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Maternal Depression and Infant Development 2.1 ANCC Contact Hours Maternal Depression and Infant Development: THEORY AND CURRENT EVIDENCE Lisa Miklush PhD, RNC, CNS and Cynthia D. Connelly PhD, RN, FAAN Abstract Maternal depression (MD) is a condition that has wide-ranging effects on the woman, her family, and the broader global society. It is generally agreed that MD is associated with untoward effects on the developmental trajectory of offspring. The aim of this article is to review the historical and theoretical underpinnings informing current thought linking MD with infant development, and to highlight some of the neuroendocrine and epigenetic processes related to MD and its sequelae. A broad understanding of the association between MD and infant developmental outcomes can inform nursing care of the childbearing family. Key Words: Attachment; Bonding; Infant develop- ment; Maternal depression. Chris Rout / Bubbles Photolibrary / Alamy / Bubbles Photolibrary Chris Rout November/December 2013 MCN 369 Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. aternal depression (MD) is a com- infant developmental outcomes. A sustained awareness mon debilitating condition associ- of MD and an appreciation of its potential sequelae are ated with numerous deleterious timely, as they encourage continued efforts to identify effects on individuals, families, and and support affected women and their families, ame- Msociety globally (Horwitz, Briggs- liorating its untoward effects. The specifi c relationship Gowan, Storfer-Isser, & Carter, between a mother and her child is the focus here; 2007; Institute of Medicine, although there is a growing body 2009). Pregnancy and childbirth of literature that addresses the is a time during the life course contribution of paternal care, when women are most vulnera- when present, and the role of care- ble to this and other psychiatric giving by nonparental individuals. disorders (Vesga-Lopez et al., 2008). The reported incidence of Infant Development: depression during this time varies We’ve Come a Long widely, from 5% to 25%, depend- ing on the population characteris- Way, Baby tics, the method of assessment, The many professions that are and the timing of the assessment concerned with the welfare of in- (Gaynes et al., 2005). MD is fre- fants and young children have quently accompanied by other progressed signifi cantly from the disorders—both medical and psy- notion of the infant as a tabula chiatric (Institute of Medicine, rasa (Locke, 1699), experiencing 2009), and there is often an asso- the world as a buzzing confusion ciation between depressive disor- (James, 1890). Throughout the ders before and during pregnancy ensuing centuries, philosophers with postpartum depression (Hor- age fotostock and theorists from Rousseau witz, Briggs-Gowan, Storfer-Isser, (1762) to Vygotsky (1978) have & Carter, 2009). Indeed, Wachs and colleagues (2009) added their individual perspectives to a rich tapestry of assert MD has a somewhat “infectious” nature, where understanding of the physical, cognitive, and socioemo- prenatal depression increases the risk for depression in tional aspects of early development. Although many the postpartum period, which increases the risk for con- theorists focused on delineating the ontogenic process tinuation of depression in the mother, which may initiate itself, other theorists examined the social and ecological depressive symptomatology in her children. determinants of development, with the maternal–infant MD is of particular concern during the perinatal pe- relationship being a primary focus. Intriguing clues to riod, due to its potential impact on fetal, infant, and the centrality of the mother–infant dyad to human devel- child development (Tronick & Reck, 2009). Effects on opment have been provided by early investigations using early ontogenic processes is a prime concern because the nonhuman primates and by human case studies of quality of development that takes place in early life is an maternal deprivation. important determinant of health, learning, and behavior over an individual’s life course, which in turn affects the The Dawning of a New Perspective degree of an individual’s well-being and ability to func- Over the years, many a student sitting in an introductory tion within and contribute to the society at large. Chil- psychology class has been moved at the sight of a baby dren who have attained optimal physical, intellectual, monkey clinging to a surrogate mother made of wire and and social development may be more resilient to the terry cloth. These classic experiments were conducted by vagaries of life, including those imposed by poverty and American psychologist Harry Harlow in the 1950s and violence (World Health Organization, 