Arch Womens Ment Health DOI 10.1007/s00737-014-0463-2
REVIEW ARTICLE
Associations between postnatal maternal depression and psychological outcomes in adolescent offspring: a systematic review Camilla Sanger & Jane E. Iles & Catharina S. Andrew & Paul G. Ramchandani
Received: 12 August 2014 / Accepted: 12 September 2014 # Springer-Verlag Wien 2014
Abstract Postnatal depression (PND) affects approximately 10–20 % of new mothers in developed countries, with accumulating research documenting its adverse impact on not only the mother but also the wider family. Longitudinal studies assessing potential effects of maternal PND on offspring are mounting, and it is therefore timely to investigate the long-term psychological outcomes for adolescent offspring who were exposed to PND in infancy. PsycINFO, Medline, and Embase databases were searched with key terms for English language abstracts. Papers of 16 were identified that examined associations between PND and internalising problems, externalising problems, psychopathology, psychosocial, and cognitive outcomes of adolescent offspring. Impaired offspring cognitive outcomes reflected some of the most consistent findings. Conflicting evidence was found for an effect of PND on adolescent offspring internalising and externalising problems and overall psychopathology. Psychosocial outcomes in offspring adolescents indicated a specific adverse effect, although based on only two studies. Significant gender differences across outcomes were found. It was concluded that PND possibly increases risk vulnerability in the presence of recurrent, concurrent, and antenatal maternal depression but that these latter factors alone may be the stronger specific predictors. Limitations of the review are discussed as well as implications for future research and clinical practice. C. Sanger (*) : J. E. Iles : P. G. Ramchandani Academic Unit of Child & Adolescent Psychiatry, The Centre for Mental Health, Hammersmith Hospital Campus Imperial College London, Du Cane Road, London W2 0NN, UK e-mail: [email protected] C. S. Andrew Berkshire Healthcare NHS Foundation Trust, Talking Health Service, 25 Erleigh Road, Reading RG1 5LR, UK C. Sanger Warneford Hospital, The Oxford Institute of Clinical Psychology Training, University of Oxford, Oxford OX3 7JX, UK
Keywords Postnatal depression . Adolescent outcomes . Offspring development . Review
Introduction Postnatal depression (PND) is a serious public health concern, with incidence of between 10 and 20 % in new mothers (Gavin et al. 2005; Wisner et al. 2013). PND not only has direct deleterious consequences for the woman herself but is also associated with marital conflict, depressive symptoms in fathers, and an increased risk of adverse outcomes for offspring in relation to behavioural difficulties, cognitive ability, and emotional functioning (Fihrer et al. 2009; Goodman 2004; Grace et al. 2003). The exact mechanisms of risk transmission between PND and adverse outcomes for offspring are unclear, and likely to be complex and multifactorial, and clearly not all offspring of postnatally depressed women will have these outcomes. The psychological literature has emphasised the importance of timing of maternal depression, with depressive symptoms in the postnatal period representing a sensitive period in infant development, in which the infant may be more susceptible to the effects of depression (Michel and Tyler 2005). One established theory for how these effects might be mediated is through an impaired mother–infant relationship (Murray et al. 2003). Research indicates that mothers with PND are less sensitive and responsive when interacting with their children (Milgrom et al. 2004), which is associated with higher rates of negative emotional expression (Murray et al. 1993) and having a higher likelihood of implementing less predictable and consistent parenting techniques (Beck 1999). The research to date has primarily focused on the impact of PND on early child developmental outcomes, and it is currently unclear as to whether these adverse outcomes extend into adolescence. For the purpose of this review, adolescence will be defined as the period of time between 11 and 18 years
