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Antenatal depression and the impact on infant cognitive, language and motor development at six and twelve months postpartum
Early Human Development 134 (2019) 41–46
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Antenatal depression and the impact on infant cognitive, language and motor development at six and twelve months postpartum
T
Niamh O'Learya, , Chaitra Jairaja, Eleanor J. Molloyb, Fionnuala M. McAuliffec, Elizabeth Nixond, Veronica O'Keanea ⁎
a
Trinity College Institute of Neuroscience, Trinity College Dublin, Ireland Paediatrics, Trinity College Dublin, Ireland c UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Dublin, Ireland d School of Psychology, Trinity College Dublin, Ireland b
ABSTRACT
Background: Antenatal depression is associated with adverse social-emotional and behavioural outcomes during childhood but there has been little investigation of the impact on infant neurodevelopment during the first postnatal year. Aims: The aim of this study was to assess the impact of depression during pregnancy on infant cognitive, language and motor development at six and twelve months using a prospective longitudinal study design. Participants: Pregnant women with a clinical diagnosis of Major Depressive Disorder (MDD; n = 23), a history of MDD (n = 34) and a control group (n = 43) and their infants. Outcome measures: MDD was measured during pregnancy and both maternal depression and infant cognitive, language and motor development were measured at six and twelve months postpartum. Results: At six months, infants in the MDD group had lower motor development scores (M = 95.48, SD = 11.87) compared with controls (M = 99.97, SD = 10.64, p = .026) after controlling for maternal concurrent depression scores. At twelve months, infants in the MDD group had lower language scores (M = 87.33, SD = 10.54) compared with controls (M = 95.06, SD = 11.78, p = .037) which attenuated after controlling for maternal concurrent depression. Conclusions: These data contribute to the growing literature investigating the impact of antenatal depression on infant cognitive, language and motor development within the first postnatal year. The association between maternal depression and lower infant motor scores highlights the importance of early intervention for both mothers and infants in situations where maternal well-being is at risk.
1. Introduction The prevalence rates of depression during pregnancy are estimated at 7–20% worldwide [1] and 16% in Ireland [2]. Accumulating evidence suggests that antenatal depression is associated with adverse infant outcomes during the early postnatal period as well as later in childhood [3]. Antenatal depression is associated with impairments in social-emotional development and an increased risk of behavioural issues or disorders in childhood and adulthood [4]. However, less is known about the association between maternal mood during pregnancy and early developmental outcomes such as infant cognitive, language and psychomotor proficiency. This is despite the evidence that these aspects of development are also strongly dependent on early experiences, frequently co-occur with behavioural and social-emotional issues and also have predictive value for depression and other psychiatric disorders later in life [5,6]. Much of the research in the area of antenatal depression and infant
⁎
neurodevelopment has focused on either early neurobehaviour in newborn infants or neurodevelopment in later toddlerhood and among children of school-age and older [7,8]. Currently, little is known about the impact of antenatal depression on neurodevelopment in infancy, particularly within the first postnatal year. Rapid brain development occurs in the infant brain during the first two years of life making this a highly sensitive period during which development is particularly susceptible to both beneficial and detrimental environmental influence [9,10]. To date, a number of studies have reported a negative association between antenatal depression and both cognitive and language development [11–16]. However, several studies have also reported no impact of antenatal depression across these core domains of infant neurodevelopment [17–21] or that negative associations hold only when mothers report both depression and anxiety symptoms [22]. Furthermore, a positive association between depressive symptoms and both motor and mental development scores at 24 months of age has also been reported [23]. An extensive literature search revealed only three
Corresponding author. E-mail address: [email protected] (N. O'Leary).
https://doi.org/10.1016/j.earlhumdev.2019.05.021 Received 11 January 2019; Received in revised form 28 May 2019; Accepted 29 May 2019 0378-3782/ © 2019 Published by Elsevier B.V.
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Fig. 1. Flow-chart of follow up and attrition rates across the three groups at birth, six months and twelve months.
studies which have focused on the impact of antenatal depression on infant cognitive, language and psychomotor outcomes specifically within the first postnatal year. Bhang and colleagues [24] reported a negative association between first trimester depressive symptoms and cognitive development at six months, whereas Husain and colleagues [21] reported no differences between women with clinically diagnosed depression in the third trimester and controls in cognitive, language or motor development at six months. A third study completed by Punamäki and colleagues [25] reported no impact of second trimester antenatal depressive symptoms on infant developmental milestones at twelve months such as standing and word utterances. A key issue contributing to inconsistencies within the literature relates to the method in which antenatal depression is defined and in particular whether participants meet the criteria for a clinical diagnosis of MDD in comparison to meeting the cut-off for probable depression using a self-report questionnaire. Matthey and Ross-Hamid [26] reported that within a sample of women who scored over 10 at first administration of the Edinburgh Postnatal Depression Scale (EPDS) [27] in the first trimester, only half of these women had a similarly high score on this measure 2 weeks later. Therefore, utilising a self-report measure on a once-off basis may indicate transient distress rather than MDD. Furthermore, data published by Pawlby and colleagues [28] indicate that although an EPDS cut-off score of > 12 is frequently used to identify women with MDD, this cut-off score resulted in a high number of ‘false negative’ cases, failing to identify the majority of women with MDD in their sample. The high degree of ‘false negative’ cases has implications for the use of the EPDS in research as a tool to stratify samples into ‘depressed’ and ‘non-depressed’ comparison groups. As a result, comparison groups may contain women who meet the criteria for MDD which may lead to an underestimation of the effect of MDD on infant and child outcomes [29]. MDD during pregnancy is associated with brain and somatic changes that impact on the maternal stress
