Reducing Maternal Depresion

7/29/2019 Reducing Maternal Depresion

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Project thriveiss B N. 2

Reducing Maternal Depressionand Its Impact on Young Children

Toward a Responsive Early Childhood Policy Framework

jan Knz n Szann tb n Kay jnsn

janay 2008


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AuthorS

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s, jan cp mmns, and Maasa isaas s anayss, Community Care

Networks for Low-Income Communities and Communities of Color, dd and nspd s k. w

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The National Center or Children in Poverty (NCCP) is the nations leading

public policy center dedicated to promoting the economic security, health, and

well-being o Americas low-income amilies and children. Founded in 1989

as a division o the Mailman School o Public Health at Columbia University,

NCCP is a nonpartisan, public interest research organization.


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Nana cn cdn n Py Reducing Maternal Depression and Its Impact on Young Children 1

Project thrive iSSue BrieF 2

Reducing Maternal Depression and Its Impact on Young Children:Toward a Responsive Early Childhood Policy Framework

jan Knz n Szann tb n Kay jnsn janay 2008

Introduction

Maternal depression is a signicant risk actor aecting

the well-being and school readiness o young children.

Low-income mothers o young children experience par-

ticularly high levels o depression, oten in combination

with other risk actors. This policy brie provides an

overview o why it is so important to address maternal

depression as a central part o the eort to ensure that

ALL young children enter school ready to succeed. It

highlights:

n what research says about the impact o maternal de-

pression on young children, particularly inants andtoddlers, and how prevalent maternal depression is;

n examples o community and programmatic strategies

to reduce maternal depression and prevent negative

cognitive, social emotional and behavioral impacts

on young children;

n key barriers to ocusing more attention to maternal

depression in policies to promote healthy early child

development and school readiness;

n state eorts to address policy barriers and crat more

appropriate policy responses; and

n recommendations or national, state and local poli-

cymakers.

Dollars invested in moms are dollars that really pay off.

D. Fank Pnam, Pss Pdas and Psyay,

unsy cnnna. 20061

Framing the Challenge

Depression is increasingly recognized as major world-

wide public health issue. It has a negative impact on

all aspects o an individuals lie work and amily

and can even lead to suicide. Typically, depression

is discussed as an adult problem aecting women or

men, and increasingly, it is recognized as a signicant

problem or children.2 But ar too rarely is depression,

particularly maternal depression, considered through a

lens that ocuses on how it aects parenting and child

outcomes, particularly or young children; how oten

it occurs in combination with other parental risks, likepost-traumatic stress disorder; and what kinds o strate-

gies can prevent negative consequences or parents, or

their parenting and or their young children.

Defning Depression through a Parenting Lens

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2 Reducing Maternal Depression and Its Impact on Young Children Nana cn cdn n Py

1) Maternal depression is widespread, particularly

among low-income women with young children.

Maternal depression is widespread across class and race,

and has been linked to genetic composition, situational

risk actors and circumstances, and environmental gene

interaction.6 Disproportionately, it impacts low-income

parents, whose depression is embedded in their lie

circumstances, poverty, lack o social supports and

networks, substance abuse, intimate partner violence,childhood abuse, and stress linked to a lie o hardship,

and too oten, no hope. (See box.) Research has shown

correlations between race and ethnicity and depression,

but the exact nature o the interaction is unclear. Ari-

can American women have very high rates o depres-

sion; rates among Latino women vary rom high to very

low, although rates in Latina adolescents are uniormly

high.14 But research also suggests that poverty is a more

powerul predictor. For poor women, rates o depres-

sion are high regardless ofethnicity. One study showedequal rates o depression among Arican American and

European American low-income women, and a study o

TANF recipients did not nd a dierence in prevalencebetween ethnic groups.15 In eect, poverty trumps race

as a actor in maternal depression.16

2) Maternal depression, alone, or in combination

with other risks can pose serious, but typically un-

recognized barriers to healthy early development

and school readiness, particularly or low-income

young children.

Maternal depression threatens two core parental unc-

tions: ostering healthy relationships and carrying outthe management unctions o parenting. The result,

long tracked in child development research, has been

linked to demonstrable reductions in young childrens

behavioral, cognitive, and social and emotional unc-

tioning. The impact o depression varies by its timing

(maternal depression during inancy has a bigger impact

on a childs development than later exposure), its sever-

ity, and the length o time it persists.17

Negative effects can start before birthThe negative eects o maternal depression on childrens

health and development can start during pregnancy.18

While the biological mechanisms are not clearly under-

stood, research on untreated prenatal depression nds

links to poor birth outcomes, including low birth-

weight, prematurity, and obstetric complications.19 The

biological eects can continue; research has ound that

maternal depression in inancy predicts a childs likeli-

hood o increased cortisol levels at preschool age, which

Prevalence Data on Maternal Depression

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pan and mpamns.13

If Mama aint happy, no one is happy.

