Alison E. Hipwell

Mental health of parents caring for infants

Summary¶The postpartum period is a sensitive time due to the presence and demands of the developing infant. The care provided by a mother to her infant during this period may be compromised if she is suffering from postnatal depression or postpartum psychosis. Evidence has been emerging which suggests that postnatal depression and postpartum psychoses have adverse effects on the quality of the mother-infant relationship and also on the infant’s subsequent cognitive and emotional development. Presented is a review of the literature relating to how these conditions impact on parenting and infant outcomes, what measures are in place to detect these conditions and evidence-based models of best clinical practice are proposed.

The Pittsburgh Girls Study: Overview and Initial Findings

The Pittsburgh Girls Study is a longitudinal, community–based study of 2,451 girls who were initially recruited when they were between the ages of 5 and 8 years. The primary aim of the study was testing developmental models of conduct disorder, major depressive disorder, and their co-occurrence in girls. In the current article, we summarize the published findings from the past 5 years of the PGS and place those results in the context of what it known to date about developmental psychopathology in girls. Key results suggest that DSM–IV mental disorders tend to have an insidious onset often beginning with subsyndromal symptom manifestation, and that there appear to be shared and unique developmental precursors to disorder in subgroups of girls based on race and poverty.

Callous-Unemotional Behaviors in Young Girls: Shared and Unique Effects Relative to Conduct Problems

Among girls, little is known about the shared and unique associations that callous-unemotional (CU) behaviors and conduct problems have with aspects of emotional and behavioral dysregulation and with parenting practices. This study examined these associations using a large community-based sample of young girls (N = 990). The findings revealed that hyperactivity–impulsivity and negative emotionality were positively and uniquely associated with conduct problems, but not with CU behaviors, after controlling for co-occurring conduct problems. Conduct problems were also positively associated with both generalized anxiety and panic/somatic anxiety. In contrast, CU behaviors were negatively related to generalized anxiety problems after controlling for co-occurring conduct problems. The results also indicated that conduct problems were more closely associated with harsh punishment and low parental warmth among girls with low versus high CU behaviors.

Depression begets depression: comparing the predictive utility of depression and anxiety symptoms to later depression.

BACKGROUND The high comorbidity between depressive and anxiety disorders, especially among females, has called into question the independence of these two symptom groups. It is possible that childhood anxiety typically precedes depression in girls. Comparing of the predictive utility of symptoms of anxiety with the predictive utility of symptoms of depression from early childhood to early adolescence is needed to test this hypothesis. METHODS Data from a population-based sample of 2,451 girls were used to examine age-related changes and year-to-year stability within and across symptoms of major depression, separation anxiety, and generalized/social anxiety by maternal report from ages 6 to 12. In addition, the predictive utility of symptoms of major depression, separation anxiety, and generalized/social anxiety at ages 7-10 years of age to depressive disorders at ages 11-13 was tested. RESULTS Symptoms of separation anxiety demonstrated a linear decrease, depression symptoms a linear increase and symptoms of generalized/social anxiety an increase from 6-8, a plateau 8-10, followed by a decrease from 10-12 years. Year-to-year changes in symptoms of major depression were best predicted by depressive symptoms in the previous year, although a small amount of additional variance was accounted for by separation anxiety symptoms in early childhood and generalized/social anxiety symptoms in mid to later childhood. Age 8 was the earliest age from which depressive disorders in early adolescence could be predicted from symptoms of depression and generalized social anxiety. CONCLUSIONS Homotypic continuity of depression and anxiety symptoms from early childhood to early adolescence is more common in girls than heterotypic continuity. Some additional information about year-to-year changes in depression symptoms and later depressive disorder is gained by assessing anxiety symptoms. Depressive symptoms themselves, however, appear to be the strongest and most reliable predictor of later depression.

Children of mothers with borderline personality disorder: identifying parenting behaviors as potential targets for intervention.

