Treating postpartum depression benefits babies

© 2021 Gwen Dewar, Ph.D., all rights reserved
baby sleeping on mother's shoulder

Treating postpartum depression is crucial for the well-being of mothers, but studies suggest that it benefits babies, too — improving an infant’s ability to regulate emotions.

Imagine you’re a baby in a researcher’s laboratory. You are sitting on your mother’s lap, facing forward, gazing at a friendly stranger.

You are wearing a little EEG cap on your head — a device fitted with electrodes for detecting brain activity. You also having your heart rate monitored, though you don’t realize it.

The main thing occupying your attention is the friendly stranger. She’s holding an interesting toy in front of your face.

How do you react? What sorts of physiological changes do you experience?

It depends, of course, on a lot of things, including your personal temperament. But it also depends on whether or not your mother is clinically depressed.

When women suffer from postpartum depression, or PPD, their infants tend to be less soothable and less cuddly. Their babies show less pleasure or enjoyment during laid-back, low key activities. Their babies pay less attention to things, too.

And in a situation like this — meeting a friendly stranger — these babies are more likely to experience physiological reactions that are linked with stress, negative emotions, and behavior problems.

For example, take brain activity. If you’re a baby meeting a friendly stranger, a healthy response is to show heightened electrical activity on left side of the frontal regions of the brain. This pattern of asymmetry (left over right) is linked with the development of better emotion regulation.

But when babies are growing up with depressed mothers, they may show the opposite pattern — greater electrical activity on the right side of the frontal cortex. It’s a pattern associated with negative emotions and social withdrawal.

What about the beating of your heart? When you meet someone new, the ideal response is to experience lots of variability in heart rate. It’s an indication that you can switch gears quickly, that you’re flexible. Not overly stressed-out.

But unfortunately, infants with depressed mothers tend to experience lower levels of heart variability. And that’s a sign that something isn’t right — that the brain is having more trouble coping with stress.

There is indication of other trouble, too. Links between maternal depression and developmental problems.

Babies who have depressed mothers are at higher risk for poor cognitive outcomes.

They tend to develop language abilities at a slower pace.

They are more likely to develop behavior problems and mood disorders (Slomian et al 2019).

Why is maternal depression linked with worse child outcomes?

To some degree, it’s a reflection of shared genes. Genetic factors can put a woman at higher risk for emotional difficulties — including postpartum depression. If her child inherits these genetic factors, that child is more likely to develop problems with emotional regulation.

But there’s also a big environmental component.

When parents are depressed, they don’t relate to their children in the same way.

They may show less warmth, closeness, or sensitivity, and they are less likely engage their kids in responsive, contingent, turn-taking conversations (Bind et al 2021).

In addition, studies suggest that depressed parents are less likely to read to their children, or to play games with them. They are less likely to share smiles and positive emotions (Slomian et al 2019).

So depression makes it harder for parents to “tune in” to their children. It can set the parent-child relationship on the wrong track, and prevent parents from providing kids with crucial learning experiences. Little wonder if children struggle.

Disturbing? Of course. But this isn’t a tale of doom and gloom. With support, parents can recover from depression. And when parents get treatment, children benefit.

Evidence that treating postpartum depression helps infants develop better emotion regulation

How can we test the idea that treating postpartum depression is beneficial to babies?

Controlled, randomized experiments are usually the best way to answer such questions. But here we have a big ethical problem. Nobody wants to take a bunch of depressed mothers, and randomly assign families to different experimental conditions.

Provide some mothers with psychotherapy, and ignore the rest. Then see how their babies turn out.

Not very humane.

So John Krzeczkowski and his colleagues — researchers at McMaster University — have tried another approach.

First, you recruit mothers who have been diagnosed with major depressive disorder in the 12 months since giving birth.

Then you match these mothers with a control group — women who aren’t depressed, but who have babies of the same age and sex, and who come from similar socioeconomic backgrounds.

The next step is to test all the babies. Find out what they are like at baseline — before you help the depressed mothers.