Papan n a s p -nm mn .

D. Maasa isaas, ex D, NAMBhA. 20045


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in turn has been linked with internalizing problems

such as anxiety, social wariness and withdrawal.21

Maternal depression can impair critical early

relationshipsRecent neuroscience is clear that the primary ingredi-

ent or healthy early brain development is the quality o

the earliest relationships rom a babys primary caregiver

(which can be either parent, o course, but most oten

is the mother, especially or low-income children).Maternal depression can interere with the early bond-

ing and attachment process between mother and baby.

Maternal depression has also been linked with nega-

tive relationships in early childhood, and with reduced

language ability, which is key to early school success.22

Three year old children whose mothers were depressed

in their inancy perorm more poorly on cognitive and

behavioral tasks.23 Mothers who are depressed lack the

energy to carry out consistent routines, to read to their

children, or simply, most importantly, to have un with

them, singing, playing, and cuddling them.24 Childreno mothers with major depression are known to be at

risk or behavior problems, and are also at high risk or

depression or other mood disorders in later childhood

and adolescence.25

Maternal depression can impair parental safety

and health managementThe impact o depression in mothers has also been

linked with health and saety concerns. Depressed

mothers are less likely to breasteed, and when they do

breasteed, they do so or shorter periods o time thannon-depressed mothers.26 Mothers who are depressed

are less likely to ollow the back-to-sleep guidelines

or prevention o SIDS or to engage in age appropri-

ate saety practices, such as car seats and socket cov-

ers.27 Depression also aects the health services use and

preventive practices or their children. For example,

depressed parents are also less likely to ollow preventive

health advice and may have diculty managing chronic

health conditions such as asthma or disabilities in their

young children.28

The cumulative impact of depression in combina-

tion with other parental risks to healthy parenting

is even greater.

Depression in women oten co-exists with otherparental adversities and lie stressors, particularly

in low-income communities. These actors include,

along with the hardships associated with not having

enough money, substance abuse, domestic violence,

and prior trauma. A recent analysis o a birth cohort

rom 1998-2000 that ollowed children rom inancy

up to age 3 years in 18 cities provides important data.

On the positive side, hal o the mothers in the sample

had no risks. But o the hal who did, one-third o

those had more than one risk,* and as the number o

risks increased, so too did the likelihood o behavioralproblems related to aggression, anxiety and depression

and inattention and hyperactivity in the children.29 At

age three, o young children o parents who experienced

no risk actors, 7 percent were aggressive, 9 percent

anxious and depressed, and 7 percent hyperactive. The

comparable gures or young children whose moms ex-

perienced three risk actors were 19 percent, 27 percent

and 19 percent. The study also ound that maternal

depression and anxiety is associated with a stronger risk

o child behavior problems than our other risks tracked

(smoking, binge drinking, emotional domestic violenceand physical domestic violence).30

If those treating domestic violence dont screen for depression and

those treating for depression dont recognize post-traumatic stress disorder

or social anxiety or if neither recognizes the impact on children,

effective services and important resources are minimized.

D. Maasa isaas, ex D, NAMBhA. 200420

__________

* Risks measured included major depressive episode (14%); generalized anxiety disorder (3.6%); smoking (28%); binge drinking or illicit druguse (5%); emotional domestic violence (21%); and physical domestic violence (9%).


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3) Depression in other caregivers can also impact

the early development o young children.

FathersOverall, depression in athers is estimated at 6 percent,31

with community sample prevalence rates ranging rom

1.2 to 25 percent.32 Eighteen percent o athers in Early

Head Start report depressive symptoms.33 In the 18-city

study highlighted above, athers had lower rates o

major depression and anxiety disorder, but higher rates

o substance abuse (including smoking, binge drinking

and illicit drug use). In amilies where both parents are

depressed, the eects on children are compounded. It

is also noteworthy that some studies show that depres-

sion in athers is strongly related to maternal depression:

rates o paternal depression are higher when mothers

suer rom post partum depression, ranging rom 24

to 50 percent.

34

Further, non-depressed athers oer aprotective eect on children o depressed mothers.35

GrandparentsWhile there is little research on depression in grandpar-

ents raising children, even the scant data that we have

suggest that as states expand strategies to address ma-

ternal depression, they should take a amily and indeed

intergenerational perspective. Over a quarter o Head

Start grandparents who are primary caregivers were

mildly depressed (26.8%) and another quarter were ei-

ther moderately depressed (9.8%) or severely depressed(17.2%); in eect, hal o the sample.36 Thus these

rates are comparable to those o mothers. A study by

Chapin Hall Center or Children o grandparents who

are the ull-time caregivers o their grandchildren ound

that over a third (36.8%) scored above the CES-D (a

depression screening tool) cuto or depression, and an

additional group reported occasional or past depression.

