J . Child Psychol. Psychiat., Vol. 17, 1976, pp. 75 to 78. Pergamon Press. Printed in Great Britain.
DEPRESSION IN MOTHERS OF PRESCHOOL CHILDREN NAOMI RICHMAN* CARE OF children is primarily the responsibility of the mother or mother substitute in our society and the emotional well-heing of hoth mother and child are mutually dependent. The ability to respond to the demands of young children requires considerable emotional and physical resources which depression is likely to impair (Weismann et al., 1972). Estimated rates of depressive disturbances in women vary considerably depending on the method of evaluation and whether they are derived from hospital admissions and outpatient attendances (Bransby, 1974), general practice consultations (Shepherd et al., 1966) or community surveys. Most surveys have not looked at the effect of having children on the prevalence of depression but there is some evidence that women with young children have particularly high rates of depression. Two community surveys in two different London Boroughs using a clinical interview to identify the presence of depression found rates of between 26 and 40 per cent in women with young children (Brown et al., 1975; Richman, 1975); the highest rate was in working class women with a child under six (Brown et al., 1975). Factors predisposing to depression are likely to act in an interactive or accumulative manner. Brown et al. (1973) showed that women who were depressed had experienced more acutely stressful events and chronic stresses during the previous year, a finding confirmed by others (Paykel, 1974). Four vulnerability factors predisposed women to develop depression under stress; these were lack of a confiding relationship with husband or boyfriend, not going out to work, having lost their own mother before the age of 11, and having three or more children under 14. In general, working class women had higher rates of depression than middle class women, particularly those with a child under six; they had more stresses in their lives but their increased susceptibility was primarily due to having a heavier loading on all the vulnerability factors except not going out to work (Brown et al., 1973). In general depressed women appear to have less material and social resources than comparable groups of non-depressed women (Weismann and Paykel, 1974). Financial and housing difficulties are amongst the predisposing chronic stresses and it may be that housing is especially important to young families because of the mother's lack of mobility, her reliance on neighbours, the long hours she spends working in the house, and the children's needs for safe and adequate space to play in. Flat living may be particularly stressful for some women (Richman, 1975). In a sample of families with a preschool child, Richman (1975) found that women living in council fiats were more likely to be depressed than those in council houses. This finding was not confirmed by Moore (1974) who does not however separate out the children by age.
•Senior Lecturer, Academic Department of Child Psychiatry, Institute of Child Health, London University, London WCl, U.K. 75
76
NAOMI RICHMAN
Caring for young children could in itself be considered a chronic stress, especially if the child is physically or mentally handicapped, because of the pressure of the child's needs, a relatively isolated existence, and little opportunity for relaxation or stimulation outside the home (Gavron, 1966). Doubts about the correct way to bring up babies and young children and lack of any previous experience with them add to women's anxieties (Lopota, 1971). It has been suggested that it is the balance between positive and negative experiences which determine whether a person becomes depressed, and for the mother at home with young children it may be very difficult for her to achieve a satisfying balance (Philips, 1968). The effects of childbirth may contribute to the increased rates of depression in women with babies. It appears to act as a precipitating factor in women who are susceptible to psychotic illness (mainly in the form of affective disorders) which increases in prevalence during the puerperium to ca. 1 per 500 births. Their course is no different from other psychotic illnesses and may be prolonged (Protheroe, 1969). However most of the depressive illnesses seen after childbirth are less severe although they may also be chronic. In a general practice population the rate of depression was increased fivefold in the three months after delivery compared with the rate during pregnancy (Ryle, 1961). Pitt (1968) described depression in 10 per cent of women following childbirth; in 4 per cent it continued for over a year. Information derived from a postal questionnaire showed that 25 per cent of wonien still had six or more symptoms one year later which they had developed following childbirth (Jacobsen et al., 1965). How much these symptoms are hormonal in origin, and how much due to fatigue and the responsibilities of the new baby is not known; as yet it does not seem possible to predict who will become depressed during the puerperium (Gordon et