MATERNAL MENTAL HEALTH AND INFANT HEALTH

Sarah Nagle-Yang MD 12/6/16

GOALS

Motherhood and mental health in the context of trauma •Mental health implications •Obstetrical implications •Parenting implications •What can we do to help?

WHY TRAUMA?

Trauma is common

Trauma informs one’s mental health and worldview

Trauma in mothers has the potential to impact their children in multiple dimensions In utero environment Attachment patterns Parenting practices

WHAT IS TRAUMA: DSM DSM V: “Exposure to actual or threatened death, serious injury, or sexual violence.”

•Combat

•Natural Disaster

•Act of Terrorism

•Assault

•Childhood abuse

•Childhood molestation

•Childhood Neglect

•Prolonged IPV

Circumscribed Prolonged

WHAT IS TRAUMA: TRAUMATIC STRESS

3 Types of stress response Positive Brief, mild-moderate

Available caring adult

Growth promoting

Tolerable More severe in magnitude

Available caring adult facilitates adaptive coping

Toxic Strong, frequent or prolonged

Absence of buffering effect of supportive adult Shonkoff 2012

WHAT IS TRAUMA: ADVERSE CHILDHOOD EVENTS

Felitti 1998

Felitti 1998

TRAUMA AND ATTACHMENT Childhood abuse involves two distinct, intertwined phenomena: occurrence of a physically threatening event failure in the ongoing protective function of

attachment figures

For infants and young children the absence of a familiar protective caregiver is a threat to the integrity of the self.

Lyons-Ruth 2005

Chemical Warfare Drill, WWII London

DIAGNOSES: COMPLEX PTSD

Proposed by Judith Herman in 1992 to describe a syndrome observed in survivors of prolonged, repeated trauma

PTSD field trial for the DSM-IV tested cPTSD as Disorders of Extreme Stress, Not Otherwise Specified (DESNOS) Much overlap with PTSD, so symptoms of DESNOS were listed as associated features of PTSD

Critical evaluation by DSM-V committee

Resick et al. 2012

DIAGNOSTIC PRESENTATION OF CHILDHOOD TRAUMA MDD

PTSD

Borderline Personality Disorder

Dissociative Disorder

Chemical Dependency

Developmental crisis which impacts the formation of self-definition and self-regulation

SYMPTOMATOLOGY: ACE STUDY #ACE Panic Reaction

% Depressed Affect %

Anxiety % Hallucinations %

0 8.3 18.4 7.8 1.3

1 10.9 25.2 9.1 1.5

2 13.6 34.1 12.4 2.3

3 16.8 38.8 14.1 2.9

4+ 20.9 (OR 2.5) 49.0 (3.6) 19.0 (2.4) 4.0 (2.7)

#ACE Sleep Disturbance % Severe Obesity % Mult Somatic Sx %

0 36.3 5.6 5.1

1 41.6 7.4 6.4

2 47.5 8.3 8.6

3 51.1 8.8 8.1

4+ 56.1 (OR 2.1) 11.9 (OR 1.9) 13.9 (OR 2.7) Felitti 1998

SYMPTOMATOLOGY: ACE STUDY #ACE Prevalence and risk of memory

impairment %

0 9.7

1 12.0

2 18.9

3 22.1

4+ 34.0 (OR 4.4)

#ACE High level of perceived stress %

Difficulty Controlling Anger %

Risk of perpetrating IPV %

0 10.5 3.5 1.6

1 13.5 4.9 3.0

2 16.0 8.0 4.0

3 17.8 8.5 5.4

4+ 24.7 (OR 2.2) 14.4 (OR 4.0) 8.8 (OR 5.5)

Felitti 1998

COMORBIDITY: ACE STUDY #ACE Smoking % Alcoholism % Illicit Drug Use % Injected Drug Use

%

0 6.5 2.5 7.9 0.2

1 7.6 5.1 13.8 0.6

2 9.3 7.4 20.0 1.4

3 11.9 10.5 24.9 1.6

4+ 14.5 (OR 1.8) 15.3 (OR 7.2) 35.2 (OR 4.5) 3.7 (OR 11.1)

#ACE Early Intercourse % Promiscuity >30 partners %

0 2.3 3.9 1 5.1 5.2 2 6.6 7.4 3 8.5 8.7 4+ 14.2 (OR 6.6) 10.8 (OR 3.6) Felitti 1998

COMORBIDITY: ACE STUDY #ACE Current Severe

Family Problems % Current Severe Job Problems %

Current Severe Financial Problems %

0 8 4 7

1-2 12 7 13

3-4 16 12 20

5+ 24 (OR 3.3) 16 (OR 2.9) 23 (OR 2.4)