The higher CES-D scores were signicantly associated

to parental incarceration; grandchildren with emotional

behavior issues; and grandparents perceptions o their

own physical health and well-being.37

Other caregiversNot surprisingly, since many who provide child care

and work in early learning programs are themselves

low-income women, emerging research also highlights

the impact o depression on other caregivers and on the

child care system in general. (See box.)

4) Much is known about how to treat depression

in women but too oten women, especially low-

income women, do not get appropriate help.

Depression is in general, a highly treatable disease. It

is responsive to combinations o traditional cognitive

and interpersonal treatment strategies, to medication,

and to creating peer-to-peer support groups.42 Studies

examining the ecacy o standardized treatment orlow-income populations, particularly with respect to the

use o cognitive-behavioral therapies suggest that core

treatment strategies need to be adapted, or example,

with more emphasis on engagement strategies, or using

phone, rather than ace-to-ace interventions.43 But even

with adaptations, there is another limitation o tradi-

tional treatment or parents.

Most interventions or depression address only the

adult; they do not address the adult as a parent, and

they do not actively include strategies to prevent or

repair damage to the early parent-child relationship,

which, as we know rom early brain science, is critical to

healthy early development.44 Further, there is very little

research that tests the ecacy o strategies that address

maternal depression in low-income women with mul-

tiple risks. In act, women with multiple risks are oten

excluded rom research. But even when treatment strat-

egies are linguistically and culturally appropriate and

Depression in child care providers exacerbates problems

in early childhood programs and is related to the high

levels o expulsion rom child care.

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n.38

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research-inormed, oten there are too ew appropriately

trained providers, particularly providers o color.46

Even more signicant is that many low-income women

lack access to health insurance in general, or mental

health insurance in particular, creating an additional

set o hurdles or them. Medicaid does allow the states

to cover parents o eligible children, but in most states,

eligibility levels are very low. (See box.)

Focus groups with low-income women rom multiple

ethnic groups also make it clear that oten the women

are reluctant to seek treatment because o how they per-

ceive depression, and what acknowledging the need or

treatment might mean or them and their amily.47

For example, many women think how they eel is just

the way it is; that depression comes with the reality

o their lie situations. Secondly, they are very leery o

the stigma involved in admitting they have a prob-

lem. There is great distrust o mental health agencies,

including community mental health centers. And, most

important o all, women are earul o what admitting

to depression will mean or their children. Many are

reluctant to take medications because they ear what the

side eects will do to their parenting (such as not being

able to get their children ready or school). Others ear

that i they are not seen as good parents, child welare

will come and take their children away. On the other

hand, researchers have successully adapted traditional

treatments to be more responsive to women by address-

ing trauma, using outreach and strengthening the ocus

on educational and support approaches.48

The gap between the availability of good treatment for parents and the

utilization of treatment is enormouswhat we tolerate for depression,

we would not tolerate for diabetes.

D. wam Bads, Aadm ca, Dpamn Psyay,

cdn's hspa Bsn. 200645

Parental Access to Mental Health Services through

Medicaid49

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What Can Help Parents With or

At Risk o Depression and Their

Young Children?

Parental depression can pose a serious risk to young

children, but it is not a sentence either or a mom or

or her young children. Promoting early identicationand screening and, or low-income women, adapting

and making traditional treatments more accessible will

help. Both research and reports rom the eld suggest

that educating parents about the eects o their depres-

sion on their children may also encourage mothers to

seek treatment. Some practitioners have ound that

presenting maternal depression treatment as a git or

your child to be highly eective to mothers who may

otherwise be resistant to treatment.55 Other important

strategies are also emerging that center around oering

amily-ocused services in settings that parents trust,such as doctors oces or early childhood programs.

A amily approach to treatment or all women with

young children, but particularly or low-income wom-

en, in settings that they trust represents an opportunity

or interventions that can help both young children and

their parents.56 It is, in other words a two-er. Treat-

ment or the mom becomes prevention or early inter-

vention or the child (and or the parent-child relation-

ship). Early childhood programs can also provide such

supportive experiences or parents that they may alsoprevent depression or reduce the need or more ormal

treatment in some amilies.

Below we highlight examples o emerging eorts across

the country to address depression in the context o par-

enting young children. In general, these eorts involve

three types o strategies:

n screening and ollow-up or women, typically in

ob/gyn or pediatric practices;

n targeted interventions to reduce maternal depressionand improve early parentingin early childhood pro-

grams such as home-visiting and Early Head Start

Programs; and

n promoting awareness about the impact o maternal

depression and what to do about it or the general

public, low-income communities, and early child-

hood and health practitioners.

