How Does Maternal Depression Affect Young Babies?

When I’ve mentioned maternal depression on this blog, I’ve sometimes been quite surprised to have readers respond as if the condition was a moral failure rather than a mental illness. That attitude was especially common when the reference was to depression in adoptive mothers-- some seemed to think that such women were simply spoiled brats who changed their minds about what they wanted after they discovered that baby care was a challenge. I don’t think there’s much point to arguing about that belief. Depression is more common in women than in men, and is especially common during the child-bearing years. Although some women who are depressed while caring for young babies have been depressed earlier in their lives, it is also true that life-changing events-- even much-wanted ones-- can trigger depressive reactions, however counter-intuitive that may be.

Mood disorders in young mothers can exist for a variety of reasons. But it doesn’t really matter whether they occur because of moral turpitude or because of a genetically-determined emotional disturbance. In all cases, effective treatment is desirable, because a depressed caregiver cannot provide the foundation for a baby’s good cognitive and emotional development.

Why is this? How can a very young baby even know what a caregiver’s mood is? And as long as it’s fed, warm, and clean, why would the baby care?

To answer these questions, it’s important to look very closely at communications between caregivers and young babies-- communications that are quite subtle and occur very quickly, so a casual observer can notice only a few, if any, of them. Understanding such communications requires a microanalysis of videotaped movements and facial expressions. These can be examined in the order in which they occurred, so it’s possible to see how each member of the pair responded to changes in the other. (As an example of this, I’m going to summarize an article by Reck, Noe, Stefenelli, Fuchs, and others, “Interactive coordination of currently depressed inpatient mothers and their infants during the postpartum period”, Infant Mental Health Journal, 2011, Vol. 32, pp. 542-562.)

Ideally, we’d expect the baby and the caregiver to be coordinated in their behavior and mood, and to respond to each other by matching a communicated mood (what Edward Tronick calls mutual regulation). But we’d also expect that the two will occasionally make mistakes or “mismatches” and respond with a smile to a frown, or vice-versa. Normally, baby and caregiver fairly quickly notice their mistakes and “repair” the communication by moving to match the other’s mood more closely. Those repair events seem to be even more important than frequent accurate matches, because they teach the baby that moods can be changed and regulated, and that mistaken communications can be corrected with effort.

Reck and her co-authors looked at a group of mothers who were hospitalized together with their babies for treatment of serious depression, and compared them to a group of healthy mothers and their infants. They observed the frequency of positive matches (when both partners showed positive emotion) and negative matches (when both showed negative emotion such as crying, withdrawal, hostility, or intrusiveness). Because it has been reported that maternal depression interferes with the development of joint attention (looking at an object and then back at each other), shared looking at objects was also studied. There was particular interest in the pairs’ abilities to repair mismatches and come to similar positive states. The babies ranged from 1 to 8 months in age.

In order to encourage mothers and babies to show their social interactions, the researchers used the “face-to-face still-face” method. In this, mother and baby were seated opposite each other, with one video camera recording each face’s expressions and a single microphone between them. The mothers were instructed to begin just with a normal interaction, to get the babies’ attention and play with them without using toys or a pacifier. After two minutes of this play, the mothers were to do two minutes of an unresponsive “still face”, in which they simply stare into space toward the baby without responding to the baby’s bids for communication. For the final two minutes (the “reunion” phase), the mothers were to return to normal responsiveness and engage with the baby again.

Depressed mothers and their babies did behave somewhat differently from healthy mothers with their babies. When the mother was depressed, repair of mismatches took longer. Healthy mothers were quicker to repair mismatches in the reunion phase than in the initial play phase, as if they were “trying harder” after the difficult period of the still-face episode, but when mothers were depressed the difference was the opposite. There were also differences in the time it took the mother-baby pairs to come to a match. For the healthy mother-baby pairs, half of them got to a positive match in 3 seconds after they began, whereas in half of the cases with depressed mothers they needed 12 seconds to get to a positive match in the play episode and 18 seconds in the reunion episode.

The babies of depressed mothers thus had quite different experiences of social interactions than did those of healthy mothers-- and experiences of this kind would be repeated many thousands of times in the early months of life in ordinary caregiving. Slower development of communication skills would certainly be expectable for babies of depressed mothers. This would be only one of several reasons why treatment of maternal depression is important with respect to infant development. Babies don’t have to know their mothers’ moods, or to care about them-- they are affected by depression in their caregivers in ways that do not support the best development.

Eye Contact With Babies: What, When, Why, and How

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When I look at the statistics Blogspot gives me, I see that day after day, large numbers of people end up at this blog when they Google questions about babies and eye contact. Parents are obviously worried about this issue, and that fact is confirmed by the existence of quite a few websites that give instructions about how to get your child to make eye contact more often. But what are the facts about all this? Can you get your child to increase eye contact? Do you need to? Why are we concerned about this matter at all?