system, the shared maternal-fetal stress system and the chemical and endocrine environment within which the fetal brain is developing [30]. The brain and somatic changes accompanied by short-term maternal distress or changes in mood are less likely to result in changes to the physiological environment of the fetus. This study aimed to compare a group of women with a clinical diagnosis of depression during pregnancy, with a control group of women with no history of psychiatric disorder and a group of women with a history of depression. Women with a history of depression represent a group that is largely neglected in the research literature, despite being at the highest risk for developing depression during the perinatal period [1]. This group may represent a sample of women who score higher on self-report measures of depression without meeting the criteria for MDD. Additionally, previous research has reported lower levels of maternal sensitivity [31] and higher rates of infant negative affectivity [32] in women with a history of MDD prior to pregnancy. This study sought to further extend the evidence base on this high risk group to determine if a previous maternal history of depression was associated with infant neurodevelopment outcomes in the first post-partum year. 2. Method 2.1. Participants Participants for this study were recruited from three maternity hospitals in Dublin between February 2014 and November 2016. Women in their second trimester of a singleton pregnancy with a competency in spoken and written English were considered for inclusion. Exclusion criteria for participation in the study were: pregnancy complications such as gestational diabetes or preeclampsia, chronic medical conditions, a history or current diagnosis of anxiety, psychotic, personality or substance abuse disorders and any long-term medication 42
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use other than antidepressants or mood stabilisers. All participants (n = 100) were interviewed by a research registrar in psychiatry who stratified participants into one of three groups. Women that met the criteria for Major Depressive Disorder (MDD) according to DSM-IV-TR [31] criteria were included in the MDD group (n = 23). Women with a history of one of more episodes of MDD but who were currently euthymic were included in the MDD History group (n = 34). Women with no history or current diagnosis of psychiatric disorder were included in the Control group (n = 43). Mothers were followed up when their infants were six and twelve months old. Two participants were excluded after the birth of their child, one due to the presence of a genetic disorder and another whose infant was born pre-term. Eighty-eight mother-infant dyads remained in the study at twelve months resulting in an overall attrition rate of 12%. A flow-chart of attrition rates across each group at birth, six months and twelve months is presented in Fig. 1.
2.4. Statistical analyses All data were analysed using SPSS version 24 [38]. Data were assessed for normality using the Shapiro-Wilk test. Non-parametric data were analysed using the Kruskal-Wallis test with post-hoc analysis using the Mann-Whitney U test. Group comparisons for infant neurodevelopment scores were carried out using Analysis of Covariance (ANCOVA) using maternal education and parity as covariates in the initial analysis. Parity was chosen as a covariate as preliminary correlational analyses indicated an association between maternal parity and infant cognitive and language development at six months. Moreover both maternal education and parity are known to be independent predictors of infant neurodevelopmental outcome within the literature [e.g. 39, 40]. Maternal concurrent depression measured using the CES-D at each time point was included as a third covariate in subsequent analyses for each subscale.
2.2. Measures
3. Results
2.2.1. Maternal demographic and health characteristics Maternal demographic information, obstetric history and details of the current pregnancy were recorded during the clinical interview. Variables derived included: maternal age, ethnicity, education, employment status, marital status, antidepressant medication and parity.
3.1. Demographic and health characteristics of the sample Maternal and infant demographic and obstetric characteristics are summarised in Table 1. There were no significant differences between the three groups for maternal age, gestation, education, parity or complications at birth. There were significant differences between the groups for employment [Fisher Exact Test, p = .006] with more than expected women in the History group currently not in employment (standardised residual: 2.1). Furthermore, there were significant differences between both the MDD and Control groups and the MDD History and Control groups for antidepressant medication use during pregnancy [p < .001, Fisher Exact Test] but no significant difference between the MDD and MDD history groups on this variable. For the infant characteristics, there were significant group differences for gestational age at birth [χ2 (2, 99) = 14.653, p < .001]. Both the MDD group [U = 245, z = −3.361, p = .001] and History group [U = 497.5, z = −2.398, p = .016] had a significantly lower gestational age compared with infants in the Control group. At 6 months there were significant group differences for hours spent in childcare [χ2
2.2.2. Maternal clinical measures The MINI International Neuropsychiatric Interview (M.I.N.I.) [33] and the Hamilton Rating Scale for Depression (HAM-D) [34] were completed by a trained clinician and the Center for Epidemiological Studies: Depression Scale (CES-D) [35] was completed by the mother at intake. Mothers also completed the CES-D at six and twelve months postpartum. 2.2.3. Infant birth characteristics Infant birth details were obtained from participant medical records at each maternity hospital. In cases where these data were not available, the information was collected from the mother. Information on the mode of onset of labour, delivery method, gestational age at birth, birthweight and 1 min and 5 min Apgars were collected. Additional information on infant characteristics such as current weight, feeding method and hours of childcare per week were provided by the mother at six and twelve months.
Table 1 Demographic and clinical characteristics of the sample.
2.2.4. Bayley Scale of Infant Development—3rd edition (BSID-III) [36] Infants were assessed using the BSID-III at 6 and 12 months of age in the mother's home. The BSID consists of five administered subtests: cognitive, receptive language, expressive language, fine motor and gross motor. Three composite scores; Cognitive, Language and Motor, are obtained from the scaled score of the cognitive subtest, the sum of the scaled scores for both the receptive and expressive language subtests and the sum of the fine and gross motor scaled scores respectively. At the 6 month time point, the mean age at testing was 6 months 13 days (Range: 5 m 29 days to 7 m 17 days). At the twelve month time point the mean age at testing was 12 months 19 days (Range: 12 m 0 days to 14 m 2 days).