Themes rom Focus Groups with Low-Income Women50

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Low-income Women, Access to and Use o Traditional

Treatment

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__________

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Screening and Follow-up

Early detection leading to treatment can be important

in reducing the impact o depression on women and

young children. One strategy that states and communi-

ties are implementing is to identiy, through the use o

standardized screening instruments, women who are

experiencing depression who are pregnant or parenting

young children. Screening is being done in a variety o

settings including pediatricians oces, womens health

clinics, and obstetrics/gynecology practices. When the

screening is implemented in pediatric practices, it is

oten part o a child-ocused eort to increase develop-

mental screening.

The American College o Obstetricians and Gynecolo-

gists (ACOG) recommends psychosocial screening o

pregnant women at least once per trimester (or three

times during prenatal care), using a simple two question

screen and urther screening i the preliminary screenindicates possible depression.58 Others support the use

o standardized, validated tools. But there is research

showing that even asking parents questions about how

they are eeling and what they are acing makes it pos-

sible to discuss otherwise seemingly o-limits issues.

Although there has been concern that amilies would

nd screening intrusive, some evidence suggests that

most seem to welcome it.59

Experience also suggests that screening should be readily

available in settings where mothers are, should be easyor both the provider and the client, and should involve

building the inrastructure to support ollow-up. The

screeners must be trained, and a reerral/ollow-up sys-

tem should be in place beore screening is implemented

so that those doing the screening know how to respond

and where they can turn i a problem is identied.

Screening or Maternal Depression in Action

n In North Carolina, a project unded by The Com-

monwealth Fund supported through its ABCD I

project (described below) piloted a project to increase

ormaldevelopmental screening and surveillance or

Medicaid-eligible children receivingEarly Periodic

Screening, Diagnosis, and Treatment (EPSDT)

servicesin pediatric and amily practices. Beginning

in one county in 2000, the project assisted pediatric

practices in implementing an ecient, practical pro-

cess or young childrenor screening, promotedearly

identication and reerral, and acilitated the prac-

ticesability to link to early intervention and other

A focus on maternal depression as a family intervention can support

strengthening families, attachment to work and employment, and

greater assurance that young children will enter school ready to learn.

D. Maasa isaas, ex D, NAMBhA57

Tools or Screening

n t ms mmn adad snn s sd

d mana dpssn a Edinburgh Postnatal

Depression Scale (EPDS), Postpartum Depression

Screen (PPDS), Beck Depression Inventory-II

(BDI-II), and Center or Epidemiological Studies-

Depression Scale (CES-D). A a m sns

dnyn ma dpss dsd, b an a-

ay dny mn dpss dsds as .60*

n Acog mmnds a smp qsn sn

a pnan mn (1. o pas ks, a

y dn, dpssd, pss? 2. o

pas ks, a y ns pa-

s n dn ns?), snn s

mn s anss nda pssb dpssn.61

n Sds nd a a -qsn pap-basd

sn, d by a b dsssn m

by a pdaan, as b asb and n

dnyn mn ndd -ps as.

on sds xamnd dn bn

a ba n and a pap m, and pap

sn as nd b a m .

62

__________

* Sm sa sss a d ypa ans n nma pnany and

pspam y, na dpssn snn s may s as as

pss, ndan a pspam-spf dpssn snn s may b

m . (hdn, jn; cx, jn. 2003.Perinatal Mental Health: A Guide to

the Edinburgh Postnatal Depression Scale (EPDS). lndn: rcPsy Pbans.)


10/28


community services. Once the approach took hold,

the designers began to embed maternal screening

into the project. The approach is now used statewide

in North Carolina and has spurred similar initiatives

elsewhere.63 It has also been the catalyst or a state-

wide policy change in North Carolinas Medicaid

program that is discussed below.

n In Chicago, spurred by the deaths o several women

who were suering rom maternal depression, the

UIC Perinatal Mental Health Projectwas ounded

to enhance the health care system's early recognition

and treatment o perinatal depression. The project

has trained over 3,000 providers in specic tools to

aid screening assessment and treatment. Technical

assistance on implementation o these procedures is

available or clinics and providers. A key component

o the intervention is telephone-based consulta-

tion or the primary care providers to ensure theyhave access to additional inormation and guidance

when necessary. In addition, a medications chart was

developed and widely disseminated to assist primary

care providers in treating perinatal depression. This

work is unded in part by a HRSA-MCHB Perinatal

Depression Grant. With support rom the Michael

Reese Health Trust and Healthcare and Family

Services, UIC is also working on two alternative

approaches to treatment o perinatal depression or

HFS-enrolled providers and women. A stepped

care model provides training and tools to primarycare providers to assess, treat and reer women

with perinatal depression. A sel-care tool provides

women with suggestions or dealing with cognitive

behavioral issues and help them emerge rom perina-

tal depression.64

n The MOMobile program, based in eight sites in

southeastern Pennsylvania, under the auspices o the

Maternity Care Coalition, sends community health

workers around neighborhoods to support pregnant

women, new parents, and amilies with inants.