What is eye contact? The term “eye contact” might be better replaced by “mutual gaze”, because of course there is no real “contact” about this common human action. In mutual gaze, two people’s faces and eyes are aligned so that each set of eyes is gazing at the other set. This is often very brief, although it can also be maintained for seconds at a time. Mutual gaze may also be performed in a sequence of episodes, for example as two friends approach each other, joining and breaking gaze along the way, stop and briefly engage in mutual gaze, and finally avert their gazes slightly while talking. Prolonged mutual gaze may indicate deep emotional involvement-- but it can be either a loving look or a hostile or frightened stare, depending on the context and the rest of the facial expression. Mutual gaze has a terrific communicative power for human beings, but it can have more than one meaning.

When does eye contact happen? From birth, babies are interested in looking at faces and especially eyes, and do this so carefully that they can and do accurately imitate facial expressions in the early days of life. Nevertheless, most new parents find that it is quite difficult to get a sense of mutual gaze until some weeks have passed. At about 4 to 6 weeks, as babies begin to do what used to be called “taking notice”, they start to look more responsively at people who are looking at them-- especially if the adult does something attention-getting like opening eyes and mouth wide and “looming” closer to the baby’s face. Soon, the baby smiles in response to a smile, and maintains a mutual gaze with a friendly adult (familiar or unfamiliar). If the adult looks blank or “stares through” the baby, though, the latter will avert the gaze, appear uncomfortable, and begin to cry. The baby expects the adult to “manage” his or her gaze in a way that coordinates with the baby’s gaze.

By about 6 months, babies begin to look toward an adult’s face and eyes for “social referencing” purposes, not for eye contact in and of itself, but to get information from the facial expression and the direction of the adult’s gaze. This information guides the baby in understanding the environment and knowing whether unfamiliar things are worrisome, neutral, or pleasant. The baby continues to pay attention to the direction of people’s gazes and between 9 and 12 months begins to show “joint attention”-- using the gaze as a “pointer” to show someone else where to look, and following another person’s gaze to see an interesting sight. These are not examples of mutual gaze, but they are other forms of communication that may emerge from mutual gaze.

It can be hard for an inexperienced parent to know whether a baby makes eye contact soon enough, long enough, or often enough. Anyone who expects prolonged mutual gaze many times a day from the time of birth is bound to be disappointed and frightened. The earliest eye contact events are fleeting, and even at 2 months the baby may not pay much attention without a good deal of adult effort. Mutual gaze during breastfeeding is not likely until the child is old enough to pause in sucking and look around, or let go the nipple temporarily and move the head-- perhaps 5 or 6 months of age.

Why is eye contact important? Mutual gaze is an important form of communication that conveys information both to the baby (“hey, people are quite interesting and pleasing”) and to the adult caregiver (“oh, my baby’s looking at me-- this feels so good-- he thinks I’m important and interesting”). It may be the foundation of other uses of gaze and other gestures for communication.

Looking at whether young children engage in mutual gaze can be a helpful way of understanding whether their development is typical or whether they have certain special needs. One of the best-known aspects of autism is the infrequency of eye contact. Individuals with Asperger’s syndrome, a disorder related to autism, may say that they dislike being looked at and find mutual gaze very uncomfortable. Persons with Fragile X syndrome are also known for their poor use of the gaze in social communication.

When people avoid looking at other’s eyes, or when they are simply inattentive to gaze information, they can miss much other information too. If an adult uses a word a child does not know, for instance, the child can often make a good guess by watching the adult’s gaze, to see what he or she is looking at. When a child also has poor language development, as is common in autism, the combination of underdeveloped language and of lack of gaze communication can make for serious difficulties, the appearance of deliberate noncompliance, and frustration for both child and adult. These facts all suggest that if a child is really not using mutual gaze or other gaze information, helping him or her gain those skills would be a valuable achievement.

However, it’s important to realize that increasing mutual gaze is not a way of increasing the child’s emotional attachment. Toddlers are more likely to engage in mutual gaze with people they are attached to, but increasing gaze episodes does not make them attached. Blind children become strongly attached to their familiar caregivers just as sighted children do; attachment is a very robust developmental phenomenon that involves hearing and touch as much as, or instead of, sight. Mutual gaze may have its strongest effect on adults, who are much influenced by the child’s gaze and feel a sense of emotional contact when exchanging gazes, so it’s possible that increasing mutual gaze can have an indirect effect on children through its influence on their caregivers. However, of course, blind parents also have strong emotional involvements with their children; they too can use other sources of communication to develop these intense relationships.