Felitti 1998

impulsivity

Unstable relationships

Illicit drug use

Decreased concentration

smoking

shame

irritability

anger

Self-hate

Preconception promiscuity

Financial stress

alcoholism depression

anxiety

TRAUMA AND PREGNANCY

TRAUMA AND OBSTETRICAL OUTCOME

TRAUMA AND PREGNANCY #ACE Fetal Death in 1st or 2nd Pregnancy (%)

0 11

1-2 13

3-6 14

5+ 16 (1.7)

Characteristic Adjusted OR for Preterm Birth

PTSD and MDD 4.08

At least 1 previous PTD

4.37

Yonkers et al. 2014

Hillis 2004

Webb 2006

PRENATAL STRESS: CHILDHOOD DEVELOPMENTAL/

BEHAVIORAL OUTCOMES

ADHD

Anxiety

Cognitive delays

Language delays Kinsella 2009

FETAL NEUROBEHAVIOR Indices of emerging differences in stress-related neurodevelopment Fetal Heart Rate Variability

Reactivity to a stimulus

Fetal Activity Coupling

Fetuses with abnormal neurobehavior are more likely to be come fussy infants at 6 weeks of age

DiPietro 2008, Kinsella 2009

FETAL NEUROBEHAVIOR DiPietro 2002 Pregnant women who self-report more life

stress are more likely to have a fetus with reduced HR variability and increased movement.

Pressman 1998 Fetuses of women in lower socio–economic

groups, and those of women reporting greater daily stress, and who had a higher resting heart rate, had less FHR and movement coupling compared to higher socio-economic status (SES) women and those with low daily stress scores

CORTISOL IN PREGNANCY pCRH hyper activation of the HPA axis Starting in the 2nd trimester, there is a

considerable rise in the ratio of free/bound cortisol that increases linearly to term As pregnant women progress through gestation,

cortisol response to stress declines, suggesting a blunting of HPA axis

11β-HSD-2 placental enzyme responsible for converting

cortisol to cortisone (inactive) Forms a barrier to maternal glucocortocoids 10-20% of maternal glucocortocoids pass

through May be downregulated by high state or trait

anxiety

Glover 2008, Kinsella 2009

PRENATAL STRESS AND NEONATAL Lundy 1999 Depressed women had higher cortisol and

norepinephrine levels and lower dopamine levels. Their newborns also had higher cortisol and

norepinephrine levels and lower dopamine levels, thus mimicking their mothers’ biochemical profile. The neonates of depressed mothers also showed

inferior performance on the orientation, reflex, excitability, and withdrawal clusters of the Brazelton scale.

FETAL PROGRAMMING Fetal, infant and early childhood brain plasticity makes it particularly sensitive to chemical influences

Evolutionary advantage?

FETAL PROGRAMMING

Monk 2012 Oberlander 2008

FETAL PROGRAMMING

Microarray analysis of fetal brain cells: increased cortisol exposure affects the expression of over a thousand genes

Salaria 2006

impulsivity

Unstable relationships

Illicit drug use

Decreased concentration

smoking

shame

irritability

anger

Self-hate

Postnatal Environment promiscuity

Financial stress

alcoholism

anxiety

depression

King-Hele 2007

TRAUMA AND MOTHERHOOD

Reduced parenting confidence

More malevolent attributions

Boundary distortion

Role reversal

Authoritarian/ Hostile parenting

Permissive/ Helpless style

Increased psychological aggression

Increased use of physical punishment

Alexander 2000, Banyard 2003, Lyons-Ruth 2005, Noll 2009

TRAUMA AND MOTHERHOOD

Disrupted infant attachment

Diminished parenting support

Child Protective Services involvement

Banyard 2003, Noll 2009

MATERNAL DEPRESSION

Depressed moms at 2 to 4 months postpartum report less: Breastfeeding Use of healthy child development

practices (eg: showing books to, playing with or talking to their infant) Routines

Depressed moms at 30 to 33 months postpartum report: More use of harsh discipline (spanking

and slapping) Fewer limits on toddler TV time Fewer safety measures (outlet covers,

safety latches) Less of a daily routine

McLearn 2006

TOXIC STRESS AND THE DEVELOPING

BRAIN Toxic Stress

Cortisol

Loman 2010

Early Experience, Stress and Neurobehavioral Development Research

Network

MARY AINSWORTH: MATERNAL SENSITIVITY Described the mother of a securely attached child as being “capable of perceiving things from {the child’s} point of view” and being able to regard her child “as a separate person; she also respects his activity-in-progress and thus avoids interrupting him.”