The advocates link amilies with services and sup-ports, provide parenting education, provide service

reerrals, and distribute baby supplies and ood in

emergency situations. Through a Pew Charitable

Trusts grant, MCCs social workers and community

health workers have begun screening newly regis-

tered clients at all eight sites or perinatal depression

using EPDS, totaling about 1,500 women each year

(previously, clients at some o the eight programs

were screened). The overall program has served over

50,000 amilies since its ounding in 1989.65

Targeted Interventions in Early ChildhoodPrograms to Address Depression*

A potentially powerul, but still underutilized strategy

is to embed explicit interventions designed to prevent,

or reduce depression and its harmul impacts on young

children into early childhood programs, especially

home-visiting and Early Head Start programs. In these

programs addressing maternal depression is an invest-

ment in improved outcomes or the children. Typically,

the interventions involve a ocus on improved parent-

child relationships and parenting practices. But it is

important to underscore that amily-ocused interven-

tions are not mental health as usual, where the adult

is treated, and sometimes the child is either treated or

screened, but they are not treated together.

Home-visiting programs, whether they are stand-alone,

or a component o Early Head Start or through eder-

ally unded Healthy Start programs, are available in

many communities across this country and represent an

important, but underutilized opportunity to prevent andaddress maternal depression and its consequences or

young children.

Research on Early Head Start, which is a nationwide,

comprehensive amily support and child development

program that seeks to enhance all aspects o develop-

ment or inants and toddlers at the poverty level, has

paid special attention to maternal depression. An initial

study ound that depressed parents participating in Ear-

ly Head Start were more likely than the control group

to improve their parenting practices and have childrenwho were less aggressive or negative when interacting

with peers; had more positive parent-child interactions;

were less likely to receive harsh discipline strategies; and

overall, were more engaged and attentive.66 The ollow-

up study, two years ater the program, shows ewer__________

* There are also powerul individual therapeutic strategies that engage parents and children. The dyadic therapy model teaches a mother how to read,interpret, and respond to her inants cues, and assists the mother in dealing with her emotions and needs related to motherhood. The model improvesattachment, increases both maternal and child sensitivity, and reduces incidence o abuse and neglect, and is eective even when the mother is de-pressed. (Parent-Child Mental Health Interventions, Zero to Three Fact Sheet. Zero to Three, National Center or Inants, Toddlers, and Families.)


11/28


depression symptoms among women who participated

in Early Head Start than in the control group.69 A

combination o child actors such as improved cogni-

tion, vocabulary at ages two and three; and improved

child engagement at age three; and amily actors, such

as improved parenting skills, reduced parenting distress,

seems to account or the reduction in depression.68

Augmenting Early Childhood Programs69

n Family Connections in Head Start: Taking

Prevention Seriously

In Boston, the Family Connections project is a

strength-based prevention model that is being imple-

mented across six Head Start and Early Head Start

sites. The core elements o the program are to:

build competence and resilience in HS/EHS sta

in order to strengthen sta s ability to engagearound issues o depression and adversity;

provide hope, to enhance parent engagement and

parenting skills;

strengthen meaningul teacher-child interactions

related to emotional expression and adversity; and

better identiy and plan or needed services or

children and amilies in emotional distress.

Family Connections (which is part o a major pre-

ventive intervention study) is based on lessons rom

several intervention models including an empiricallytested amily-ocused intervention developed or to

help older, middle class children and parents cope

with depression.70

Reports by Head Start parents, teachers, and director

showed that it is easible to deliver training sessions

linked to consultation and to develop and sustain par-

ent and teacher activities. Most strikingly, sta turn-

over and sick days decreased markedly in more than

one center in response to the program. Sta also report

increase in skills. Positive change in teacher attitudes

and practices relating to mental health and related

adversities were evident in all centers. Findings varied

by center, based on site organization and readiness.71

n Every Child Succeeds (Cincinnati): Addressing

Depression Directly

Recognizing that the challenges o helping depressed

moms cuts across dierent home-visiting models,

Every Child Succeeds has developed and approach

that embeds cognitive behavioral therapy into three

dierent home visiting models. Pilot results show

that the two-generational approach resulted in

signicant decreases in parental depression and im-

proved language and cognitive unctioning in inants

and toddlers.72 ECS therapists provide an adapted

orm o cognitive behavior therapy to mothers in

their homes, working to treat depression and preventrelapses, as well as maximize the eectiveness o the

home visiting program. The programs success rates

are comparative to antidepressants or typical cogni-

tive behavior therapy.73The early results show thato the 29 percent o mothers who enter ECS with

clinically signicant levels o depression, hal are no

longer depressed ater nine months in the program.74

A randomized control trial is now in progress that

will also track child outcomes.

