The relationship between post-natal depression and mother-child interaction. A Stein, D H Gath, J Bucher, A Bond, A Day and P J Cooper BJP 1991, 158:46-52. Access the most recent version at DOI: 10.1192/bjp.158.1.46
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British Journal of Psychiatry (1991), 158, 46—52
The Relationship between Post-natal Depression and Mother—Child Interaction ALAN STEIN, DENNIS H. GATH, JANET BUCHER, ALISON BOND, ANN DAY and PETER J. COOPER
The study was based on an index group of 49 mothers who had had depressive disorders in the post-natal year, and 49 control mothers who had been free from any psychiatric disorder since delivery. Nineteen months after childbirth, the interaction between mother and child was assessedby blind assessorsusing defined observationalmethods. Comparedwith controls, index mother—childpairs showed a reduced quality of interaction (e.g. mothers showed less facilitation of their children, children showed less affective sharing and less initial sociability with a stranger). Similar but reduced effects were seen in a subgroup of index mothers and children where the mother had recovered from depression by 19 months. Social and marital difficulties were associated with reduced quality of mother—childinteraction.
There is good evidence for a link between depressive
interfering with the functions and responsibilities of a
disorder in mothers and emotional disturbance in their children (Richman eta!, 1982; Biffings & Moos,
care giver and with the development
1983; Pound et a!, 1985). The reasons for this link are not established, but Rutter & Quinton (1984) have suggested several possibilities, including the influence of the mothers' depression on the way the mother and child interact. Two studies have thrown light on such interaction. Firstly, in a study of children aged two to three years,
children (up to the age of 18 months) are likely to be particularly vulnerable to effects of this kind, since they
Radke-Yarrow
non-depressed
Situation
et al(1985)
used Ainsworth's
are entirely dependent on their carers. Hence studies
of mothers who were depressed in the post-natal year should throw speciallight on mother-child interactions. Field (1984) found that the young infants of post natally depressed mothers (compared with those of
Strange
and found that insecure attachment
mothers had no such history. The evidence for insecure attachment was the child's avoidance of and
resistance to the mother when reunited with her after brief separation. The second study also examined children aged two to three years (Cox et a!, 1987). Compared with children of non-depressed mothers, those of depressed mothers showed more behaviour problems and more difficulties in expressive language. The important findings were that depressed mothers were less likely to use explanations, suggestions and questions when dealing with their children, and more likely to ignore their children's requests. Depressed mothers were also less likely to pick up cues from their children; if they did so, their responses were up by the children.
mothers) showed less frequent positive
and more frequent negative facial expressions. They also vocalised more. The depressed mothers showed similar differences in facial expressions; they vocalised less and spent less time looking at and touching their children. In a recent study, Murray (personal communication) found that post-natally depressed mothers were slower to respond to their children; the latter looked at their mothers less and showed more self-directed activity. These studies have largely focused on mothers with concurrent depression. It is arguable however that mother—child interactions should also be studied after the mother has recovered from her depression. Post-natal depression provides a good opportunity for studying this question since it is often of relatively short duration. Thus, by studying the mothers and children during the second year of the children's lives, a good proportion of mothers will have recovered from their depression while some will have remained depressed. We therefore examined mother child interactions in three groups 19 months after the child was born. In the first group the mother was depressed during the post-natal year and also at 19 months; in the second, the mother was depressed in the post-natal year but not at 19 months; and in the third the mother had been free from depression
was
more frequent in children whose mothers had a history of major depression than in those whose
less likely to be taken
of a good affective
relationship with the child―.It is arguable that younger
The
complexity of possible causal factors was shown by the finding that depressed mothers were also having more marital and social difficulties. When reporting their study of children aged two to three years, Radke-Yarrow eta! (1985) commented that: “¿the depressed parent is the primary environ ment of the young child. . - the behaviours and mental status of a depressed person are all potentially
46
47
POST-NATAL DEPRESSIONAND MOTHER-CHILD INTERACTION throughout. The aim was to discover whether impaired
mother—childinteraction was more frequent in (a) mothers who had been depressed during the post-natal year when compared with those free from depression;
(b) mothers who had recovered from their depression by 19 months when compared with mothers free from depression (since the birth of their children).