Maternal age, mean (SD) Gestational week, mean (SD) Educated to third level degree or above (n, %) Employed (n, %) Nulliparous (n, %) Antidepressant medication during pregnancy (n, %) Gestational age at birth, mean (SD) Birthweight in kg, mean (SD) Birth Complications (n, %) Sex (male, %) C-Section (n, %) Apgar 1 min, mean (SD) Apgar 5 min, mean (SD) Breastfed (n, %) Hours of childcare, mean (SD) 6 months 12 months
2.3. Missing data A number of participants did not return their CES-D questionnaires at six months (19%) or twelve months (9%). Little's test [37] of Missing Completely at Random (MCAR) was significant [χ2 = 646.019, df = 579, p = .028] indicating that the data missing in this study were Missing Not at Random (MNAR). As a result it was not appropriate to use multiple imputation with the dataset and participants with this missing data were excluded from the analyses which included these variables.
MDD (n = 23)
MDD History (n = 34)
Control (n = 43)
31.61 (3.88) 25.35 (4.75) 15 (65.2%)
32.44 (5.24) 26.35 (2.92) 22 (64.7%)
33.91 (4.73) 26.63 (3.98) 35 (81.4%)
18 (78.3%) 12 (52.2%) 10 (43.5%)⁎⁎
21 (63.6%)⁎ 8 (23.5%) 10 (29.4%)⁎⁎
40 (93%) 21 (48.8%) 0 (0%)
39.09(1.4)⁎⁎⁎
39.67⁎ (1.19)
40.42 (1.1)
3.46 (0.48) 1 (4.35%) 12 (52.2%) 4 (17.4%) 8.52 (0.93) 9.05 (0.81) 13 (76.5%)
3.77 (0.46) 5 (14.7%) 19 (55.9%) 9 (26.4%) 8.59 (1.01) 9.06 (0.44) 23(85.2%)
3.7 (0.49) 5 (11.62%) 30 (69.8%) 10 (23.3%) 8.76 (0.89) 9.12 (0.45) 30(84.6%)
0.38 (1.39)⁎ 10.13 (14.42)⁎⁎
1.33 (6.12)⁎ 15.28 (17.67)
8.26 (13.58) 24.65 (15.48)
Comparisons made with control group. ⁎ p < .05. ⁎⁎ p < .01. ⁎⁎⁎ p < .001. 43
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Table 2 Mean scores for the measures of maternal mood during pregnancy and postpartum. MDD (n = 23)
MDD History (n = 34)
Control (n = 43)
Statistic, p value
HAM-D, mean (SD) Pregnancy
20.82 (5.01)
3.48 (4.3)
1.44 (1.6)
χ2(2, 98) = 55.81, p < .001ᵃᵇᶜ
CES-D, mean (SD) Pregnancy 6 months 12 months
35.55 (12.28) 25.08 (12.75) 21.50 (12.63)
13.62 (8.7) 12.48 (11.72) 12.88 (10.21)
6.38 (5.75) 6.08 (6.52) 8.86 (7.36)
χ2(2, 96) = 49.907, p < .001ᵃᵇᶜ χ2(2, 72) = 22.315, p < .001ᵃᵇᶜ χ2(2, 79) = 14.756, p < .001ᵃᵇ
HAM-D: Hamilton Rating Scale for Depression, CES-D: Center for Epidemiological Studies: Depression Scale. Significant group differences: ᵃMDD vs control ᵇMDD vs MDD history ᶜMDD history vs control.
(72) = 8.086, p = .018] with infants in the Control group in childcare for a significantly longer duration per week compared with both those in the MDD group [U = 307.5, z = −2.328, p = .020] and the MDD history group [U = 161, z = −1.972, p = .049]. At 12 months, there were also significant group differences for childcare hours [χ2 (74) = 8.749, p = .013], with children in the Control group in childcare for significantly longer duration compared with the MDD group [U = 129, z = −2.774, p = .006]. There were no significant group differences for infant sex, birthweight, C-section delivery, Apgar scores or breastfeeding. Simple linear regression analyses indicated that there were no significant associations between antidepressant medication or birth complications and any of the neurodevelopmental outcome measures.
motor development [F (2, 64) = 3.872, p = .026] for infants in the MDD group in comparison to those in the Control group. At twelve months, the initial ANCOVA model, with education and parity as covariates, reported that infants in the MDD group had significantly lower language scores compared to infants in the MDD History and Control groups [F (2, 72) = 3.444, p = .037]. There were no significant group differences for the cognitive [F (2, 80) = 0.995, p = .374] or the motor subscales of the BSID at twelve months [F (2, 77) = 0.350, p = .706]. The subsequent model, in which maternal twelve month CES-D score was included as a third covariate revealed no further group differences for the cognitive [F (2, 71) = 0.526, p = .593], language [F (2, 64) = 1.610, p = .208] or motor [F (2, 68) = 1.099, p = .339] subscales at 12 months. Exploratory analyses using an independent samples t-test to investigate potential sex differences within the three groups on the cognitive, language and motor scales of the BSID at six and twelve months indicated that male infants in the Control group had significantly higher language scores at twelve months compared to female infants [t (33) = −2.082, p = .045]. There were no further within group sex differences for any of the remaining subscales of the BSID at either time-point.
3.2. Maternal measures of mood during pregnancy and postpartum Mean HAM-D scores during pregnancy and mean CES-D scores during pregnancy and at six and twelve months for each group are presented in Table 2. Mothers in the MDD group had significantly higher HAM-D scores compared with mothers in the History and Control groups during pregnancy. Mothers in the MDD group also had significantly higher CES-D scores compared to the History and Control groups during pregnancy and at six and twelve months postpartum. Mothers in the History group also had significantly higher CES-D scores compared to Controls during pregnancy and at six months postpartum. There were no differences for CES-D scores between the History and Control groups at twelve months.