C. Sanger et al.
of age for both its inclusivity across the literature and its clinical relevance. Adolescence is a developmental period when individuals are beginning to individuate from their family and develop a sense of autonomy (Erikson 1968). As such, it is of particular interest as to whether adolescents are still being influenced by their early experiences of a mother with PND, which is the focus of this review. Although depression doubtless affects both mothers and fathers (Wee et al. 2011), for the purpose of this review, all references to PND will relate to that experienced by women. Previous reviews A small number of reviews have explored associations between PND and offspring outcomes; however, these have mainly focused on outcomes in younger children. Beck (1998) conducted a meta-analysis of eight studies, which included offspring up to the age of 10, and one study with adolescent offspring.1 She found small but significant effects between PND and impaired cognitive and emotional development of offspring (r=.18–.22, d=.36–.45). In a subsequent review, Grace et al. (2003) included Beck’s findings, but their additional search did not find any studies that explored PND and offspring outcomes beyond a 7-year follow-up. Overall, they found small effects on cognitive development, with male offspring more adversely impacted. In terms of behavioural problems, their findings were mixed, with some support for PND having a deleterious impact on offspring development up to the age of 5. They also suggested that the later recurrence and chronicity of depression might be more important than early exposure to PND alone. Most recently, Brand and Brennan (2009) published what they described as a “representative overview… rather than an exhaustive review of this area of literature” (Brand and Brennan 2009, p. 442). They included some studies of offspring outcomes into adolescence and reported on the effects of perinatal stress, anxiety, and depression, in association with a range of offspring outcomes. The strongest, most consistent predictors of long-term adverse child outcomes were those associated with maternal antenatal anxiety/stress, exposure to chronic maternal depression, and experience of stressful life events throughout childhood. Like Grace et al. (2003), they concluded that PND might only have a partial predictive value for long-term offspring outcomes. The current review This review sets out to examine whether maternal PND is associated with offspring psychological (cognitive, externalising, internalising, psychosocial, and psychiatric) 1
This study (Margolies 1989) was not included in the current review as it did not meet the inclusion/exclusion criteria.
outcomes; specifically exploring whether the previously found developmental adversity found in early and middle childhood extends into adolescence. To our knowledge, there has been no systematic review in the last 10 years investigating the impact of PND on offspring adolescent outcomes. Therefore, an updated and extended review of the literature and systematic critique of the evidence base is timely. Such information is essential to inform risk models and contribute to the development of preventive early interventions for depressed mothers (and possibly their infants) in the postnatal period as well as relevant interventions for their offspring in adolescence.
Methods Search strategy The principal method of finding papers suitable for the review involved searching EMBASE, MEDLINE, and PsychINFO (through to September 2013) using combinations of the following search terms and subject headings: “child”, “adolescent”, “offspring” and “postnatal depression”, “perinatal depression”, and “postpartum depression”. The search was limited to include studies written in English in peer-reviewed journals, using human populations. The reference lists of identified articles and existing reviews were also searched using the ancestry method. Additionally, key journal contents over the last 2 years were hand-searched (i.e. “Child Development”, “Development and Psychopathology”), as well as correspondence being sent to the principal author of the studies identified in the previous searches to request any relevant articles that may have been missed, and data of any in-press articles. Study selection This search strategy returned a total of 5965 studies, with 3368 articles remaining after removing duplicates. Only studies examining associations between maternal PND and internalising problems, externalising problems, psychopathology, psychosocial, and cognitive outcomes of adolescent offspring were included. Additionally, all study outcomes were required to be based on empirical measures with established psychometric properties. For the purpose of the search, PND was defined as the presence of maternal depressive symptoms within 1 year following birth (Gaynes et al. 2005; Scottish Intercollegiate Guidelines Network [SIGN] 2002), and adolescence was defined as a period from 11 to 18 years of age. Two raters independently filtered the titles/abstracts of the remaining articles according to these inclusion and exclusion criteria. Any discrepancies between raters were discussed with
Postnatal depression and adolescent offspring outcomes
eating disorders, emergent bipolar, or psychosis. It was also used to categorise articles that did not differentiate between psychiatric disorders in their analysis.
