“BABY LOVE”
Improving Mother-Infant Attachment in Depressed Mothers; Better outcomes for Health, Legal and Education Systems
ANNE BUIST *
Postnatal depression affects approximately 15% of women giving birth in Australia; many of those at risk for depression are also at risk for parenting difficulties, either through the effect of the depression, or through poor attachment and abusive or neglectful childhood experiences with their own parents.
Numerous studies investigating aetiology agree that current, past and family history of depression has the strongest predictive value of who gets depressed postpartum. After this, level of support, number of stresses, perfectionist personality and childhood abuse are all important contributors.
Focus on postnatal depression has been in recent years on screening and early detection the principle being that if treatment is instigated early then the outcomes for mother and child will be better. This focus has been important; if postnatal depression is not asked about up to 50% of cases are missed.
Women do not readily identify their experience as depression, thinking that they have the baby they love and planned for and thus have nothing to be depressed about. In addition they are reluctant to identify the problem as themselves, because they fear the stigma not just of a mental illness but of being labelled as a bad mother.
Following on from identification, attention has turned to treatment. As with depression at other times, anti-depressants and a range of psychotherapies have been shown to be effective. However this in itself does not improve the mother-infant relationship, and where the baby triggers negative memories and emotions, the relationship – and being a mother- can continue to act as a stressor for relapse and treatment resistance.
John Bowlby, who was responsible for Bowlby’s Attachment theory essentially describes how the relationship with the primary carer in the first 18 months of life - usually the mother- provides the basis for the child’s self esteem, sense of self and ability to relate to others in later life.
Measurement of attachment status is difficult – as a child, as considered by Mary Ainsworth to be the Ainsworth Strange Situation, or of an adult with the Adult Attachment interview. The Strange Situation, so called, can be summarised as follows:
In the 1960s, Ainsworth devised a procedure, called A Strange Situation, to observe attachment relationships between a caregiver and child.
In this procedure of the strange situation the child is observed playing for 20 minutes while caregivers and strangers enter and leave the room, recreating the flow of the familiar and unfamiliar presence in most children's lives. The situation varies in stressfulness and the child's responses are observed. The child experiences the following situations:
- Parent and infant are introduced to the experimental room.
- Parent and infant are alone. Parent does not participate while infant explores.
- Stranger enters, converses with parent, then approaches infant. Parent leaves inconspicuously.
- First separation episode: Stranger's behaviour is geared to that of infant.
- First reunion episode: Parent greets and comforts infant, then leaves again.
- Second separation episode: Infant is alone.
- Continuation of second separation episode: Stranger enters and gears behaviour to that of infant.
- Second reunion episode: Parent enters, greets infant, and picks up infant; stranger leaves inconspicuously.
Four aspects of the child's behavior are observed:
- The amount of exploration (e.g. playing with new toys) the child engages in throughout.
- The child's reactions to the departure of its caregiver.
- The stranger anxiety (when the baby is alone with the stranger).
- The child's reunion behaviour with its caregiver.
On the basis of their behaviors, the children were categorized into three groups, with a fourth added later. Each of these groups reflects a different kind of attachment relationship with the caregiver.
Measurement of Attachment status is difficult as is that of the Strange Situation and both take considerable training time and are time consuming. Studies using them however estimate that about 60% of the population have secure attachments. The remainder have anxious ambivalent or avoidant and some 10% disorganised attachments. The latter has been strongly associated with later psychiatric disorder, particularly borderline personality; both disorganised and insecure attachments have a higher association with a range of other problems in later life, in particular depression and anxiety.
Follow up of the children of depressed and anxious mothers suggest that they are at higher risk of developing depression and anxiety.
Antenatal depression is more a risk than postnatal depression, having both being the highest correlation to negative outcomes for the child. Antenatal anxiety is thought to operate through increasing the infant's cortisol level; - which remains high through childhood, and a possible genetic driver. Work on the serotonin transporter gene also, of interest, gas found links between genetics and upbringing- some gene combinations found to be protective against later psychiatric illness where others increase risk exponentially if the child is also exposed to abuse.
Postnatal depression adds to this effect and numerous studies point to the depressed anxious parenting style as problematic; the likely mechanism is through attachment, and modelling, neglect and inability to protect throughout the childhood adding to the problem.
Children exposed to this intergenerational parenting have problems from an early age; boys have a higher rate of conduct disorders, disrupt classes, learn less and become at a higher risk for legal problems in their teenage years. Increasing it seems girls may also be at similar problems but research suggest their depression and anxiety is more likely to present as depression, suicide and self harm.
Currently in Melbourne we have a unique opportunity to not just identify and treat women – a task recommended by Beyondblue and taken up by the Commonwealth government nationally, but also, at least, through mother baby units, and ideally, ultimately, through protective services.
The ambition of the programe is to identify depressed women who also have relationship difficulties stemming from their own childhood into that with their infant – and intervene early, before attachment is “finalised”.
One program to address this, called “BABY LOVE” we have introduced for women admitted to either the Northpark private mother baby unit or the Austin public parent infant unit. The principles are based on:
- Group intervention informed by Attachment theory, based on a US program.
- Publicly, it runs as a weekly 1½ hr closed group, running for six months.
- Privately it runs as a 13 week day program.
- In both public and private programs, the mother-child (we take children up to five, but the oldest to date has been 2½ years and the youngest 8 weeks) relationship is videoed.
- Each week segments of the video are used to help women reflect on the needs of their infant - and how to see the world through their infant’s eyes.
- We then reflect on their own parenting experience and how that can interfere with their ability to see their infant’s needs.
- In the private program we have added exercises as applicable to other children in the family, and activities such as dance and music therapy to promote the mother-infant interaction in a new way.
The basis of the "BABY LOVE" process is that case examples – with use of video-recording of the mother-child interaction will illustrate the powerful use of video in helping women break intergenerational patterns.
Copyright 2009. Greek Legal and Medical Conference