4. Discussion This study demonstrates that infants of mothers with a diagnosis of clinical depression during pregnancy had lower motor development scores at six months after controlling for maternal concurrent depression. At twelve months, infants of mothers in the MDD group had lower language scores which attenuated after controlling for maternal depression scores. The inclusion of a group with a history of depression is a novel aspect of this study and represents a group which is largely neglected in the research literature, despite being at the highest risk for developing depression across the perinatal period [1]. The results of this study indicate that, despite significantly higher depression scores during pregnancy and at six months post-partum for mothers in the History group, there were no differences observed for infant development in this group compared with either the MDD or Control groups. To date, studies investigating the association between antenatal
3.3. Infant neurodevelopment: Bayley Scales of Infant Development Mean and standard deviation for the cognitive, language and motor scores of the BSID for each group at six and twelve months are summarised in Table 3. At six months, there were no significant group differences between the MDD, MDD History or Control groups for either the cognitive [F (2, 83) = 0.140, p = .870], language [F (2, 81) = 0.561, p = .573] or motor [F (2, 81) = 0.949, p = .391] subscales of the BSID. Following the inclusion of maternal six month CES-D score as a covariate there were significant group differences in infant Table 3 Mean scores for each subscale of the BSID at 6 and 12 months. MDD
MDD history
Control
Statistica, p value
6 months, mean (SD) Cognitive Language Motor
104.29 (10.99) 93.8 (11.87) 95.48 (11.87)
106.55 (8.25) 93.61 (9.49) 96.49 (20.26)
105.26 (6.25) 97.08 (7.18) 99.97 (10.64)
F (2, 66) = 2.461, p = .093 F (2, 65) = 2.214, p = .117 F (2, 64) = 3.872, p = .026
12 months, mean (SD) Cognitive Language Motor
111.32 (11.77) 87.33 (10.54) 90.94 (11.52)
107.41 (11.21) 94.04 (9.42) 92.35 (10.08)
106.84 (11.94) 95.06 (11.78) 93.51 (9.05)
F (2, 77) = 0.526, p = .593 F (2, 64) = 1.610, p = .208b F (2, 68) = 1.099, p = .339
a b
All analyses included covariates of maternal education, parity and concurrent CES-D score. p < 0.05 after controlling for education and parity. 44
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depression and infant development have focused on behaviour in newborn infants. Few studies have explored the association between antenatal depression and development within the first postnatal year beyond the neonatal period. This study is the first to report group differences for motor development in infants of six months born to mothers with antenatal depression. Lower motor development has previously been reported in new-born infants of mothers with antenatal depression [41,42]. However, studies in older infants have reported no association with infant motor development and maternal mood during pregnancy [24,25]. The discrepancy of these findings with previously reported research in children of this age cannot be explained by differences regarding self-report or clinically diagnosed depression. However, group differences were not found at twelve months, suggesting that within this sample, these differences were not pervasive or dissipated over time. At twelve months there were significant differences between the MDD and Control group for infant language scores, which attenuated after controlling for postnatal depression. Determining differences in infant development which arise as a result of exposure to antenatal depression, postnatal depression or as a consequence of the continuation of depression across the perinatal period are difficult to ascertain in studies using a case-control methodology. In studies of this nature, including postnatal depression as a confounding variable eliminates group differences due to depression being the factor under which participants were allocated to those groups in the first instance. In the literature, language delays have previously been reported in older children born to mothers with antenatal depression [12,15] and in children whose mothers had postnatal depression [43]. It is possible that postnatal depression may potentially have an indirect effect on language development through maternal behaviour. Mothers with postnatal depression express more negative affect, focus less on infant experience within interactions and show less acknowledgement of infant agency [44]. Mothers with postnatal depression also demonstrate impaired caregiving ability and read to their children less than nondepressed mothers both of which have a negative impact on language development [45,46]. The outcomes reported in this study raise the question of whether the chronicity of symptoms leading from the antenatal period to the postnatal period has a greater impact on infant development than just antenatal depression alone. Recent studies, investigating the trajectory of maternal symptoms across the perinatal period have examined the timing of perinatal depression in predicting infant developmental outcome. Park and colleagues [47] identified three trajectories of maternal depressive symptoms from the antenatal period to when the children were six years. These patterns reflected mothers whose symptoms increased, decreased or remained low across this period of time. The children of mothers whose depression decreased over this period had equivalent behavioural and executive function scores to those in the low symptom group, whereas those in the increasing group had poorer scores at each time-point. The pattern that the chronicity of depression constitutes a major factor for infant outcomes fits with the findings of the current study. However, further analyses stratifying those women who were depressed at particular time-points were not possible within this dataset due to the limited sample size. Missing data, a common issue in longitudinal research, provided further limitations for statistical analysis in this study. Lastly, the inclusion of a further measure of maternal socio-economic status (e.g. total household income), in addition to that of maternal education, would have been of benefit in the interpretation of the results of this study. To conclude, the data in this study demonstrates that infants of mothers with a diagnosis of clinical depression during pregnancy had lower motor development scores at six months. At twelve months, infants of mothers in the MDD group had lower language scores which attenuated after controlling for maternal concurrent depression scores. This study contributes to the growing literature investigating the impact of antenatal depression on infant cognitive, language and motor