Every Child Succeeds is a collaborative regionalprogram that has three ounding partners: Cincin-

nati Childrens Hospital Medical Center, Cincinnati-

Hamilton County Community Action Agency/Head

Start, and the United Way o Greater Cincinnati.

Funding comes rom a public-private partnership

that includes Medicaid, state and county unding,

United Way o Greater Cincinnati agencies, corpo-

rate and individual sponsorships.

Two other strategies refecting practice and experiential

wisdom should also be noted: peer-to-peer support/recovery groups or depressed women in low-income

communities, and expanding access to mental health

consultants in both early childhood programs (includ-

ing home-visiting programs) and health care settings,

such as pediatric practices.

Peer-to-peer support groups, requently called Sister

Circles, have been shown to reduce depression in black

and Latino women.75 The groups provide support and

social networks, and they may particularly appeal to

women who ear the stigma o traditional mental healthservices.76 Most groups do not ocus on young children;

however, we did identiy one program that ocuses on

parents with inants and toddlers.

n In New York City, the Caribbean Womens Health

Association organizes the Community Moms Pro-

gram, a program or immigrant women who are

pregnant and parenting children, birth to age two.

The program provides health education workshops,


12/28


support services, home visiting, and screening and

reerrals or maternal depression.77 Active, older com-

munity members were recruited to provide direct ser-

vices, such as home visiting and community engage-

ment. The Health Workers build strong connections

with mothers to both build social support networks

and to provide education about maternal depression

at the one-on-one and community level. Because

the Health Workers come rom the communities

in which they work, they are uniquely equipped tounderstand the roles o racism, cultural gender roles,

and stress o the daily lives o the women.78

Linking mental health consultants to home-visiting

programs is another approach to strengthening the ca-

pacity to respond to amilies with depression and other

risks. The consultants role is to help the home-visitors

identiy and respond eectively to relationship based

problems, including depression, to help home-visitors

decide i reerrals are needed and in some programs, to

work directly with the amily alongside the home-visi-tor. Below is an example o embedding a mental health

consultant in the Nurse Family Partnership Program.

n Louisiana Nurse-Family Partnership Program:

Adding Mental Health Consultants

The Louisiana Nurse-Family Partnership Program

augmented the standard nurse intervention with

extra training and with mental health proession-

als in order to deal with the increased inant and

maternal mental health risks they knew to be pres-

ent in the Louisiana population, including maternaldepression. In a preliminary trial, the nurses and the

mental health consultants received intensive training

in inant mental health issues and child development

and then worked together in an extremely high-risk

population, with one consultant per site nursing team

(typically eight nurses and one nurse supervisor or

160 amilies). While the study was small, it indicated

that incorporating mental health consultants into

the home visiting program strengthened the team

approach o the Nurse-Family Partnership, increased

the skills o both the nurses and the clinicians to deal

with maternal and inant mental health issues, and

allowed the consultants to reach a greater number o

amilies than would otherwise be possible.79

These on-the-ground examples suggest that core com-

ponents o successul eorts to address maternal and

other risks in early childhood settings:n link services and supports or parents and children,

through ormal and inormal strategies;

n provide training and support to home visitors, teach-

ers and child care providers to help amilies and to

get support or their own depression;

n help parents address specic parenting challenges

related to depression and other adversities;

n ensure that children in higher-risk amilies have ac-

cess to high-quality child development programs like

Early Head Start to reinorce social and emotionalskills and early learning opportunities; and

n provide clinical treatment when it is needed in set-

tings amilies trust.

Policymakers should focus serious attention on maternal depression

as part of the larger efforts across the country to improve healthy

developmental and school-readiness outcomes in young children.


13/28


Building the Policy Framework

State Eorts

The lesson rom research is clear: adult depression is

not only bad or adults, it is bad or children, especially

young children. Yet crating a coherent policy responsebeyond demonstration programs is very dicult. A

basic issue is that most low-income women, as noted

above, lack access to health insurance, o i they have

it, coverage or mental health. Policy mechanisms to

pay or screening and ollow-up are limited. Even more

challenging is sustaining amily-ocused interventions in

the context o early childhood programs such as home-

visiting and Early Head Start. In act, most o the initia-

tives highlighted above are either oundation unded, or

time-limited research and demonstration programs. Few

states have the capacity, nor are there ederal incentives,to take research-inormed practices to scale. At the same

time, states are trying to respond.