al., 1965) although those with a history of previous psychotic breakdown are at increased risk (Paffenburger, 1964). What are the effects of depression on the children? Psychiatric disturbance in the mother is related to behaviour problems in preschool children both in clinic populations (Wolff, 1961) and in the community (Richman, 1975). When the content of depressive thought is directed towards the child, as often happens in puerperal psychosis, e.g. hostile feelings, fear of harming the child, anxiety that the child is abnormal or not getting enough to eat, the child seems to suffer more (Rutter, 1966). In extreme cases alternative care has to be provided, but even when this does not happen it is not surprising that a depressed woman finds it hard to cope with the demands made on her (Weismann et al., 1972). The risk of her losing control and physically abusing the children may also be increased in depression (Richman, 1975). Apart from the possibility of the child being taken into care and/or the mother going into hospital, it could be that the experience of parental depression as a young child has long term effects on emotional well being, which might be especially marked in girls. How far can our present knowledge assist in prevention and treatment? A number of measures could diminish stress in the lives of women with children and possibly help to prevent depressions or. alleviate them—since social stresses appear to contribute to the development and chronicity of neurotic illnesses (Cooper et al., 1970; Kedward and Sylph, 1974; Brown et al., 1975). These should include adequate finance, housing and playspace, and provision of sufficient preschool facilities of
ANNOTATIONS
77
various types. Going out to work may protect a woman from hecoming depressed (Brown et al., 1973) or contribute to her recovery (Mostow and Newherry, 1975) and women who want to work should he ahle to do so. More experimentation is needed to find the most effective measures for dealing with depression. Closer co-operation with adult psychiatrists would be useful so that they recognise the stress of child rearing, and appreciate that "social" and "medical" approaches are not mutually exclusive. For instance, a day hospital for adults can he combined with a nursery group for their children (Radford et al., 1974). Self help groups may become an important means for women to break through their feelings of helplessness and isolation; and an organised paid neighbourhood group might help effectively with many incipient problems by providing support and information about services, e.g. to women after childbirth, to families with a handicapped child. The difficulties and confiicts of women's role in society today are being increasingly acknowledged (Gove and Tudor, 1973)* and are perhaps most obvious in women with young children. We need to consider further how these problems contribute to the development of depression and whether therapeutic efforts take them sufficiently into account. REFERENCES BRANSBY, E . R . (1974) The extent of mental illness in England and Wales. Hlth Trends 6, 56-59. BROWN, G . W . , HARRIS, T . O . and PETO, S. (1973) Life events and psychiatric disorders—2. Nature of causal link. Psychol. Med. 3, 159-176. BROWN, G . W . , BHROLCHAIN, M . N . and HARRIS, T . (1975) Social class and psychiatric disturbance among women in an urban population. Sociology 9, 225-254. COOPER, B., EASTWOOD, M . R . and SYLPH, J. (1970) Psychiatric morbidity and social adjustment in a general practice population. In Psychiatric Epidemiology: An International Symposium (Edited by HARE, E . H . and WING, J. K.), pp. 198-309. Oxford University Press, London. GAVRON, H . (1966) The Captive Wife. Conflicts of Housebound Mothers. Routledge & Kegan Paul, London. GORDON, R . , KOPOSTINS, E . and GORDON, K . (1965) Factors in post-partum emotional adjustment. Obstet. Gynecol. 25, 158-166. GOVE, W . R . and TUDOR, J. F. (1973) Adult sex roles and mental illness. In Changing Women in a Changing Society (Edited by HUBER, J.). University Chicago Press, Chicago. JACOBSON, L . , KAIJ, L . and NILLSON, A. (1965) Post partum mental disorders in an unselected sample. Frequency of symptoms and predisposing factors. Br. Med. J. 1, 1640-1643. KEDWARD, M . B. and SYLPH, J. (1974) Social correlates of chronic neurotic disorder. Soc. psychiat. 9, 91-98. LOPOTA, H . Z . (1971) Occupation Housewife. Oxford University Press, London. MOORE, N . C . (1974) Psychiatric illness and living in flats. Br. J . Psychiat. 125, 500-507. MOSTOW, E . and NEWBERRY, P. (1975) Work role and depression in women. A comparison of workers and housewives in treatment. Am. J. Orthopsychiat. 45, 538-548. NATHANSON, C . (1975) Illness and the feminine role: a theoretical review. Soc. Sci. Med. 9, 57-62. PAFFENBURGER, R . S. (1964) Epidemiological aspects of post partum mental illntss.Br. J. Prev. Soc. Med. 18, 189-195. PAYKEL, E . S. (1974) Life events and acute depression. In Separation and Anxiety: Clinical and Research Aspects (Edited by SCOTT, J. P. and SENAY, E . ) . Am. Ass. Advancement of Science, Chicago. •Nathanson (1975).