development in the first postnatal year. This study highlights the importance of considering the chronicity of maternal depression from the antenatal into the postnatal period and the importance of early intervention, be it during pregnancy or in the early postpartum period, in situations where maternal well-being or infant development may be at risk. Acknowledgments The authors would like to thank all of the women who participated in the study as well as Professor Anthony McCarthy, Dr Ann O’GradyWalshe and Professor John Sheehan for their help with this research. References [1] A. Biaggi, S. Conroy, S.S. Pawlby, C.M. Pariante, Identifying the women at risk of antenatal anxiety and depression: a systematic review, J. Affect. Disord. 191 (2016) 62–77, https://doi.org/10.1016/j.jad.2015.11.014. [2] C. Jairaj, C.M. Fitzsimons, F.M. McAuliffe, N. O'Leary, N. Joyce, N., A. 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Early Human Development journal homepage: www.elsevier.com/locate/earlhumdev
Antenatal depression and the impact on infant cognitive, language and motor development at six and twelve months postpartum
T
Niamh O'Learya, , Chaitra Jairaja, Eleanor J. Molloyb, Fionnuala M. McAuliffec, Elizabeth Nixond, Veronica O'Keanea ⁎
a
Trinity College Institute of Neuroscience, Trinity College Dublin, Ireland Paediatrics, Trinity College Dublin, Ireland c UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Dublin, Ireland d School of Psychology, Trinity College Dublin, Ireland b
ABSTRACT
Background: Antenatal depression is associated with adverse social-emotional and behavioural outcomes during childhood but there has been little investigation of the impact on infant neurodevelopment during the first postnatal year. Aims: The aim of this study was to assess the impact of depression during pregnancy on infant cognitive, language and motor development at six and twelve months using a prospective longitudinal study design. Participants: Pregnant women with a clinical diagnosis of Major Depressive Disorder (MDD; n = 23), a history of MDD (n = 34) and a control group (n = 43) and their infants. Outcome measures: MDD was measured during pregnancy and both maternal depression and infant cognitive, language and motor development were measured at six and twelve months postpartum. Results: At six months, infants in the MDD group had lower motor development scores (M = 95.48, SD = 11.87) compared with controls (M = 99.97, SD = 10.64, p = .026) after controlling for maternal concurrent depression scores. At twelve months, infants in the MDD group had lower language scores (M = 87.33, SD = 10.54) compared with controls (M = 95.06, SD = 11.78, p = .037) which attenuated after controlling for maternal concurrent depression. Conclusions: These data contribute to the growing literature investigating the impact of antenatal depression on infant cognitive, language and motor development within the first postnatal year. The association between maternal depression and lower infant motor scores highlights the importance of early intervention for both mothers and infants in situations where maternal well-being is at risk.
1. Introduction The prevalence rates of depression during pregnancy are estimated at 7–20% worldwide [1] and 16% in Ireland [2]. Accumulating evidence suggests that antenatal depression is associated with adverse infant outcomes during the early postnatal period as well as later in childhood [3]. Antenatal depression is associated with impairments in social-emotional development and an increased risk of behavioural issues or disorders in childhood and adulthood [4]. However, less is known about the association between maternal mood during pregnancy and early developmental outcomes such as infant cognitive, language and psychomotor proficiency. This is despite the evidence that these aspects of development are also strongly dependent on early experiences, frequently co-occur with behavioural and social-emotional issues and also have predictive value for depression and other psychiatric disorders later in life [5,6]. Much of the research in the area of antenatal depression and infant
⁎
neurodevelopment has focused on either early neurobehaviour in newborn infants or neurodevelopment in later toddlerhood and among children of school-age and older [7,8]. Currently, little is known about the impact of antenatal depression on neurodevelopment in infancy, particularly within the first postnatal year. Rapid brain development occurs in the infant brain during the first two years of life making this a highly sensitive period during which development is particularly susceptible to both beneficial and detrimental environmental influence [9,10]. To date, a number of studies have reported a negative association between antenatal depression and both cognitive and language development [11–16]. However, several studies have also reported no impact of antenatal depression across these core domains of infant neurodevelopment [17–21] or that negative associations hold only when mothers report both depression and anxiety symptoms [22]. Furthermore, a positive association between depressive symptoms and both motor and mental development scores at 24 months of age has also been reported [23]. An extensive literature search revealed only three
Corresponding author. E-mail address: [email protected] (N. O'Leary).
https://doi.org/10.1016/j.earlhumdev.2019.05.021 Received 11 January 2019; Received in revised form 28 May 2019; Accepted 29 May 2019 0378-3782/ © 2019 Published by Elsevier B.V.
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Fig. 1. Flow-chart of follow up and attrition rates across the three groups at birth, six months and twelve months.