Meins 2001

MATERNAL SENSITIVITY: AINSWORTH

1. Sensitivity to baby’s signals ability to perceive and to interpret

accurately the communications implicit in her infant's behavior, and given this understanding, to respond to them appropriately and promptly

2. Cooperation with Baby’s ongoing behavior

3. Physical and Psychological Availability

4. Acceptance of the Baby's Needs

Meins 2001

ATTACHMENT AND SELF-REGULATION

A mother’s capacity to regulate her infant’s fear and distress is crucial to that child’s ultimate feeling of security.

Secure attachment is the direct outcome of successful containment, namely the parent’s capacity to both reflect the infant’s internal state, as well as represent that state for the infant as a manageable experience.

The mutual regulatory processes of early childhood gradually allow for an increase in the child’s ability to self-regulate

Meins 2001

In order to respond sensitively, a parent needs to be able to make sense of her own and her child’s mental states.

TRAUMA AND MOTHERHOOD

Reduced parenting confidence

More malevolent attributions

Boundary distortion

Role reversal

Authoritarian/ Hostile parenting

Permissive/ Helpless style

Increased psychological aggression

Increased use of physical punishment

Alexander 2000, Banyard 2003, Lyons-Ruth 2005, Noll 2009

INTERGENERATIONAL TRANSMISSION OF ATTACHMENT

HOWEVER, a h/o trauma does not necessarily dictate a specific pattern of parenting

Van IJzendoorn 1992: Metanalysis We tend to repeat the automatic attachment and

parenting interactions we experienced However, the intergenerational transmission of

parenting in situations of trauma is more related to the caregiver’s state of mind regarding the trauma than the trauma itself

Van IJzendoorn 1992

WHAT IS MATERNAL REFLECTIVE FUNCTIONING?

A mother’s capacity step back from her own affective experience in order to reflect upon her child’s uniquely subjective intentions during moments of stress or conflict

Painful affect (in either the caregiver or the child) becomes manageable because the caregiver can see painful feelings, or disturbing thoughts, as merely mental states, rather than concrete realities, thus opening the possibility for modulation and change over time.

It is this capacity, in turn, that allows the caregiver, time after time, to remain both emotionally engaged and sufficiently in control, so that she can contain the infant’s distress and transform it into a tolerable experience over which the child can begin to develop a sense of mastery.

Grienenberger 2005

MATERNAL REFLECTIVE FUNCTIONING Negatively correlated with dysfunctional maternal behavior

Grienenberger 2005

Positively correlated with infant attachment security Parents with high RF are more likely to be classified

as autonomous on AAI and to have children who are themselves securely attached

Fonagy 1991

MATERNAL REFLECTIVE FUNCTIONING

High RF in adoptive mothers= lower child externalizing

Higher mind-mindedness Behavioral sensitivity Interactive synchrony

Lundy 2003, Priel 2000

Higher RF in a sample of mothers with significant trauma history was significantly associated with an balanced internal representations of her child

Schechter 2005

WHAT CAN WE DO?

•Recognize maternal mental health disorders as a risk factor for infant morbidity and mortality.

•Prioritize the mental health and wellness of mothers by • destigmatizing mental health treatment, • increasing access to mental health treatment for mothers • increasing parenting supports for women with mental health disorders

WHAT CAN WE DO?

•Educate colleagues and clients about the RISKS of mental health and substance abuse disorders that occur during and after pregnancy.

•If you work in obstetrics or pediatrics, inquire about SCREENING for trauma, mental health and substance use disorders in your practice

•Know about your local MENTAL HEALTH RESOURCES, particularly those that are targeted towards pregnant or postpartum women

•Address the stigma of mental health treatment. Let mothers you work with know that these are COMMON and TREATABLE conditions.

•If you have the opportunity to work directly with a mother-child pair, let that mother know that you VALUE her and are there as a support to HER. Validate that parenthood is hard, and important.

EXAMPLES OF TARGETED INTERVENTIONS Mother-infant Therapy Group for Postpartum Depression Roseanne Clark, U of Wisconsin CBT-based depression group for moms, dyadic

group focused on reflective functioning

Mothers and Toddlers Program Nancy Suchman, Yale Individual therapy program targeting

parenting difficulties among substance abusing mothers Aim to build healthier maternal representation

of their children and higher reflective functioning Results show participants show greater

maternal sensitivity

EXAMPLES OF TARGETED INTERVENTIONS

MOM Power Maria Muzik, U of Michigan 13-week manualized group psychoeducational program for trauma-exposed mothers of young

children ages 0-6 Topics include: Understanding your child’s attachment needs

Restoring your emotional balance

Impact of trauma on one’s own parenting experience

Building a parenting support system

Questions?