Children of mothers with borderline personality disorder (BPD) should be considered a high-risk group given the wide array of poor psychosocial outcomes that have been found in these children. This article describes the parenting strategies that might explain the transmission of vulnerability from mothers with BPD to their offspring, from infancy through adolescence. We conclude that oscillations between extreme forms of hostile control and passive aloofness in their interactions with their children may be unique to mothers with BPD. We provide an overview of interventions that are currently recommended for mothers and family members with BPD, namely attachment therapy and psychoeducational approaches. On the basis of an integration of the empirical findings on parenting and child outcomes, as well as from the review of current approaches to intervention, we conclude with recommendations for treatment targets. We argue that mothers with BPD need psychoeducation regarding child development and recommended parenting practices and skills for providing consistent warmth and monitoring, including mindfulness-based parenting strategies.

Contextual risk factors as predictors of disruptive behavior disorder trajectories in girls: the moderating effect of callous‐unemotional features

BACKGROUND The presence of callous-unemotional (CU) features may delineate a severe and persistent form of conduct problems in children with unique developmental origins. Contextual risk factors such as poor parenting, delinquent peers, or neighborhood risk are believed to influence the development of conduct problems primarily in children with low levels of CU features. However, longitudinal studies examining the moderating effect of CU features on the relation between contextual risk factors and conduct problems trajectories in girls are rare. METHODS Growth curve analysis was conducted using five annual measurements of oppositional defiant disorder/conduct disorder (ODD/CD) behaviors in a community sample of 1,233 girls aged 7-8 at study onset. The relation between contextual risk factors in multiple domains (i.e., family, peer, community) and trajectories of ODD/CD behaviors across time were examined for girls with differing levels of CU features. RESULTS Growth curve analysis indicated that CU features were associated with chronically high levels of ODD/CD symptoms over time. Low levels of parental warmth were also associated with chronically high levels of ODD/CD, and this effect was particularly pronounced for girls with high CU features. Exposure to harsh parenting was associated with higher ODD/CD behaviors for girls in childhood regardless of their level of CU features, but this effect dissipated over time. CONCLUSIONS Girls with elevated CU features who are exposed to low levels of parental warmth seem to exhibit particularly severe ODD/CD symptoms and should be targeted for intensive intervention in childhood.

The Clinical Utility of the Proposed DSM-5 Callous-Unemotional Subtype of Conduct Disorder in Young Girls

OBJECTIVE A callous-unemotional (CU) subtype of conduct disorder (CD) has been proposed as an addition to the fifth edition of the Diagnostic and Statistic Manual of Mental Disorders (DSM-5). This study tested the hypothesis that young girls with the CU subtype of CD would exhibit more severe antisocial behavior and less severe internalizing problems over time relative to girls with CD alone. Second, the developmental outcomes of girls with CU traits in the absence of CD was examined because these girls would be overlooked by the proposed CU subtyping scheme. METHOD Theses issues were examined in a community sample of 1,862 girls 6 to 8 years of age at study onset. Outcomes included internalizing and externalizing problems, academic achievement, and global impairment assessed concurrently and at a 6-year follow-up. RESULTS Girls with the CU subtype of CD had higher levels of externalizing disorder symptoms, bullying, relational aggression, and global impairment than girls with CD alone. Girls with CD alone tended to have more anxiety problems than girls with the CU subtype of CD. Girls with high CU traits without CD exhibited higher ODD and attention-deficit/hyperactivity disorder (ADHD) symptoms and lower academic achievement at the 6-year follow-up relative to girls without CU traits and CD. Group differences at the 6-year follow-up were primarily accounted for by baseline differences on the outcomes. CONCLUSIONS The proposed DSM-5 CU subtype of CD identifies young girls who exhibit lower anxiety problems and more severe aggression, CD symptoms, academic problems and global impairment across time than girls with CD alone.