studies which have focused on the impact of antenatal depression on infant cognitive, language and psychomotor outcomes specifically within the first postnatal year. Bhang and colleagues [24] reported a negative association between first trimester depressive symptoms and cognitive development at six months, whereas Husain and colleagues [21] reported no differences between women with clinically diagnosed depression in the third trimester and controls in cognitive, language or motor development at six months. A third study completed by Punamäki and colleagues [25] reported no impact of second trimester antenatal depressive symptoms on infant developmental milestones at twelve months such as standing and word utterances. A key issue contributing to inconsistencies within the literature relates to the method in which antenatal depression is defined and in particular whether participants meet the criteria for a clinical diagnosis of MDD in comparison to meeting the cut-off for probable depression using a self-report questionnaire. Matthey and Ross-Hamid [26] reported that within a sample of women who scored over 10 at first administration of the Edinburgh Postnatal Depression Scale (EPDS) [27] in the first trimester, only half of these women had a similarly high score on this measure 2 weeks later. Therefore, utilising a self-report measure on a once-off basis may indicate transient distress rather than MDD. Furthermore, data published by Pawlby and colleagues [28] indicate that although an EPDS cut-off score of > 12 is frequently used to identify women with MDD, this cut-off score resulted in a high number of ‘false negative’ cases, failing to identify the majority of women with MDD in their sample. The high degree of ‘false negative’ cases has implications for the use of the EPDS in research as a tool to stratify samples into ‘depressed’ and ‘non-depressed’ comparison groups. As a result, comparison groups may contain women who meet the criteria for MDD which may lead to an underestimation of the effect of MDD on infant and child outcomes [29]. MDD during pregnancy is associated with brain and somatic changes that impact on the maternal stress
system, the shared maternal-fetal stress system and the chemical and endocrine environment within which the fetal brain is developing [30]. The brain and somatic changes accompanied by short-term maternal distress or changes in mood are less likely to result in changes to the physiological environment of the fetus. This study aimed to compare a group of women with a clinical diagnosis of depression during pregnancy, with a control group of women with no history of psychiatric disorder and a group of women with a history of depression. Women with a history of depression represent a group that is largely neglected in the research literature, despite being at the highest risk for developing depression during the perinatal period [1]. This group may represent a sample of women who score higher on self-report measures of depression without meeting the criteria for MDD. Additionally, previous research has reported lower levels of maternal sensitivity [31] and higher rates of infant negative affectivity [32] in women with a history of MDD prior to pregnancy. This study sought to further extend the evidence base on this high risk group to determine if a previous maternal history of depression was associated with infant neurodevelopment outcomes in the first post-partum year. 2. Method 2.1. Participants Participants for this study were recruited from three maternity hospitals in Dublin between February 2014 and November 2016. Women in their second trimester of a singleton pregnancy with a competency in spoken and written English were considered for inclusion. Exclusion criteria for participation in the study were: pregnancy complications such as gestational diabetes or preeclampsia, chronic medical conditions, a history or current diagnosis of anxiety, psychotic, personality or substance abuse disorders and any long-term medication 42
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use other than antidepressants or mood stabilisers. All participants (n = 100) were interviewed by a research registrar in psychiatry who stratified participants into one of three groups. Women that met the criteria for Major Depressive Disorder (MDD) according to DSM-IV-TR [31] criteria were included in the MDD group (n = 23). Women with a history of one of more episodes of MDD but who were currently euthymic were included in the MDD History group (n = 34). Women with no history or current diagnosis of psychiatric disorder were included in the Control group (n = 43). Mothers were followed up when their infants were six and twelve months old. Two participants were excluded after the birth of their child, one due to the presence of a genetic disorder and another whose infant was born pre-term. Eighty-eight mother-infant dyads remained in the study at twelve months resulting in an overall attrition rate of 12%. A flow-chart of attrition rates across each group at birth, six months and twelve months is presented in Fig. 1.
2.4. Statistical analyses All data were analysed using SPSS version 24 [38]. Data were assessed for normality using the Shapiro-Wilk test. Non-parametric data were analysed using the Kruskal-Wallis test with post-hoc analysis using the Mann-Whitney U test. Group comparisons for infant neurodevelopment scores were carried out using Analysis of Covariance (ANCOVA) using maternal education and parity as covariates in the initial analysis. Parity was chosen as a covariate as preliminary correlational analyses indicated an association between maternal parity and infant cognitive and language development at six months. Moreover both maternal education and parity are known to be independent predictors of infant neurodevelopmental outcome within the literature [e.g. 39, 40]. Maternal concurrent depression measured using the CES-D at each time point was included as a third covariate in subsequent analyses for each subscale.
2.2. Measures
3. Results
2.2.1. Maternal demographic and health characteristics Maternal demographic information, obstetric history and details of the current pregnancy were recorded during the clinical interview. Variables derived included: maternal age, ethnicity, education, employment status, marital status, antidepressant medication and parity.
3.1. Demographic and health characteristics of the sample Maternal and infant demographic and obstetric characteristics are summarised in Table 1. There were no significant differences between the three groups for maternal age, gestation, education, parity or complications at birth. There were significant differences between the groups for employment [Fisher Exact Test, p = .006] with more than expected women in the History group currently not in employment (standardised residual: 2.1). Furthermore, there were significant differences between both the MDD and Control groups and the MDD History and Control groups for antidepressant medication use during pregnancy [p < .001, Fisher Exact Test] but no significant difference between the MDD and MDD history groups on this variable. For the infant characteristics, there were significant group differences for gestational age at birth [χ2 (2, 99) = 14.653, p < .001]. Both the MDD group [U = 245, z = −3.361, p = .001] and History group [U = 497.5, z = −2.398, p = .016] had a significantly lower gestational age compared with infants in the Control group. At 6 months there were significant group differences for hours spent in childcare [χ2
2.2.2. Maternal clinical measures The MINI International Neuropsychiatric Interview (M.I.N.I.) [33] and the Hamilton Rating Scale for Depression (HAM-D) [34] were completed by a trained clinician and the Center for Epidemiological Studies: Depression Scale (CES-D) [35] was completed by the mother at intake. Mothers also completed the CES-D at six and twelve months postpartum. 2.2.3. Infant birth characteristics Infant birth details were obtained from participant medical records at each maternity hospital. In cases where these data were not available, the information was collected from the mother. Information on the mode of onset of labour, delivery method, gestational age at birth, birthweight and 1 min and 5 min Apgars were collected. Additional information on infant characteristics such as current weight, feeding method and hours of childcare per week were provided by the mother at six and twelve months.
Table 1 Demographic and clinical characteristics of the sample.
2.2.4. Bayley Scale of Infant Development—3rd edition (BSID-III) [36] Infants were assessed using the BSID-III at 6 and 12 months of age in the mother's home. The BSID consists of five administered subtests: cognitive, receptive language, expressive language, fine motor and gross motor. Three composite scores; Cognitive, Language and Motor, are obtained from the scaled score of the cognitive subtest, the sum of the scaled scores for both the receptive and expressive language subtests and the sum of the fine and gross motor scaled scores respectively. At the 6 month time point, the mean age at testing was 6 months 13 days (Range: 5 m 29 days to 7 m 17 days). At the twelve month time point the mean age at testing was 12 months 19 days (Range: 12 m 0 days to 14 m 2 days).