78
NAOMI RICHMAN
PHILIPS, D . L . (1968) Social class and psychological disturbance: the influence of positive and negative experience. Soc. Psychiat. 3, 41-46. PITT, B. (1968) Atypical depression following childbirth. Br. J. Psychiat. 114, 1325. PROTHEROE, C . (1969) Puerperal psychosis: a long-term study 1927-1961. Br. J. Psychiat. 115, 9-30. RADFORD, M . , POUND, A., LINDSEY, C . and WILLIAMS, I. (1974) Introduction of an observation and
treatment group for mothers and young children to an adult psychiatric day hospital. (Unpublished.) RICHMAN, N . (1974) The effects of housing on preschool children and their mothers. Develop. Med. Child. Neurol. 16, 53-58. RICHMAN, N . Behaviour problems in preschool children: Family and social factors. Submitted for publication. RUTTER, M . (1966) Children of Sick Parents. Maudsley Monogr., Oxford University Press, London. RYLE, A. (1961) The psychological disturbances associated with 345 pregnancies in 137 women. J . Ment. Sci. 107, 279-286. SHEPHERD, M . , COOPER, B., BROWN, A. C. and KALTON, G . W . (1966) Psychiatric Illness in General
Practice. Oxford University Press, London. WEISMANN, M . , PAYKEL, E . S . and KLERMAN, G . L . (1972) The depressed woman as a mother.
Soc. Psychiat. 7, 98-108. WEISMANN, M . and PAYKEL, E . (1974) The Depressed Woman: A Study of Social Relationships. Univ. Chicago Press, Chicago. WOLFF, S . (1961) Social and family background of preschool children with behaviour disorders attending a child guidance clinic. J. Child Psychol. Psychiat. 2, 260-268.
DEPRESSION IN MOTHERS OF PRESCHOOL CHILDREN NAOMI RICHMAN* CARE OF children is primarily the responsibility of the mother or mother substitute in our society and the emotional well-heing of hoth mother and child are mutually dependent. The ability to respond to the demands of young children requires considerable emotional and physical resources which depression is likely to impair (Weismann et al., 1972). Estimated rates of depressive disturbances in women vary considerably depending on the method of evaluation and whether they are derived from hospital admissions and outpatient attendances (Bransby, 1974), general practice consultations (Shepherd et al., 1966) or community surveys. Most surveys have not looked at the effect of having children on the prevalence of depression but there is some evidence that women with young children have particularly high rates of depression. Two community surveys in two different London Boroughs using a clinical interview to identify the presence of depression found rates of between 26 and 40 per cent in women with young children (Brown et al., 1975; Richman, 1975); the highest rate was in working class women with a child under six (Brown et al., 1975). Factors predisposing to depression are likely to act in an interactive or accumulative manner. Brown et al. (1973) showed that women who were depressed had experienced more acutely stressful events and chronic stresses during the previous year, a finding confirmed by others (Paykel, 1974). Four vulnerability factors predisposed women to develop depression under stress; these were lack of a confiding relationship with husband or boyfriend, not going out to work, having lost their own mother before the age of 11, and having three or more children under 14. In general, working class women had higher rates of depression than middle class women, particularly those with a child under six; they had more stresses in their lives but their increased susceptibility was primarily due to having a heavier loading on all the vulnerability factors except not going out to work (Brown et al., 1973). In general depressed women appear to have less material and social resources than comparable groups of non-depressed women (Weismann and Paykel, 1974). Financial and housing difficulties are amongst the predisposing chronic stresses and it may be that housing is especially important to young families because of the mother's lack of mobility, her reliance on neighbours, the long hours she spends working in the house, and the children's needs for safe and adequate space to play in. Flat living may be particularly stressful for some women (Richman, 1975). In a sample of families with a preschool child, Richman (1975) found that women living in council fiats were more likely to be depressed than those in council houses. This finding was not confirmed by Moore (1974) who does not however separate out the children by age.