How to increase mutual gaze? I notice on several websites a variety of instructions for improving eye contact with children. These include wearing funny glasses (something like this was suggested by Nikolaas Tinbergen 40 years ago), playing games based on prolonging eye contact, and giving the child sweets while maintaining mutual gaze.

Whether these methods are a good idea depends in part on whether the child really does show too little eye contact for his age and situation. This is a point on which most parents need professional guidance. If the parent’s motivation comes from the belief that more eye contact would cause better attachment, and especially if the parent believes the child is poorly attached because he or she is disobedient, there is certainly little point in doing any of these things.

However, if the child is being treated for a developmental problem that is characterized by poor mutual gaze, the parent may already have received some training in rewarding eye contact or may at least be aware of how the behavior therapist works with this. An article that describes one method is to be found at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2649838/ (Hall, S.S., Maynes, N.P., & Reiss, A.L. [2009]. Using percentile schedules to increase eye contact in children with Fragile X syndrome. Journal of Applied Behavior Analysis, 42, 171-176). Similar work can be done at home, but it needs to be carefully thought out beforehand.

**** Readers, if you accessed this post in a search for current work on eye contact and autism, please look at my post for Nov. 7, 2013, which discusses the Nature article by Warren Jones and Ami Klin.****


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Breastfeeding: Test Your Knowledge-- True or False?

The important human function of breastfeeding is the subject of many myths and misunderstandings. A fascinating meld of biological and behavioral events, it’s worth the attention of everyone interested in early development, even those who will not be participating at the adult end. Test your knowledge of breastfeeding by reading these “true or false?” questions.

1. Breastfeeding helps the baby resist infectious diseases. True or false?

Very true! Although babies are born with a supply of antibodies they got from their mothers’ immune systems, those antibodies can only protect against diseases the mother had already been exposed to, not exposure to new diseases after the birth. In addition, those antibodies will have diminished by the time the baby is about 8 months old, a point at which infants do not yet do a good job of making their own antibodies. The nursing mother acts as an “auxiliary immune system” to her infant. She supplies more of the antibodies she already had, and if the nursing pair are exposed to a new disease, the mother’s efficient immune system goes to work to produce antibodies and pass them on to the baby in her milk. What if the baby is exposed to something, and the mother not exposed to it? Don’t worry, she will be exposed quickly, because the physical intimacy of nursing (and other infant care) means she will come into contact with the baby’s mucus, urine, and feces.

Do note that the baby can still use this kind of help toward the end of the first year. Babies who live in clean conditions, with modern food supplies and access to modern medicine, are less affected by a lack of breastfeeding, but those living in primitive conditions may die of infections that could have been prevented by breastfeeding.


2.Nursing mothers need to eat a lot more than usual. True or false?
It depends on the conditions. If the mother was well nourished during the pregnancy, she has laid down extra fat and extra calcium in her bones, and these will be used to support lactation, so she needs little if any extra food. If the mother is living at a subsistence level, she will need extra calories to compensate for those consumed by the baby. An ounce of human milk has about 20 calories on the average, so you can do the math, considering the amount of milk consumed by babies of different sizes and ages.

The nursing mother does need to drink a lot more fluid than when she is not breastfeeding. Every ounce of fluid the baby takes needs to be replaced. Many nursing mothers automatically go to drink a glass of water before they pick up the baby to nurse, or have a cup of tea while breastfeeding. Traditionally, nursing mothers drank dark beers like porter, which supplied extra fluid and a hefty dose of B vitamins, and gave everyone a nice nap too-- nowadays we tend to frown on this, and certainly this practice would have its dangers if it occurred more than once in a while .

3. You can’t breastfeed a baby once he or she gets teeth. True or false?

False. Babies can easily be taught not to bite the nipple, if the mother is vigilant (and believe me, after one bite she WILL be vigilant). Biting and sucking take different jaw movements, and an attentive mother can see when a sucking baby re-adjusts its jaw position in preparation for a chomp. The mother then gently inserts her finger between the baby’s jaws, toward the back of the mouth. This breaks the suction, so the baby cannot get any milk, and if he or she bites down, there’s not much satisfaction, because those itchy teething gums are in the front. Within 24 hours, the baby will have learned that although you can bite lots of things, you can’t bite that nipple-- it just doesn’t work.

Nursing mothers really have to teach biting babies not to bite, or their nipples can actually be damaged, and the baby will have to be weaned from the breast.

4. Nursing babies don’t like the milk that’s flavored by strong-tasting foods their mothers have eaten. True or false?

This is mainly false, with some possible individual exceptions. The taste researchers Menella and Beauchamp fed a group of nursing mothers an all-garlic-flavored lunch, waited a couple of hours, and then timed how long the babies nursed. When they compared this to nursing time after a bland lunch, they found that the babies actually nursed longer when the milk had a garlic flavor.