Maternal age, mean (SD) Gestational week, mean (SD) Educated to third level degree or above (n, %) Employed (n, %) Nulliparous (n, %) Antidepressant medication during pregnancy (n, %) Gestational age at birth, mean (SD) Birthweight in kg, mean (SD) Birth Complications (n, %) Sex (male, %) C-Section (n, %) Apgar 1 min, mean (SD) Apgar 5 min, mean (SD) Breastfed (n, %) Hours of childcare, mean (SD) 6 months 12 months
2.3. Missing data A number of participants did not return their CES-D questionnaires at six months (19%) or twelve months (9%). Little's test [37] of Missing Completely at Random (MCAR) was significant [χ2 = 646.019, df = 579, p = .028] indicating that the data missing in this study were Missing Not at Random (MNAR). As a result it was not appropriate to use multiple imputation with the dataset and participants with this missing data were excluded from the analyses which included these variables.
MDD (n = 23)
MDD History (n = 34)
Control (n = 43)
31.61 (3.88) 25.35 (4.75) 15 (65.2%)
32.44 (5.24) 26.35 (2.92) 22 (64.7%)
33.91 (4.73) 26.63 (3.98) 35 (81.4%)
18 (78.3%) 12 (52.2%) 10 (43.5%)⁎⁎
21 (63.6%)⁎ 8 (23.5%) 10 (29.4%)⁎⁎
40 (93%) 21 (48.8%) 0 (0%)
39.09(1.4)⁎⁎⁎
39.67⁎ (1.19)
40.42 (1.1)
3.46 (0.48) 1 (4.35%) 12 (52.2%) 4 (17.4%) 8.52 (0.93) 9.05 (0.81) 13 (76.5%)
3.77 (0.46) 5 (14.7%) 19 (55.9%) 9 (26.4%) 8.59 (1.01) 9.06 (0.44) 23(85.2%)
3.7 (0.49) 5 (11.62%) 30 (69.8%) 10 (23.3%) 8.76 (0.89) 9.12 (0.45) 30(84.6%)
0.38 (1.39)⁎ 10.13 (14.42)⁎⁎
1.33 (6.12)⁎ 15.28 (17.67)
8.26 (13.58) 24.65 (15.48)
Comparisons made with control group. ⁎ p < .05. ⁎⁎ p < .01. ⁎⁎⁎ p < .001. 43
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Table 2 Mean scores for the measures of maternal mood during pregnancy and postpartum. MDD (n = 23)
MDD History (n = 34)
Control (n = 43)
Statistic, p value
HAM-D, mean (SD) Pregnancy
20.82 (5.01)
3.48 (4.3)
1.44 (1.6)
χ2(2, 98) = 55.81, p < .001ᵃᵇᶜ
CES-D, mean (SD) Pregnancy 6 months 12 months
35.55 (12.28) 25.08 (12.75) 21.50 (12.63)
13.62 (8.7) 12.48 (11.72) 12.88 (10.21)
6.38 (5.75) 6.08 (6.52) 8.86 (7.36)
χ2(2, 96) = 49.907, p < .001ᵃᵇᶜ χ2(2, 72) = 22.315, p < .001ᵃᵇᶜ χ2(2, 79) = 14.756, p < .001ᵃᵇ
HAM-D: Hamilton Rating Scale for Depression, CES-D: Center for Epidemiological Studies: Depression Scale. Significant group differences: ᵃMDD vs control ᵇMDD vs MDD history ᶜMDD history vs control.
(72) = 8.086, p = .018] with infants in the Control group in childcare for a significantly longer duration per week compared with both those in the MDD group [U = 307.5, z = −2.328, p = .020] and the MDD history group [U = 161, z = −1.972, p = .049]. At 12 months, there were also significant group differences for childcare hours [χ2 (74) = 8.749, p = .013], with children in the Control group in childcare for significantly longer duration compared with the MDD group [U = 129, z = −2.774, p = .006]. There were no significant group differences for infant sex, birthweight, C-section delivery, Apgar scores or breastfeeding. Simple linear regression analyses indicated that there were no significant associations between antidepressant medication or birth complications and any of the neurodevelopmental outcome measures.
motor development [F (2, 64) = 3.872, p = .026] for infants in the MDD group in comparison to those in the Control group. At twelve months, the initial ANCOVA model, with education and parity as covariates, reported that infants in the MDD group had significantly lower language scores compared to infants in the MDD History and Control groups [F (2, 72) = 3.444, p = .037]. There were no significant group differences for the cognitive [F (2, 80) = 0.995, p = .374] or the motor subscales of the BSID at twelve months [F (2, 77) = 0.350, p = .706]. The subsequent model, in which maternal twelve month CES-D score was included as a third covariate revealed no further group differences for the cognitive [F (2, 71) = 0.526, p = .593], language [F (2, 64) = 1.610, p = .208] or motor [F (2, 68) = 1.099, p = .339] subscales at 12 months. Exploratory analyses using an independent samples t-test to investigate potential sex differences within the three groups on the cognitive, language and motor scales of the BSID at six and twelve months indicated that male infants in the Control group had significantly higher language scores at twelve months compared to female infants [t (33) = −2.082, p = .045]. There were no further within group sex differences for any of the remaining subscales of the BSID at either time-point.