In a previous study, Cooper etal(1988) had examined a large
seriesof 483mothers four times:two months before child birth, and three, six and 12 months after delivery. At each assessment the mothers had completed the 60-item General (GHQ; Goldberg,
1972). Mothers with
aGHQ total score of l2or above had been further examined with a standardised psychiatric interview, the Present State Examination (PSE; Wing eta!, 1974);the depression rating scale (MADRS) devised by Montgomery & Asberg (1979) was also completed. Sixty women had been identified as PSE cases on at least one of the three post-natal assessments. In the present study, 19 months after childbirth 49 of these 60 women were assessed with their infants. Eleven of
the 60 wereomitted; of these, two had had twins,two were known to the research assessors, and the rest had moved away. Also assessed was a control group of 49 mothers who
had scored below 12on the GHQ at all three post-partum assessments; they were individually matched by age, social class and parity. Their sociodemographic
characteristics
are
given in Table 1. Fortuitously equal numbers of mothers in both
groups
were
cohabiting
with
male
partners.
characteristics
of mothers
Index group Control group
(n=49) (17-37)No. Medianage(range): years27 class2322No. inmiddle cohabiting4545No. married and/or stably primiparous1414
(n=49)
(16—40)27
Assessments
Index and control mothers were examined on two occasions when the child was 19 months old. Firstly, an independent research assessor examined each mother's mental state with the PSE and the MADRS. The assessor confirmed that none
of the control mothers had had any psychological difficulties since delivery. She also took the opportunity
to assessrecentlifeevents(Paykel, 1980)and chronicsocial difficulties. This interview ascertains the occurrence of potentially stressful events during the previous 12 months under six headings:
for ratings of events and difficulties
was found
to besatisfactory (weighted kappa0.76—0.94). Secondly, within the following week, each mother and child were assessed by one of two research psychiatrists,
who wereblind to the mother's index/control status. Five assessments were made in the following order.
This assessment was based on a semi-standardised
procedure
devised by Stevenson & Lamb (1979) to assess the child's initial responses to a stranger in the mother's presence. In this procedure, which was originally designed for laboratory
use, the stranger makes a series of increasinglyintrusive approaches to the child. In the present study, the technique was first practised in the laboratory and later adapted for the home. To adapt the procedure for use in the home, some elements of Thompson & Lamb's method were omitted,
but the essentials were the same as theirs. The test lasted three to five minutes. It began with the child sitting on the mother's lap. The stranger (the research psychiatrist) offered the child a toy, and then tried to initiate
a ‘¿give-and-take' exchange of the toy. Next an assessment was made of the child's response to being placed on the floor. Finally, the researcher moved to the floor, and again offered the child a toy, and again tried to start a ‘¿give-and take' exchange. The child's response to each initiative was rated on a 1-5 scale ranging from withdrawn/distressed to utgoing/friendly (see Appendix for details). The interrater reliability for this assessment was 0.78 (weighted kappa). Mother and child in structured play
Table 1 Sociodemographic
reliability
Child's sociability to a stranger
Method
Health Questionnaire
unpublished manual). Chronic social difficulties were scored on a five-point scale from absent to severe. Inter-rater
work, finance,
health,
relationships,
legal and other. The interview was modified and extended to make a detailed assessment of any chronic social difficulties, for example marital and housing problems. Ratings of ‘¿objective negative impact' and ‘¿the degree of independence' for each life event was made by the interviewers (as recommended by Paykel & Mangen, 1980,
The mother and child were observed at play in three situations each lasting three minutes. The mother was asked to behave as she usually would. Firstly, the child was given a large plastic nut and bolt; this was chosen as a simple toy which was likely to interest the child only briefly and would require substantial effort by the mother to sustain the child's interest. Secondly, the child was given a toy hippopotamus which could be pulled on a string; also five plastic shapes could be posted through the animal's back and retrieved from its mouth. This was chosen as a more complex toy, which was likely to interest but also to frustrate the child if the mother did not help. Thirdly, the child was given a picture book and the mother
was asked to read it with the child. These situations were chosen in order to assess how the mother and child dealt with them; for example, how the
child approached the toy, and how the mother maintained the child's interest and dealt with any difficulties. For this purpose six categories of behaviour were defined:
(a) child approaches assessor with/without toy (b) child plays with toy without involving mother (c) child and mother interact verbally or non-verbally in playing with toy
(d) mother ignores child (e) mother facilitates child (this fifth category, derived from the work of Mills eta! (1985), was defined as any maternal behaviour (verbal or non-verbal) which
48
STEIN ET AL Table 2 Structured play results for (a) 49 cases v. 49 controls, (b) 25 recovered cases v. 25 controls, and (c) 14 index subjects with severechronic social difficulties (SCSD)v. 35 index subjects without SCSD Structured
play items(a)(b)(C)ControlsCasesCasesSCSD
Non-SCSD(n=49)(n=49)(n=25)(n=14) (n=35)Mean
MeanZMeanZMeanMean
ZChild playsalone3.1 0.47Child turnstoobserver0.3 0.9Child's affective sharing3.8 2.1―Mother and child interact21.1 1.5Motherignoreschild0.8 1.74Motherfacilitates20.9
3.60.793.40.5473.63.6 0.51.30.20.590.60.5
2.42.9―2.52.24―1.13.0 17.02.7―17.71.614.118.3 1.51.161.61.342.41.1 15.82.78―17.11.91'10.817.8
2.4―
‘¿P