Using ABCD as a Catalyst

The major strategy that is emerging across the country,

largely as theresult o an on-going project developed

by the Commonwealth Funds Assuring Better Child

Health and Development (ABCD) program, is screen-

ing or maternal depression, either in context o pedi-

atric practice or prenatal care. The ABCD program,administered by the National Academy or State Health

Policy (NASHP) is designed to assist states in improv-

ing the delivery o early child development services

or low-income children and their amilies. The rst

ABCD consortium (ABCD I) was created in 2000 and

provided grants to our states (NC, UT, VT, WA) to

develop or expand service delivery and nancing strate-

gies aimed at enhancing healthy child development or

low-income children and their amilies.

The ABCD II Initiative, launched in 2003, is designedto assist states in building the capacity o Medicaid

programs to deliver care that supports childrens healthy

mental development. The initiative is unding work

in ve states (CA, IL, IA, MN, UT).80 An additional

20 states currently receive support through the ABCD

Screening Academy. Some o the ABCD II sites have

integrated maternal depression screening and pediatric

social-emotional screening into primary care. Below we

highlight policy activities related to, or including mater-

nal depression in two states.

n North Carolina, the North Carolina ABCD I ini-

tiative. The North Carolina eort to promote paren-

tal screening or depression is part o a larger eort

to promote and pay or developmental screening or

all young children. Ater the project to test strategiesto increase screening in pediatric oces was success-

ully replicated in nine counties (see earlier descrip-

tion), it was expanded to cover the state, backed by

ormal changes in the state Medicaid policy in 2004.

The policy requires that practices to use a ormal,

standardized developmentalscreening tool at 6, 12,

18, or 24 months and 3, 4, and 5 yearso age, and

as o 2006, more than 70 percent o children were

being screened at well-child visits, compared to an

average o only 15.3 percent prior to implementa-

tion.81

Parents are screened or depression by theirchildrens primary care providers. North Carolina

has also provided or parental access to treatment.

They have expanded coverage to reimburse or up to

26 mental health visits or covered children. Parents

can be seen under their childs Medicaid benets or

the rst six visits, and providers can include PCPs,

LCSWs, and psychologists. The project has worked

to co-locate mental health providers within primary

care practices, which both makes it easier or ami-

lies to access care and reduces stigma by delivering

services within locations and communities whereparents are already comortable.82

n Great Start Minnesota, the Minnesota ABCD II ini-

tiative, integrates mental health screening into pedi-

atric care. The clinic systems co-locate mental health

proessionals into pediatric clinics. While the ocus is

on childrens mental health, parents are screened or

mental health issues during the prenatal and perinatal

periods, and or postpartum depression. In addition,

the project assisted with passing the 2005 Postpartum

Depression Education legislation in 2005, which

requires physicians, traditional midwives, and otherlicensed health care proessionals providing prenatal

care to have inormation about postpartum depres-

sion (PPD) available, and hospitals to hand out writ-

ten inormation about postpartum depression to new

parents as they leave the hospital ater birth.83 The

legislation also requires the Minnesota Department

o Health to work with a broad array o health care

providers, consumers, mental health advocates, and


14/28


amilies to develop materials and inormation about

postpartum depression.

The eorts just described generally involve multiple

stakeholders coming together to gure out how to

use existing resources in ways that will maximize their

impact or mothers with depression and their young

children. In particular, they are embedding screen-ing or treatment across settings (in ob/gyn as well as

pediatric practices) and they are nding ways to extend

parental eligibility through Medicaid. However, the

recent regulations proposed by the Center or Medicare

and Medicaid Studies pose serious threats to many o

these strategies.

Enacting State Legislation

At least one state, New Jersey, has enacted legislation

requiring screening or depression and strengthening

the capacity to respond to the identied need.

n New Jerseyenacted the Postpartum Depression

Lawin April, 2006, that requires physicians, nurse

midwives, and other licensed health care proession-

als to screen new mothers and to educate pregnant

women and their amilies about post partum depres-

sion.84 New Jersey has long been at the oreront o

postpartum depression action and legislation, due

in part to the advocacy work o Mary Jo Codey, the

wie o the ormer governor Richard Codey, and thiswas the rst law in the country to require health care

providers to screen all women who have recently

given birth, and to educate women and amilies.

The bill provides $4.5 million or a comprehensive

program, including the establishment o a statewide

perinatal mental health reerral network. New Jersey

is also the original developer o the Speak Up When

Youre Down campaign, which is now used in Wash-

ington State. (See box.)

Using the State Early Childhood ComprehensiveSystems (ECCS) grants to leverage change

In a number o states the ECCS coordinators and the

ECCS grant itsel have been the catalyst or ocused,

cross-system attention to maternal depression and

how it impacts the broader early childhood goals.

For example:

n As part oIowas ECCS activities, Maternal Depres-

sion Screening: Train the Trainer workshops are

oered in partnership with the Iowa departments o

Public Health, Human Rights, Management, Educa-

tion, Human Services, Prevent Child Abuse Iowa,

Head Start Collaboration Oce, and the University

o Iowas Depression and Clinical Research Center.