After these preliminary tests, you provide the struggling mothers with therapy. Then you re-test the babies, and see if the children of depressed mothers have improved. Are they reacting the same as before? Or are they beginning to look more like the healthy children of non-depressed mothers?

Krzeczkowski and his team did this in two separate studies, and in both cases, they saw babies change over time.

In one study, researchers tested babies’ reactions to that “friendly-stranger-with-a-toy” situation.  

The babies with depressed mothers showed evidence of poorer emotional regulation on every measure —  lower scores on behaviors like soothability; greater electrical activity on the right side of the frontal cortex; and reduced heart rate variability.

But that was before mothers completed 9 weeks of cognitive behavioral therapy, a type of “talk” therapy that helps you identify maladaptive thinking and habits, and then replace these with effective, problem-solving strategies.

After this treatment, the babies improved — so much so that their responses were indistinguishable from those of infants in the control group.  They reacted and behaved like the babies of mothers who had never experienced postpartum depression (Krzeczkowski et al 2020).

That’s good news, and it was echoed in a second study, a study where the researchers tested how babies responded to a potentially disturbing sight — their own mothers staring at them with a wooden, emotionless expression.

There was a notable difference between groups at the beginning of the study. Babies with depressed mothers were more likely to respond to the “still face” by acting sad, or attempting to disengage.

But after their mothers received cognitive behavioral therapy, these babies became less withdrawn, eventually reaching a point where their responses to the “still face” were indistinguishable from those of babies whose mothers had never struggled with postpartum depression (Ntow et al 2021).

Does this mean that everything will go well if mothers get treatment for postpartum depression?

Treatment is really important, especially given how long-lasting postpartum depression can be. In a recent study of American mothers, 25% were still experiencing depression symptoms at three years postpartum (Putnick et al 2020). This isn’t something you want to “wait out.”

But it’s also crucial to realize that treating postpartum depression is only part of the solution.

As noted above, depression can steer the parent-child relationship off-course. It’s not unusual for families to get caught up in a vicious circle — reacting to each other in ways that keep triggering more negativity. Recovering from depression is helpful, but it won’t necessarily change all of these behaviors. Not if they’ve become habits.

So sometimes treating the depression isn’t enough. Parents may need help getting the parent-child relationship back on track. This includes learning to read their babies’ behavioral cues, and coming up with the best responses to challenging behaviors — responses that will enhance the parent-child bond, and support the development of emotional and social skills.

What’s a good therapy for improving parent-child interactions?

Researchers have tested a number of approaches, including these:

  • Video feedback. The parent and child are video-recorded during everyday activities; a trained therapist shares highlights with the parent, calling attention to moments where the parent was especially attuned to the child’s signals.
  • Parent-infant psychotherapy. A therapist meets with both parent and child, and helps the parent discover an individualized approach to improving the child’s behavior.
  • Parent-child interaction therapy (PCIT). An approach for coping with behavior problems in children ages 2-7, PCIT provides parents with “live” coaching.
  • Group-based interventions that combine direct instruction (on how to better understand your child’s cues) with real-time practice.

There are studies supporting the use of these approaches, but unfortunately much of the research lacks rigorous controls. So experts often rate the evidence as mixed or inconclusive.

For instance, a recent meta-analysis of published studies reports “…moderate‐certainty evidence that video feedback may improve sensitivity in parents of children who are at risk for poor attachment outcomes due to a range of difficulties.” But it also finds “no evidence of the effectiveness of video feedback on child behaviour” (O’Hara et al 2019).

Similarly, another meta-analysis has concluded that while parent-child psychotherapy “is a promising model in terms of improving infant attachment security in high-risk families, there were no significant differences compared with no treatment or treatment-as-usual for other parent-based or relationship-based outcomes” (Barlow et al 2015).

But I think it’s a good bet that any approach is worthwhile if it helps you (1) foster positive emotions and defuse stress; (2) understand and tune into your baby; and (3) feel respected, supported, and capable.

Along these lines, a recent study published in Australia reports positive results for a group-based parenting program for mothers recovering from depression.