•Senior Lecturer, Academic Department of Child Psychiatry, Institute of Child Health, London University, London WCl, U.K. 75
76
NAOMI RICHMAN
Caring for young children could in itself be considered a chronic stress, especially if the child is physically or mentally handicapped, because of the pressure of the child's needs, a relatively isolated existence, and little opportunity for relaxation or stimulation outside the home (Gavron, 1966). Doubts about the correct way to bring up babies and young children and lack of any previous experience with them add to women's anxieties (Lopota, 1971). It has been suggested that it is the balance between positive and negative experiences which determine whether a person becomes depressed, and for the mother at home with young children it may be very difficult for her to achieve a satisfying balance (Philips, 1968). The effects of childbirth may contribute to the increased rates of depression in women with babies. It appears to act as a precipitating factor in women who are susceptible to psychotic illness (mainly in the form of affective disorders) which increases in prevalence during the puerperium to ca. 1 per 500 births. Their course is no different from other psychotic illnesses and may be prolonged (Protheroe, 1969). However most of the depressive illnesses seen after childbirth are less severe although they may also be chronic. In a general practice population the rate of depression was increased fivefold in the three months after delivery compared with the rate during pregnancy (Ryle, 1961). Pitt (1968) described depression in 10 per cent of women following childbirth; in 4 per cent it continued for over a year. Information derived from a postal questionnaire showed that 25 per cent of wonien still had six or more symptoms one year later which they had developed following childbirth (Jacobsen et al., 1965). How much these symptoms are hormonal in origin, and how much due to fatigue and the responsibilities of the new baby is not known; as yet it does not seem possible to predict who will become depressed during the puerperium (Gordon et al., 1965) although those with a history of previous psychotic breakdown are at increased risk (Paffenburger, 1964). What are the effects of depression on the children? Psychiatric disturbance in the mother is related to behaviour problems in preschool children both in clinic populations (Wolff, 1961) and in the community (Richman, 1975). When the content of depressive thought is directed towards the child, as often happens in puerperal psychosis, e.g. hostile feelings, fear of harming the child, anxiety that the child is abnormal or not getting enough to eat, the child seems to suffer more (Rutter, 1966). In extreme cases alternative care has to be provided, but even when this does not happen it is not surprising that a depressed woman finds it hard to cope with the demands made on her (Weismann et al., 1972). The risk of her losing control and physically abusing the children may also be increased in depression (Richman, 1975). Apart from the possibility of the child being taken into care and/or the mother going into hospital, it could be that the experience of parental depression as a young child has long term effects on emotional well being, which might be especially marked in girls. How far can our present knowledge assist in prevention and treatment? A number of measures could diminish stress in the lives of women with children and possibly help to prevent depressions or. alleviate them—since social stresses appear to contribute to the development and chronicity of neurotic illnesses (Cooper et al., 1970; Kedward and Sylph, 1974; Brown et al., 1975). These should include adequate finance, housing and playspace, and provision of sufficient preschool facilities of
ANNOTATIONS
77