2004). Conse- 1960s. Like most in the scientifi c community during this quently, investing in early child development pays sig- time, Harlow was infl uenced by Sigmund Freud’s psycho- nifi cant dividends in human and economic development analytic theory, which asserted, among other things, the by fostering the development of productive and capable maternal–infant relationship was paramount in human adults. development (Freud, 1949). Harlow was also infl uenced The association between MD and its potential delete- by the work of René Spitz (1945) who described the det- rious effects on human ontogeny (the development of an rimental effects of the separation of mothers and infants organism) is perhaps intuitive, but the linking of these in state-run hospitals and orphanages in post-World War issues is a product of an extensive history of investiga- II Europe. Spitz reported a lack of maternal contact re- tion and theory development spanning the centuries sulted in what he termed hospitalism, a spectrum of psy- (Table 1). This review describes some of the notable chogenic maladies characterized by arrested growth, historical and theoretical underpinnings that support a lethargy, diverse psychological and behavioral patholo- connection between MD and infant development, and gies, and even death in the institutionalized children. The current research that has measured the impact of MD on incidence of psychopathology and mortality were not 370 volume 38 | number 6 November/December 2013 Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. The most relevant consequence of the obstetric dilemma is the limitation it imposes on the degree of brain development that can occur prenatally. offset by the provision of food and attendance to hygiene of others began a paradigm shift in the fi eld of infant and needs (Spitz, 1945). Intrigued by these fi ndings, Harlow child development. Although it was understood animal conducted a series of investigations examining the mother– models do not fully mimic human behavior, observations infant affectional bond, using rhesus monkeys as a model in nonhuman primates correlated well with human stud- for human behavior. The outcomes of these experiments ies involving maternal deprivation, and thus paved the are a familiar story. Baby monkeys deprived of their way for theorists to develop the important constructs of mothers became emotionally disturbed and demonstrat- bonding (Bowlby, 1988) and attachment (Klaus, Kennel, ed abnormalities in behavior. When baby monkeys were & Klaus, 1995). These theorists began to illuminate the given two surrogate mothers, a bare wire surrogate nature of the relationship between infants and young mother that had a nipple for feeding and a cozier cloth- children with their primary caregivers. covered surrogate, the baby monkeys developed a strong attachment to the cloth surrogates and little or no attach- Attachment, Bonding, and Beyond ment to the bare wire surrogates, regardless of which English child psychiatrist John Bowlby (1988) drew on surrogates provided nourishment. Among other things, the fi ndings of Spitz, Harlow, and other investigators these experiments pointed to the importance of what who focused on the effects of maternal care on early Harlow termed contact comfort (Harlow & Harlow, development (Sumoni, van der Horst, & van der Veer, 1962). However, contact comfort alone was not suffi - 2008). Along with American developmental psychol- cient for normal development to proceed. Harlow also ogist Mary Ainsworth, Bolby described the mutual noted none of the baby monkeys that clung to cloth sur- process by which infants and their primary caregivers rogates developed into normal adolescents or adults— interact with each other, resulting in the formation of neither socially nor sexually. This led Harlow to specu- the intimate emotional attachment bonds. Bowlby and late there must be multiple processes connecting mothers Ainsworth described a variety of infant behaviors that and babies, and maternal–infant social phenomena comprise a repertoire of signals designed to keep the such as vocalizations, gestures, and various other social individual to whom the infant has bonded close at hand, behaviors may be essential elements supporting early thus ensuring the infant’s needs are met. The maternal– developmental processes. Harlow’s work and the work infant social phenomena about which Harlow specu- lated are demonstrated by infant behaviors such as smiles, coos, and eye contact, which are aimed at elicit- Infant development: ing a reciprocal response of warmth and social contact TABLE 1. from caregivers. A brief timeline of thinking The construct of attachment was refi ned by Klaus, Kennel, and Klaus (1995). It is generally
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