All mothers in the study received cognitive behavioral therapy for postpartum depression, but only half of them were randomly assigned to receive an additional treatment — four special sessions that focused on observing and understanding infant cues, and learning how to respond to these cues in ways that promote good feelings and a healthy attachment bond (Holt et al 2021; Milgrom and Holt 2014).

Compared to mother-infant pairs in the control group, mother-infant pairs in the treatment group were less likely — six months later — to experience impaired bonding (Holt et al 2021).

More information about postpartum depression, treatment, and improving parent-child interactions

What are the signs and symptoms of postpartum depression? How to doctors distinguish between postpartum depression and less severe mood disorders? Read more about it in the Parenting Science article, “Postpartum depression symptoms: When is it more than the “baby blues?”

And for more information about keeping the parent-child relationship on track, check out these Parenting Science offerings:

References: Treating postpartum depression

Barlow J, Bennett C, Midgley N, Larkin SK, Wei Y. 2015. Parent-infant psychotherapy for improving parental and infant mental health. Cochrane Database Syst Rev. 1:CD010534.

Bind RH, Biaggi A, Bairead A, Du Preez A, Hazelgrove K, Waites F, Conroy S, Dazzan P, Osborne S, Pawlby S, Sethna V, Pariante CM. 2021. Mother-infant interaction in women with depression in pregnancy and in women with a history of depression: the Psychiatry Research and Motherhood – Depression (PRAM-D) study. BJPsych Open. 7(3):e100.

Holt C, Gentilleau C, Gemmill AW, Milgrom J. 2021. Improving the mother-infant relationship following postnatal depression: a randomised controlled trial of a brief intervention (HUGS). Arch Womens Ment Health. 2021 Mar 19. doi: 10.1007/s00737-021-01116-5. Online ahead of print.

Krzeczkowski JE, Schmidt LA, Van Lieshout RJ. 2020. Changes in infant emotion regulation following maternal cognitive behavioral therapy for postpartum depression. Depress Anxiety. 2021 Apr;38(4):412-421.

McLearn KT, Minkovitz CS, Strobino DM, Marks E, Hou W. 2006. Maternal depressive symptoms at 2 to 4 months post partum and early parenting practices. Arch Pediatr Adolesc Med. 160(3):279-84

Milgrom J and Holt C. 2014. Early intervention to protect the mother-infant relationship following postnatal depression: study protocol for a randomised controlled trial. Trials. 15:385.

Ntow KO, Krzeczkowski JE, Amani B, Savoy CD, Schmidt LA, Van Lieshout RJ. 2021. Maternal and Infant Performance on the Face-to-Face Still-Face Task following Maternal Cognitive Behavioral Therapy for Postpartum Depression.  J Affect Disord. 2021 Jan 1;278:583-591. doi: 10.1016/j.jad.2020.09.101. Epub 2020 Sep 29. PMID: 33032029

O’Hara L, Smith ER, Barlow J, Livingstone N, Herath NI, Wei Y, Spreckelsen TF, and Macdonald G. 2019. Video feedback for parental sensitivity and attachment security in children under five years.  Cochrane Database Syst Rev. 11(11):CD012348.

Putnick DL, Sundaram R, Bell EM, Ghassabian A, Goldstein RB, Robinson SL, Vafai Y, Gilman SE, Yeung E. 2020. Trajectories of Maternal Postpartum Depressive Symptoms. Pediatrics. 146(5):e20200857. doi: 10.1542/peds.2020-0857.

Rogers A, Obst S, Teague SJ, Rossen L, Spry EA, Macdonald JA, Sunderland M, Olsson CA, Youssef G, Hutchinson D. 2020. Association Between Maternal Perinatal Depression and Anxiety and Child and Adolescent Development: A Meta-analysis. JAMA Pediatr. 174(11):1082-1092.

Slomian J, Honvo G, Emonts P, Reginster JY, Bruyère O. 2019. Consequences of maternal postpartum depression: A systematic review of maternal and infant outcomes. Womens Health (Lond). 15:1745506519844044.

Content of “Treating postpartum depression benefits babies” last modifed 7/26/21

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