3.2. Maternal measures of mood during pregnancy and postpartum Mean HAM-D scores during pregnancy and mean CES-D scores during pregnancy and at six and twelve months for each group are presented in Table 2. Mothers in the MDD group had significantly higher HAM-D scores compared with mothers in the History and Control groups during pregnancy. Mothers in the MDD group also had significantly higher CES-D scores compared to the History and Control groups during pregnancy and at six and twelve months postpartum. Mothers in the History group also had significantly higher CES-D scores compared to Controls during pregnancy and at six months postpartum. There were no differences for CES-D scores between the History and Control groups at twelve months.
4. Discussion This study demonstrates that infants of mothers with a diagnosis of clinical depression during pregnancy had lower motor development scores at six months after controlling for maternal concurrent depression. At twelve months, infants of mothers in the MDD group had lower language scores which attenuated after controlling for maternal depression scores. The inclusion of a group with a history of depression is a novel aspect of this study and represents a group which is largely neglected in the research literature, despite being at the highest risk for developing depression across the perinatal period [1]. The results of this study indicate that, despite significantly higher depression scores during pregnancy and at six months post-partum for mothers in the History group, there were no differences observed for infant development in this group compared with either the MDD or Control groups. To date, studies investigating the association between antenatal
3.3. Infant neurodevelopment: Bayley Scales of Infant Development Mean and standard deviation for the cognitive, language and motor scores of the BSID for each group at six and twelve months are summarised in Table 3. At six months, there were no significant group differences between the MDD, MDD History or Control groups for either the cognitive [F (2, 83) = 0.140, p = .870], language [F (2, 81) = 0.561, p = .573] or motor [F (2, 81) = 0.949, p = .391] subscales of the BSID. Following the inclusion of maternal six month CES-D score as a covariate there were significant group differences in infant Table 3 Mean scores for each subscale of the BSID at 6 and 12 months. MDD
MDD history
Control
Statistica, p value
6 months, mean (SD) Cognitive Language Motor
104.29 (10.99) 93.8 (11.87) 95.48 (11.87)
106.55 (8.25) 93.61 (9.49) 96.49 (20.26)
105.26 (6.25) 97.08 (7.18) 99.97 (10.64)
F (2, 66) = 2.461, p = .093 F (2, 65) = 2.214, p = .117 F (2, 64) = 3.872, p = .026
12 months, mean (SD) Cognitive Language Motor
111.32 (11.77) 87.33 (10.54) 90.94 (11.52)
107.41 (11.21) 94.04 (9.42) 92.35 (10.08)
106.84 (11.94) 95.06 (11.78) 93.51 (9.05)
F (2, 77) = 0.526, p = .593 F (2, 64) = 1.610, p = .208b F (2, 68) = 1.099, p = .339
a b
All analyses included covariates of maternal education, parity and concurrent CES-D score. p < 0.05 after controlling for education and parity. 44
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depression and infant development have focused on behaviour in newborn infants. Few studies have explored the association between antenatal depression and development within the first postnatal year beyond the neonatal period. This study is the first to report group differences for motor development in infants of six months born to mothers with antenatal depression. Lower motor development has previously been reported in new-born infants of mothers with antenatal depression [41,42]. However, studies in older infants have reported no association with infant motor development and maternal mood during pregnancy [24,25]. The discrepancy of these findings with previously reported research in children of this age cannot be explained by differences regarding self-report or clinically diagnosed depression. However, group differences were not found at twelve months, suggesting that within this sample, these differences were not pervasive or dissipated over time. At twelve months there were significant differences between the MDD and Control group for infant language scores, which attenuated after controlling for postnatal depression. Determining differences in infant development which arise as a result of exposure to antenatal depression, postnatal depression or as a consequence of the continuation of depression across the perinatal period are difficult to ascertain in studies using a case-control methodology. In studies of this nature, including postnatal depression as a confounding variable eliminates group differences due to depression being the factor under which participants were allocated to those groups in the first instance. In the literature, language delays have previously been reported in older children born to mothers with antenatal depression [12,15] and in children whose mothers had postnatal depression [43]. It is possible that postnatal depression may potentially have an indirect effect on language development through maternal behaviour. Mothers with postnatal depression express more negative affect, focus less on infant experience within interactions and show less acknowledgement of infant agency [44]. Mothers with postnatal depression also demonstrate impaired caregiving ability and read to their children less than nondepressed mothers both of which have a negative impact on language development [45,46]. The outcomes reported in this study raise the question of whether the chronicity of symptoms leading from the antenatal period to the postnatal period has a greater impact on infant development than just antenatal depression alone. Recent studies, investigating the trajectory of maternal symptoms across the perinatal period have examined the timing of perinatal depression in predicting infant developmental outcome. Park and colleagues [47] identified three trajectories of maternal depressive symptoms from the antenatal period to when the children were six years. These patterns reflected mothers whose symptoms increased, decreased or remained low across this period of time. The children of mothers whose depression decreased over this period had equivalent behavioural and executive function scores to those in the low symptom group, whereas those in the increasing group had poorer scores at each time-point. The pattern that the chronicity of depression constitutes a major factor for infant outcomes fits with the findings of the current study. However, further analyses stratifying those women who were depressed at particular time-points were not possible within this dataset due to the limited sample size. Missing data, a common issue in longitudinal research, provided further limitations for statistical analysis in this study. Lastly, the inclusion of a further measure of maternal socio-economic status (e.g. total household income), in addition to that of maternal education, would have been of benefit in the interpretation of the results of this study. To conclude, the data in this study demonstrates that infants of mothers with a diagnosis of clinical depression during pregnancy had lower motor development scores at six months. At twelve months, infants of mothers in the MDD group had lower language scores which attenuated after controlling for maternal concurrent depression scores. This study contributes to the growing literature investigating the impact of antenatal depression on infant cognitive, language and motor
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