Subthreshold Symptoms of Depression in Preadolescent Girls Are Stable and Predictive of Depressive Disorders

OBJECTIVE Given the risk for adolescent depression in girls to lead to a chronic course of mental illness, prevention of initial onset could have a large impact on reducing chronicity. If symptoms of depression that emerge during childhood were stable and predictive of later depressive disorders and impairment, then secondary prevention of initial onset of depressive disorders would be possible. METHOD Drawing from the Pittsburgh Girls Study, an existing longitudinal study, 232 nine-year-old girls were recruited for the present study, half of whom screened high on a measure of depression at age 8 years. Girls were interviewed about depressive symptoms using a diagnostic interview at ages 9, 10, and 11 years. Caregivers and interviewers rated impairment in each year. RESULTS The stability coefficients for DSM-IV symptom counts for a 1- to 2-year interval were in the moderate range (i.e., intraclass coefficients of 0.40-0.59 for continuous symptom counts and Kendall tau-b coefficients of 0.34-0.39 for symptom level stability). Depressive disorders were also relatively stable at this age. Poverty moderated the stability, but race and pubertal stage did not. Among the girls who did not meet criteria for a depressive disorder at age 9 years, the odds of meeting criteria for depressive disorders and for demonstrating impairment at age 10 or 11 years increased by 1.9 and 1.7, respectively, for every increase in the number of depression symptoms. CONCLUSIONS Early-emerging symptoms of depression in girls are stable and predictive of depressive disorders and impairment. The results suggest that secondary prevention of depression in girls may be accomplished by targeting subthreshold symptoms manifest during childhood.

Children’s Social Representations in Dolls’ House Play and Theory of Mind Tasks, and their Relation to Family Adversity and Child Disturbance

Five-year-old children of depressed and well mothers were assessed on theory of mind tasks, and enacted scenes from their family lives in dolls’ house play. Performance on theory of mind tasks was only weakly related to family circumstances and child distur-bance, but was significantly associated with measures of the child’s general and verbal intelligence. In contrast, children’s social representations elicited during dolls’ house play showed systematic relationships with family adversity (maternal depression and parental conflict) in interaction with the child’s gender: girls exposed to difficulties depicted particularly harmonious mother-child relationships, and their accounts showed a high degree of narrative structure; while boys so exposed depicted poor parenting, and their accounts were relatively incoherent. The children’s dolls’ house play was also associated with several aspects of their wider experience, including objective assessments of mother-child interactions, and behavioural and emotional adjustment in school. This technique may usefully elucidate the basis of child behavioural problems and psychopathology in the context of disturbed family relationships, and provide a route for therapeutic intervention.

In Search of Neural Endophenotypes of Postpartum Psychopathology and Disrupted Maternal Caregiving

This is a selective review that provides the context for the study of perinatal affective disorder mechanisms and outlines directions for future research. We integrate existing literature along neural networks of interest for affective disorders and maternal caregiving: (i) the salience/fear network; (ii) the executive network; (iii) the reward/social attachment network; and (iv) the default mode network. Extant salience/fear network research reveals disparate responses and corticolimbic coupling to various stimuli based upon a predominantly depressive versus anxious (post‐traumatic stress disorder) clinical phenotype. Executive network and default mode connectivity abnormalities have been described in postpartum depression (PPD), although studies are very limited in these domains. Reward/social attachment studies confirm a robust ventral striatal response to infant stimuli, including cry and happy infant faces, which is diminished in depressed, insecurely attached and substance‐using mothers. The adverse parenting experiences received and the attachment insecurity of current mothers are factors that are associated with a diminution in infant stimulus‐related neural activity similar to that in PPD, and raise the need for additional studies that integrate mood and attachment concepts in larger study samples. Several studies examining functional connectivity in resting state and emotional activation functional magnetic resonance imaging paradigms have revealed attenuated corticolimbic connectivity, which remains an important outcome that requires dissection with increasing precision to better define neural treatment targets. Methodological progress is expected in the coming years in terms of refining clinical phenotypes of interest and experimental paradigms, as well as enlarging samples to facilitate the examination of multiple constructs. Functional imaging promises to determine neural mechanisms underlying maternal psychopathology and impaired caregiving, such that earlier and more precise detection of abnormalities will be possible. Ultimately, the discovery of such mechanisms will promote the refinement of treatment approaches toward maternal affective disturbance, parenting behaviours and the augmentation of parenting resiliency.