrast to 11% of mothers in couple families), if they were a teenager at the time of birth, if they lived in a household with no-one in employment, and if they lived in a household with a lower equivalised† income. Many of these factors also share an association with problematic parenting and poor child outcomes. Although statistical techniques available now are able to distinguish independent effects of different factors to some extent, there is an increasing belief that it is the multiplicity of risks that cause the most detrimental effects on a child (Sameroff 1998).
The impact of poor maternal mental health is increasingly thought to be mediated through parenting (Beeber and Miles 2003). For very early parenting, there is consistent evidence that depressed mothers may be less responsive than mentally healthy mothers to their infants' efforts to engage with them and that this, in turn, affects the strength of infants' attachment to the mother (Murray et al. 1991). Poor attachment, in turn, has been shown to be related to impaired cognitive functioning at 18 months (Murray et al. 1996). Mental illness is associated with problematic parenting, that is parenting that is associated with poorer child outcomes, socially, emotionally or behaviourally. Poor parenting may manifest through a lack of confidence in one's parenting, and through either overly lax parenting at one end of the scale, or overly harsh parenting at the other end (Dix and Meunier 2009; Oyserman et al. 2005). Depression, in particular, is thought to relate to maternal withdrawal, that is low responsiveness towards the child and a lack of involvement. It is also linked to maternal intrusiveness, and flat, or negative, emotional responses towards the child, with little positive expression (Dix and Meunier 2009). Depressed mothers may provide less structure and guidance to their children, and set fewer rules (Goodman and Brumley 1990 quoted in Gelfand and Teti 1990). Finally, maternal depression may lead to increased use of ineffective discipline, which may be harsh, manipulative, inconsistent or indulgent (Dix and Meunier 2009).
So what can policy-makers, health and social work professionals do to help mothers experiencing poor mental health? At the moment, a large part of the problem is in identifying these women. In Scotland as a whole, there is no universal contact with a health professional after the six to eight week postpartum check. The majority of families will bring their child for immunisations, however there is some evidence that particularly vulnerable women may be less likely to attend routine appointments, such as those for immunisations, or to engage in help-seeking behaviours (Mabelis and Marryat 2011).
NHS Greater Glasgow and Clyde has recently re-introduced a universal contact with health visitors for children aged 30 months. While the primary aim of this check is to assess the child's development in social, emotional and behavioural development and language acquisition, by having a contact, often in the home with the mother, health visitors will at least have the opportunity to pick up on problems related to the mother's mental health and interactions with the child (Thompson and Wilson 2010). The 24-30 month short life working group is looking into the feasibility of re-introducing a developmental universal check for all children. However, it is not enough just to assess mothers' mental health, health professionals need the skills and knowledge to be able to discuss with women any problems which may arise, and care pathways need to be there to then help women. Currently, there are various trials of schemes which target both common mental health problems and parenting including Triple P, Mellow Parenting and the Family Nurse Partnership¥, and early results appear to be promising.
In conclusion, for a substantial minority of mothers, poor mental health is experienced well beyond the postpartum period and through the early years of their child's life. They often experience disadvantage, including living in poverty and lacking social support. There appears to be a link between maternal mental health problems and child outcomes, however, the fact that these children often experience multiple other risks can make the association difficult to isolate. Maternal mental health impacts on parenting behaviours, including overly lax or restrictive parenting, inconsistent parenting and using harsh punishment. While various programmes to help both with parenting and mental health problems are currently being piloted, identifying women with such problems remains a challenge. It is hoped that the possible introduction of a universal health check in the early years will allow health professionals to identify more women who need extra help to allow them to become the best parents they can be.
† Equivalised income is a measure of household income which takes account of the differences in a household's size and composition, and so is made equivalent for all household sizes and compositions. It is used for calculating poverty and social exclusion indicators.
Louise Marryat is a research assistant and PhD student based at the University of Glasgow. She works on the Evaluation of the Parenting Support Framework in Glasgow, while her PhD focuses on trajectories of social and emotional development of children from disadvantaged backgrounds in Glasgow. Before this, Louise was a senior researcher at the National Centre for Social Research, where she conducted research into children and families, primarily working on Scotland's national birth cohort study, the 'Growing Up in Scotland' study.
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