Tuesday, June 17, 2014
Can Post-Partum and Post-Adoption Worry Amount to Maternal Depression?
Over the last couple of days, the New York Times has been featuring articles on maternal mental illness in the year following childbirth. A striking account of one tragic case is at www.nytimes.com/2014/06/17/health/maternal-mental-illness-can-arrive-months-after-baby.html?hpw&rref=health. In this case, a mother developed terrible fears that she had caused, or permitted by her carelessness, serious brain damage to her perfectly healthy child. She sought extensive diagnostic work for the baby, but the assurances that there was no brain damage, and that brain damage could not have occurred under the circumstances she described did nothing to change her distress or her delusions. When the baby was ten months old, she put him in a carrier and jumped with him from a height that killed her, but the child was cushioned by her body and survived.
It is only in the last ten years that real understanding of perinatal mental illness has begun to develop. (I use the term perinatal because such disorders can show up or be predictable before the baby is born, not only post-partum.) One important step has been the demonstration that screening of all new mothers can help identify those who may need treatment while their babies are young. I am happy to say that my own state, New Jersey, has screening for all new mothers, thanks to the impressive leadership of Mary Jo Codey, wife of former governor Richard Codey and herself a survivor of perinatal mental illness. Such screening is based in part on the understanding that perinatal mental illness is not a single entity, but involves a continuum of trouble that ranges from the sadness and slowing of responses we usually think of as depression, to the hallucinations and delusions that have led to suicide and murder in cases like that of the tragic Andrea Yates. Concerns about perinatal mental illness have been led to some extent by the understanding that for every child’s or mother’s death due to perinatal mental illness, there are probably hundreds in which a child’s language and cognitive development are impacted by her mother’s depression.
It has been enormously important for people to understand that poor care for babies, or even attacks on them, are not necessarily because the mothers are “bad people”, or even because poor environmental circumstances push the mothers past a breaking point. These events may be part of a mental illness that will respond to medication and psychotherapy. Blaming the mothers will not help them or their children.
The Times articles bring up two other important points. One is that it is now clear that maternal mental illness does not necessarily appear right after childbirth. An older view that tried to attribute perinatal mood disorders to hormonal changes tended to insist on an onset fairly soon after the birth. But it is now clear that there is much more to these disorders than a response to changing hormones, as is shown by emergence of the mental disturbance months after a new hormonal balance has been achieved, in some cases.
The second point is that although we think of mood disorders and depression as characterized by sadness and hopelessness, anxiety may be an important feature for some people, and in perinatal mental illness it is likely to be focused on the baby. Although every parent worries about their baby, a constant concern, with an inability to be reassured, and a sense of having harmed or being about to harm the baby, can be an indication of maternal mental illness and should be treated as such. (I am saying nothing here about fathers’ mood disorders because they have received very little study, but presumably they can exist.)
Reading about the Times case, in which the mother could not escape the delusion that she had damaged her child’s brain, made me think of some questions I receive from readers of this blog. Not all, but a few people who comment, seem to be excessively worried about the possibility that their child is autistic, and that they, the parents, may be at fault either because they caused the condition or because they are not getting treatment soon enough.
One post I wrote several years ago (http://childmyths/blogspot.com/2011/07/eye-contact-with-babies-what-when-why.html) has had thousands of reads and is almost always the post that gets most reads in any given day. Many readers have responded with questions about eye contact and autism, often in reference to babies of a few weeks old, who are far too young for anyone to diagnose autism even if they had it (which they probably don’t). Now, it is not surprising that people worry about this. First, there is a great deal of misunderstanding about what baby eye contact actually consists of, and many young parents think their baby will look steadily into their eyes for minutes at a time; young babies don’t do this, so the parents are disappointed and frightened. Second, sensational journalism has spread the idea that there is an “epidemic” of autism, rather than the actual shift in diagnostic criteria, so young parents are sure that this “epidemic” is threatening their babies, especially the boys. Third, young parents have heard about early intervention and the logical position that early treatment can prevent the development of some problems, so they naturally do not want to fail to get early treatment for any disorder. Add these to the natural tendency to worry about early development, and it’s hardly surprising that there’s so much concern.
However, I am asking myself whether severe concerns about autism, concerns that are taken from specialist to specialist without any reassurance ever being successful, can be evidence of maternal mental illness. Obviously a line has to be drawn between the typical worried state of young parents, which will resolve with ordinary support, time, and experience, and a mood disorder that becomes more and more frantic, at best creates developmental problems, and at worst culminates in tragedy. But when there seems to be no reason to be concerned about a baby, but a young mother is constantly deeply distressed, whether about brain injury or autism, would it not be a good idea for someone to ascertain whether this is really about treatable mental illness? The mother’s own primary care physician will probably not be aware of the problem; her OB/Gyn may pick it up at some point; but her pediatrician is most likely to know whether she is repeatedly asking for referrals. (The health insurer may also know this, but probably will not figure it out for many months.) Her partner, friends, and relatives may also catch on to the fact that there is more at stake than is typical of this stage of life. And clearly the handling of this situation by anyone who is aware of it must be most delicate, because the stigma of mental illness is still such that the affected person may essentially flee in panic anyone who suggests that she needs help.
I want to make one more point about this issue, and that is to remind people that maternal mental illness may emerge not only post-partum, but post-adoption. It is perfectly reasonable for adoptive parents to think about their adopted child’s background. Were alcohol or drugs a factor in relinquishment by the biological parents? What might have been the outcomes of neglect or abuse in earlier life? The answers to these questions might sometimes help adoptive parents to know what they may expect and what they need to do, but there may be no answers. It is perhaps in response to this set of concerns that adoptive parents can become terribly worried about disorders caused by fetal exposure to alcohol, and about Reactive Attachment Disorder. Certainly they are bombarded by descriptions and explanations of these problems even when they do not ask. Unfortunately, some of these descriptions and explanations are quite inaccurate, and they convey the message that such disorders can have signs that are so subtle that only a very few diagnosticians can detect them-- or even that the children can slyly conceal their problems in order to cause trouble.
As is the case for nonadoptive parents, adoptive parents can have their natural worries ratcheted up painfully by misinformation. In addition to that problem, however, when maternal mental illness emerges following adoption, its symptoms may include the inability to believe that a child does not have an attachment disorder or suffer from drug or alcohol effects. Mothers with these mood-disorder-fueled terrors can be easy prey for charlatans, who may be unable or unwilling to consider that a mother seeking them out might be mentally ill. In addition, medical professionals, partners, friends, and relatives may be bogged down in the old belief that perinatal mood disorders are caused by hormonal change, and therefore may dismiss the possibility that an adoptive mother could have a mental disturbance related to the adoption.
Could injuries to adopted children-- including starvation, caging, and so on—be caused in part by unrecognized maternal mental illness? I emphasize the words in part, but I believe this possibility deserves serious consideration by those of us who are concerned with the welfare of all children.