an expert third party and resolved accordingly. This resulted in 61 articles undergoing full-text review and 16 original articles meeting all of the above criteria. The flow of studies through the review selection procedure is shown in Fig. 1. Data extraction The articles were initially organised based on the offspring outcome construct being investigated and were split into the following: Cognitive development
Socioemotional development Internalising problems Externalising problems
Overall psychopathology
This included all outcome measures relating to academic, intellectual, IQ, language, and cognitive developmental outcomes. This included all outcome measures relating to social and emotional developmental outcomes. This included symptom ratings or diagnoses related to depression and/or anxiety disorders. This included symptom ratings or diagnoses related to aggression, violence, conduct disorder (CD), oppositional defiant disorder (ODD), and attention deficit hyperactivity disorder (ADHD). This included outcomes that did not fit into either the internalising or externalising constructs, for example,
Fig. 1 Flow diagram of included and excluded studies
Key characteristics (i.e. study design, methodology, sample size, attrition issues, maternal PND diagnosis criteria) of the included articles were extracted based on the PRISMA guidelines (Moher et al. 2009). The data extracted was then reviewed using a descriptive and narrative approach to summarise the key findings (see Tables 1, 2, 3, 4, and 5)
Results Overview Of the 16 studies included in the review, the majority included adolescent outcomes for internalising (n=10) or externalising problems (n=7), with fewer reporting findings relating to cognitive (n=4), psychopathology (n=2), and socioemotional (n=2) adolescent outcomes. All of the studies used a prospective longitudinal design, although the particular methodology and number of follow-up time points varied. The total number of families included in this review at baseline totaled 13,199 across eight cohorts. A number of the studies used the same cohort of participants and investigated more than one of the outcome constructs being explored in this review. The studies accessed participants from a wide range of different countries,
C. Sanger et al.
including the United Kingdom (UK), Barbados, Sweden, Finland, Canada, and North America. Overall, the study sites were based in developed countries, with specific socially disadvantaged populations being targeted in some studies. Although Barbados has been considered a developing country historically, at the time of the research, literacy was reported to be 99 %, and extremes of poverty were not present (Galler et al. 2004; UNICEF 1980). Cognitive development Hay et al. have published a number of reports based on the South London Child Development Study (SLCDS), which followed a UK cohort of 204 socioeconomically disadvantaged urban families from pregnancy. At 11-year follow-up (Hay et al. 2001; n=132; n=29 with PND), the results indicated a significant association between PND and lower full-scale offspring IQ scores at 11 years (t=3.0, p
REVIEW ARTICLE
Associations between postnatal maternal depression and psychological outcomes in adolescent offspring: a systematic review Camilla Sanger & Jane E. Iles & Catharina S. Andrew & Paul G. Ramchandani
Received: 12 August 2014 / Accepted: 12 September 2014 # Springer-Verlag Wien 2014
Abstract Postnatal depression (PND) affects approximately 10–20 % of new mothers in developed countries, with accumulating research documenting its adverse impact on not only the mother but also the wider family. Longitudinal studies assessing potential effects of maternal PND on offspring are mounting, and it is therefore timely to investigate the long-term psychological outcomes for adolescent offspring who were exposed to PND in infancy. PsycINFO, Medline, and Embase databases were searched with key terms for English language abstracts. Papers of 16 were identified that examined associations between PND and internalising problems, externalising problems, psychopathology, psychosocial, and cognitive outcomes of adolescent offspring. Impaired offspring cognitive outcomes reflected some of the most consistent findings. Conflicting evidence was found for an effect of PND on adolescent offspring internalising and externalising problems and overall psychopathology. Psychosocial outcomes in offspring adolescents indicated a specific adverse effect, although based on only two studies. Significant gender differences across outcomes were found. It was concluded that PND possibly increases risk vulnerability in the presence of recurrent, concurrent, and antenatal maternal depression but that these latter factors alone may be the stronger specific predictors. Limitations of the review are discussed as well as implications for future research and clinical practice. C. Sanger (*) : J. E. Iles : P. G. Ramchandani Academic Unit of Child & Adolescent Psychiatry, The Centre for Mental Health, Hammersmith Hospital Campus Imperial College London, Du Cane Road, London W2 0NN, UK e-mail: [email protected] C. S. Andrew Berkshire Healthcare NHS Foundation Trust, Talking Health Service, 25 Erleigh Road, Reading RG1 5LR, UK C. Sanger Warneford Hospital, The Oxford Institute of Clinical Psychology Training, University of Oxford, Oxford OX3 7JX, UK
