Parenting difficulties in the context of postnatal depression: implications for primary health care assessment and intervention

Postnatal depression (PND) is associated with impairments in the mother-child relationship, and these impairments are themselves associated with adverse child outcomes. Thus, compared to the children of non-depressed mothers, children of mothers with (PND) are more likely to be insecurely attached, and to have externalizing behavior problems and poor cognitive development. Each of these three child outcomes is predicted by a particular pattern of difficulty in parenting: insecure attachment is related to maternal insensitivity, particularly in relation to infant distress and emotional vulnerability; externalizing problems are particularly common in the context of hostile parenting; and poor cognitive development is related to parental difficulties in noticing infant signs of interest and supporting their engagement with the environment. There is no evidence that these parenting difficulties resolve with spontaneous or treatment-induced improvement in maternal depression. Specific interventions targeting parenting are therefore necessary. However, intervention requires identification, and, to date there is no reliable method for assessing early mother-child relationships in routine clinical practice. We set out procedures for how parenting could be assessed in ways that are sensitive to the domain-specific associations between parenting and child outcome, while remaining sensitive to the child’s developmental stage. This set of assessments requires field testing. SUMMARY BOX (4 TO 5 KEY POINTS) i. Postnatal depression is associated with disturbances in child attachment, emotion regulation and behaviour problems, and cognitive development. ii. Each domain of child disturbance is predicted by a particular disturbance in the mother-child relationship iii. Since neither the mother child relationship nor child outcome improve in response to remission in the maternal mood disorder, specific intervention is required. iv. An assessment procedure is specified that is sensitive to the domain-specific associations between parenting and child outcome, and to the child’s developmental stage.