There may be some individual differences, with particular babies possibly disliking certain flavors. One important point is that when a nursing mother has had a mild breast infection, the milk on that side seems to be a little saltier than usual, and babies may not care for it-- to the mother’s frustration, as frequent thorough nursing is a help in clearing up these problems.

Symbiosis, Intersubjectivity, and Early Relationships

When people concerned about adoption discuss relationships between babies and mothers, they sometimes refer to a period of symbiosis, in which the identities or “selves” of mother and child are somehow fused, so the baby cannot tell the self from the mother effectively. As I’ve pointed out before, this idea is derived from the work of Margaret Mahler and other psychoanalytically-oriented thinkers, who considered this symbiotic period to last from about the second month to the seventh month or so. It’s important to note that Mahler herself did not think the symbiotic period included the first weeks of life or that the events of that period would have any effect on babies who were separated early from their birth mothers and adopted into different families.

Daniel Stern, in The Interpersonal World of the Infant, refers to symbiosis and discusses the concept in detail, but points out that modern research on early development has revealed a number of phenomena that contradict the possibility of early symbiosis as “fusion”. I want to review a number of facts that suggest that babies have an early concept of “self” versus “other” that makes a sense of fusion unlikely for the baby (although mothers may feel that their “selves” include their babies). This sense has been referred to as “primary intersubjectivity”.

One thing that suggests that young babies already “know” (or act as if they know) the difference between the self and another is that shortly after birth they will imitate the facial expressions of others, opening their mouths, even sticking out their tongues (Meltzoff, A., & Moore, A. [1989]. Imitation in newborn infants: Exploring the range of gestures imitated and the underlying mechanisms. Developmental Psychology, 25, 954-962). It is difficult to imagine that a baby would imitate itself (which brings to mind some infinite progression of mirrors), so the great majority of developmental psychologists today would interpret imitation as some primitive awareness that there are other people “out there”. Incidentally, this newborn imitation is not confined to the mother’s facial expressions as we might expect if the birth mother already had overwhelming importance for the infant.

Another point contradicting the possibility of “fusion” and symbiosis is the infant’s response to the so-called “still-face” situation. In this situation, an adult (the mother or someone else) faces a baby, but does not make eye contact and maintains a blank and unresponsive demeanor (this is not easy to do when the baby is signaling that it wants attention, by the way). From a few months of age, babies are distressed by this and become disorganized in their behavior, whimpering, averting the gaze, looking at their hands, even hiccupping. Babies who are in the developmental period where symbiosis had been thought to occur change their behavior in response to the still-face rather than accepting the unresponsiveness as a part of the “fused selves”.

At the same time, though, mothers or other primary caregivers continue to act as if they feel fused with their young babies. They interpret baby sounds, looks, and gestures as if they (the mothers) know the babies’ intentions. They talk to the baby about his or her needs and feelings. When talking to other adults, they may “speak for the baby”, voicing what they feel to be the babies’ opinions and answering questions or comments made to the baby by other adults. Sometimes they begin their baby remarks by saying “Say” in a lower voice, then switching to a high voice for the words the baby is supposed to mean to say (“Yes, I’m sleepy, Grandma”). As so often occurs, the mothers’ feelings and behavior are parallel to and supportive of the babies’ actions, but are by no means the same.

It’s notable that mothers’ sense of fusion fosters good infant development at the same time that it is not actually in line with reality. The mother who interprets her infant’s signals fairly accurately is encouraging the development of communication, followed by speech and eventually by other cognitive abilities. If she felt “unfused”, was convinced that the baby did not intend to communicate or that she could not understand, and did not try to respond, the mother would not do such a good job and the baby’s development might well be slowed. Problems are likely to occur when the mother is too depressed, tired, or sick to be responsive, or when there are too many young children to care for at once (as in low-quality group care for infants).

Even infants of a few months notice differences in adult emotional facial expressions, but they don’t respond with concern for the worried or frightened adult. By 8 or 9 months, they are interested in the meaning the adult’s emotions have for the child (is there something to be afraid of?). But it’s not until 12 months or so that they begin to have “theory of mind”-- the assumption that other people have their own separate feelings and knowledge, and that those adult facial expressions indicate feelings inside the adult. Without theory of mind, infants can hardly feel a sense of intimacy, much less symbiotic emotional fusion, with adults.

It’s a problem to assume that mothers’ and babies’ feelings about each other are mutual, with each a mirror of the other. We can’t make good guesses about infant abilities just from knowing how adults function. Research on infant abilities tells us that no matter what mothers may feel, babies don’t experience symbiosis. However much adoption reform is needed, it would not be wise to make reforms based on the assumption that mothers and young infants are in symbiotic relationships.