various types. Going out to work may protect a woman from hecoming depressed (Brown et al., 1973) or contribute to her recovery (Mostow and Newherry, 1975) and women who want to work should he ahle to do so. More experimentation is needed to find the most effective measures for dealing with depression. Closer co-operation with adult psychiatrists would be useful so that they recognise the stress of child rearing, and appreciate that "social" and "medical" approaches are not mutually exclusive. For instance, a day hospital for adults can he combined with a nursery group for their children (Radford et al., 1974). Self help groups may become an important means for women to break through their feelings of helplessness and isolation; and an organised paid neighbourhood group might help effectively with many incipient problems by providing support and information about services, e.g. to women after childbirth, to families with a handicapped child. The difficulties and confiicts of women's role in society today are being increasingly acknowledged (Gove and Tudor, 1973)* and are perhaps most obvious in women with young children. We need to consider further how these problems contribute to the development of depression and whether therapeutic efforts take them sufficiently into account. REFERENCES BRANSBY, E . R . (1974) The extent of mental illness in England and Wales. Hlth Trends 6, 56-59. BROWN, G . W . , HARRIS, T . O . and PETO, S. (1973) Life events and psychiatric disorders—2. Nature of causal link. Psychol. Med. 3, 159-176. BROWN, G . W . , BHROLCHAIN, M . N . and HARRIS, T . (1975) Social class and psychiatric disturbance among women in an urban population. Sociology 9, 225-254. COOPER, B., EASTWOOD, M . R . and SYLPH, J. (1970) Psychiatric morbidity and social adjustment in a general practice population. In Psychiatric Epidemiology: An International Symposium (Edited by HARE, E . H . and WING, J. K.), pp. 198-309. Oxford University Press, London. GAVRON, H . (1966) The Captive Wife. Conflicts of Housebound Mothers. Routledge & Kegan Paul, London. GORDON, R . , KOPOSTINS, E . and GORDON, K . (1965) Factors in post-partum emotional adjustment. Obstet. Gynecol. 25, 158-166. GOVE, W . R . and TUDOR, J. F. (1973) Adult sex roles and mental illness. In Changing Women in a Changing Society (Edited by HUBER, J.). University Chicago Press, Chicago. JACOBSON, L . , KAIJ, L . and NILLSON, A. (1965) Post partum mental disorders in an unselected sample. Frequency of symptoms and predisposing factors. Br. Med. J. 1, 1640-1643. KEDWARD, M . B. and SYLPH, J. (1974) Social correlates of chronic neurotic disorder. Soc. psychiat. 9, 91-98. LOPOTA, H . Z . (1971) Occupation Housewife. Oxford University Press, London. MOORE, N . C . (1974) Psychiatric illness and living in flats. Br. J . Psychiat. 125, 500-507. MOSTOW, E . and NEWBERRY, P. (1975) Work role and depression in women. A comparison of workers and housewives in treatment. Am. J. Orthopsychiat. 45, 538-548. NATHANSON, C . (1975) Illness and the feminine role: a theoretical review. Soc. Sci. Med. 9, 57-62. PAFFENBURGER, R . S. (1964) Epidemiological aspects of post partum mental illntss.Br. J. Prev. Soc. Med. 18, 189-195. PAYKEL, E . S. (1974) Life events and acute depression. In Separation and Anxiety: Clinical and Research Aspects (Edited by SCOTT, J. P. and SENAY, E . ) . Am. Ass. Advancement of Science, Chicago. •Nathanson (1975).
78
NAOMI RICHMAN
PHILIPS, D . L . (1968) Social class and psychological disturbance: the influence of positive and negative experience. Soc. Psychiat. 3, 41-46. PITT, B. (1968) Atypical depression following childbirth. Br. J. Psychiat. 114, 1325. PROTHEROE, C . (1969) Puerperal psychosis: a long-term study 1927-1961. Br. J. Psychiat. 115, 9-30. RADFORD, M . , POUND, A., LINDSEY, C . and WILLIAMS, I. (1974) Introduction of an observation and
treatment group for mothers and young children to an adult psychiatric day hospital. (Unpublished.) RICHMAN, N . (1974) The effects of housing on preschool children and their mothers. Develop. Med. Child. Neurol. 16, 53-58. RICHMAN, N . Behaviour problems in preschool children: Family and social factors. Submitted for publication. RUTTER, M . (1966) Children of Sick Parents. Maudsley Monogr., Oxford University Press, London. RYLE, A. (1961) The psychological disturbances associated with 345 pregnancies in 137 women. J . Ment. Sci. 107, 279-286. SHEPHERD, M . , COOPER, B., BROWN, A. C. and KALTON, G . W . (1966) Psychiatric Illness in General
Practice. Oxford University Press, London. WEISMANN, M . , PAYKEL, E . S . and KLERMAN, G . L . (1972) The depressed woman as a mother.
Soc. Psychiat. 7, 98-108. WEISMANN, M . and PAYKEL, E . (1974) The Depressed Woman: A Study of Social Relationships. Univ. Chicago Press, Chicago. WOLFF, S . (1961) Social and family background of preschool children with behaviour disorders attending a child guidance clinic. J. Child Psychol. Psychiat. 2, 260-268.