Keywords Postnatal depression . Adolescent outcomes . Offspring development . Review
Introduction Postnatal depression (PND) is a serious public health concern, with incidence of between 10 and 20 % in new mothers (Gavin et al. 2005; Wisner et al. 2013). PND not only has direct deleterious consequences for the woman herself but is also associated with marital conflict, depressive symptoms in fathers, and an increased risk of adverse outcomes for offspring in relation to behavioural difficulties, cognitive ability, and emotional functioning (Fihrer et al. 2009; Goodman 2004; Grace et al. 2003). The exact mechanisms of risk transmission between PND and adverse outcomes for offspring are unclear, and likely to be complex and multifactorial, and clearly not all offspring of postnatally depressed women will have these outcomes. The psychological literature has emphasised the importance of timing of maternal depression, with depressive symptoms in the postnatal period representing a sensitive period in infant development, in which the infant may be more susceptible to the effects of depression (Michel and Tyler 2005). One established theory for how these effects might be mediated is through an impaired mother–infant relationship (Murray et al. 2003). Research indicates that mothers with PND are less sensitive and responsive when interacting with their children (Milgrom et al. 2004), which is associated with higher rates of negative emotional expression (Murray et al. 1993) and having a higher likelihood of implementing less predictable and consistent parenting techniques (Beck 1999). The research to date has primarily focused on the impact of PND on early child developmental outcomes, and it is currently unclear as to whether these adverse outcomes extend into adolescence. For the purpose of this review, adolescence will be defined as the period of time between 11 and 18 years
C. Sanger et al.
of age for both its inclusivity across the literature and its clinical relevance. Adolescence is a developmental period when individuals are beginning to individuate from their family and develop a sense of autonomy (Erikson 1968). As such, it is of particular interest as to whether adolescents are still being influenced by their early experiences of a mother with PND, which is the focus of this review. Although depression doubtless affects both mothers and fathers (Wee et al. 2011), for the purpose of this review, all references to PND will relate to that experienced by women. Previous reviews A small number of reviews have explored associations between PND and offspring outcomes; however, these have mainly focused on outcomes in younger children. Beck (1998) conducted a meta-analysis of eight studies, which included offspring up to the age of 10, and one study with adolescent offspring.1 She found small but significant effects between PND and impaired cognitive and emotional development of offspring (r=.18–.22, d=.36–.45). In a subsequent review, Grace et al. (2003) included Beck’s findings, but their additional search did not find any studies that explored PND and offspring outcomes beyond a 7-year follow-up. Overall, they found small effects on cognitive development, with male offspring more adversely impacted. In terms of behavioural problems, their findings were mixed, with some support for PND having a deleterious impact on offspring development up to the age of 5. They also suggested that the later recurrence and chronicity of depression might be more important than early exposure to PND alone. Most recently, Brand and Brennan (2009) published what they described as a “representative overview… rather than an exhaustive review of this area of literature” (Brand and Brennan 2009, p. 442). They included some studies of offspring outcomes into adolescence and reported on the effects of perinatal stress, anxiety, and depression, in association with a range of offspring outcomes. The strongest, most consistent predictors of long-term adverse child outcomes were those associated with maternal antenatal anxiety/stress, exposure to chronic maternal depression, and experience of stressful life events throughout childhood. Like Grace et al. (2003), they concluded that PND might only have a partial predictive value for long-term offspring outcomes. The current review This review sets out to examine whether maternal PND is associated with offspring psychological (cognitive, externalising, internalising, psychosocial, and psychiatric) 1
This study (Margolies 1989) was not included in the current review as it did not meet the inclusion/exclusion criteria.
outcomes; specifically exploring whether the previously found developmental adversity found in early and middle childhood extends into adolescence. To our knowledge, there has been no systematic review in the last 10 years investigating the impact of PND on offspring adolescent outcomes. Therefore, an updated and extended review of the literature and systematic critique of the evidence base is timely. Such information is essential to inform risk models and contribute to the development of preventive early interventions for depressed mothers (and possibly their infants) in the postnatal period as well as relevant interventions for their offspring in adolescence.
Methods Search strategy The principal method of finding papers suitable for the review involved searching EMBASE, MEDLINE, and PsychINFO (through to September 2013) using combinations of the following search terms and subject headings: “child”, “adolescent”, “offspring” and “postnatal depression”, “perinatal depression”, and “postpartum depression”. The search was limited to include studies written in English in peer-reviewed journals, using human populations. The reference lists of identified articles and existing reviews were also searched using the ancestry method. Additionally, key journal contents over the last 2 years were hand-searched (i.e. “Child Development”, “Development and Psychopathology”), as well as correspondence being sent to the principal author of the studies identified in the previous searches to request any relevant articles that may have been missed, and data of any in-press articles. Study selection This search strategy returned a total of 5965 studies, with 3368 articles remaining after removing duplicates. Only studies examining associations between maternal PND and internalising problems, externalising problems, psychopathology, psychosocial, and cognitive outcomes of adolescent offspring were included. Additionally, all study outcomes were required to be based on empirical measures with established psychometric properties. For the purpose of the search, PND was defined as the presence of maternal depressive symptoms within 1 year following birth (Gaynes et al. 2005; Scottish Intercollegiate Guidelines Network [SIGN] 2002), and adolescence was defined as a period from 11 to 18 years of age. Two raters independently filtered the titles/abstracts of the remaining articles according to these inclusion and exclusion criteria. Any discrepancies between raters were discussed with
Postnatal depression and adolescent offspring outcomes
eating disorders, emergent bipolar, or psychosis. It was also used to categorise articles that did not differentiate between psychiatric disorders in their analysis.
an expert third party and resolved accordingly. This resulted in 61 articles undergoing full-text review and 16 original articles meeting all of the above criteria. The flow of studies through the review selection procedure is shown in Fig. 1. Data extraction The articles were initially organised based on the offspring outcome construct being investigated and were split into the following: Cognitive development
Socioemotional development Internalising problems Externalising problems
Overall psychopathology
This included all outcome measures relating to academic, intellectual, IQ, language, and cognitive developmental outcomes. This included all outcome measures relating to social and emotional developmental outcomes. This included symptom ratings or diagnoses related to depression and/or anxiety disorders. This included symptom ratings or diagnoses related to aggression, violence, conduct disorder (CD), oppositional defiant disorder (ODD), and attention deficit hyperactivity disorder (ADHD). This included outcomes that did not fit into either the internalising or externalising constructs, for example,
Fig. 1 Flow diagram of included and excluded studies
Key characteristics (i.e. study design, methodology, sample size, attrition issues, maternal PND diagnosis criteria) of the included articles were extracted based on the PRISMA guidelines (Moher et al. 2009). The data extracted was then reviewed using a descriptive and narrative approach to summarise the key findings (see Tables 1, 2, 3, 4, and 5)
Results Overview Of the 16 studies included in the review, the majority included adolescent outcomes for internalising (n=10) or externalising problems (n=7), with fewer reporting findings relating to cognitive (n=4), psychopathology (n=2), and socioemotional (n=2) adolescent outcomes. All of the studies used a prospective longitudinal design, although the particular methodology and number of follow-up time points varied. The total number of families included in this review at baseline totaled 13,199 across eight cohorts. A number of the studies used the same cohort of participants and investigated more than one of the outcome constructs being explored in this review. The studies accessed participants from a wide range of different countries,
C. Sanger et al.
including the United Kingdom (UK), Barbados, Sweden, Finland, Canada, and North America. Overall, the study sites were based in developed countries, with specific socially disadvantaged populations being targeted in some studies. Although Barbados has been considered a developing country historically, at the time of the research, literacy was reported to be 99 %, and extremes of poverty were not present (Galler et al. 2004; UNICEF 1980). Cognitive development Hay et al. have published a number of reports based on the South London Child Development Study (SLCDS), which followed a UK cohort of 204 socioeconomically disadvantaged urban families from pregnancy. At 11-year follow-up (Hay et al. 2001; n=132; n=29 with PND), the results indicated a significant association between PND and lower full-scale offspring IQ scores at 11 years (t=3.0, p