As o the end o scal year 2007, 34 trainers were

trained atthe Maternal Depression Screening: Trainthe Trainer workshops, and these trainers held 15 lo-

cal trainings or providers in Iowa. Preliminary results

rom two demonstration sites indicate a 70 percent

increase in rates o screening or maternal depres-

sion.87

n Rhode Islands ECCS project includes supporting

screening in child care and primary care settings, and

increasing the capacity o service providers to addressparent and amily behavioral health issues, through

treatment and reerral as objectives. Watch Me Grow

RI trains participating pediatric and amily prac-

tices to screen parents using the Early Childhood

Screening Assessment, which has our questions that

directly screen or maternal depression. Providers are

also trained in how and where to reer parents who

screen positive or depression.88

Speak Up When Youre Down in Washington State

Washington State nds a pb aanss ampan

da mn and ams ab sympms

and amn pspam dpssn. t Speak Up

When Youre Down ampan, fs dpd by N

jsy, s d by wasnn cn Pnn

cd Abs and N, an pan anza-

ns, ndn mmny mmbs, dana n-

sns, and pssna anzans n wasnn

Sa. t ampan, sad n 2005

hrSA ans, pds dana maas and

ns a am n ms sn m ps pam

dpssn.85 t pam ad n ndn a ya

b as ndd by a n m n bd (

a ampn n sa sa) $250,000

m yas, san jy 1, 2007. t p-

ams n as nd xpandn ampan

f anas (ens, Spans, vnams, rssan,

and Sma); nsn a maas a ay

mpn; and an a pb s annnmn

ampan sn, pn, and ad. t campanas pand unsy wasnn S

Nsn spp a wb-basd pd ann a

as dpd by S n a an.86


15/28


n In Connecticut, the ECCS Director also acilitates

the Statewide Perinatal Depression Screening Work-

group. The Department o Public Health convened

a Perinatal Depression Screening: Implications or

Consumers and Providers summit in May 2006,

and has launched a perinatal depression screening

public awareness campaign. A pilot perinatal depres-

sion screening project has been started in two com-munity health clinics, and eorts are underway to

institutionalize perinatal screening in DPH unded

perinatal case management programs.

Putting It All Together

Over the past several years, Illinois has ocused major

energy on improving and linking its eorts on behal o

young children. Illinois has a strong state policy rame-

work that includes legislation that calls or preschool or

all young children and includes a set-aside or inants

and toddlers. In addition, the state has a strong leader-

ship group, built on solid relationships among advocates

and state ocials, that has made a special eort to ocus

on the importance o promoting healthy early relation-

ships. Illinois success is based on public/private part-

nerships, strong advocacy, and state agencies working

together to assure the service delivery system meets the

needs o young children.

The ocus on maternal depression builds on earlier

work to promote healthy social and emotional develop-

ment in young children, or example, by expanding ac-

cess to early childhood mental health consultation and

the Childrens Mental Health Partnership. The partner-

ship brings together a broad-based strategy to address

the mental health and social/emotional development

o children and adolescents, including young children.

Recognizing the importance o maternal depression and

particularly its impact on inants and toddlers, Illinois

has taken a number o steps across multiple agencies

and communities to develop a putting it all togetherstrategy. Largely driven through public-private collabo-

rations, the work has grown out o the states Birth-to-

Five early childhood systems development initiative,

convened by Illinois Ounce o Prevention Fund and

through state agency work to address the health needs

o young children. The eort can be linked to the states

ECCS grant work and the governors initiatives to im-

prove health outcomes o children and assure they are

ready to learn.

Eorts to assure the healthy mental development o

young children are many:

n In July 2006, Governor Blagojevich implemented

All Kids, which provides uninsured children accessto comprehensive health care with a rich benet

package (similar to that under Medicaid EPSDT).

In December 2007, FamilyCare eligibility (aord-

able coverage or parents and caretaker relatives) was

raised to 400 percent o the poverty level, thereby

assuring health benets or many more Illinoisans.

To assure that beneciaries have access to care

and a medical home, the Illinois Department o

Healthcare and Family Services (HFS), the single

state agency responsible or the administration o

Title XIX and Title XXI o the Social Security Act,

FamilyCare, and the All Kids program, imple-

mented a mandatory statewide Primary Care Case

Management (PCCM) program, with a strongquality assurance process that includes ongoing

tracking and monitoring. Feedback to providers on

key indicators and ongoing provider training are

among the strategies incorporated in the program.

HFS contract with its Managed Care Organiza-

tions (MCO) was strengthened to specically

require objective developmental screening o

young children and perinatal depression screening,

reerral and treatment, with ongoing monitoring

and tracking. Enrollment in an MCO is voluntary

and available in seven counties, including Cook

County.

n Public Act 93-0536 (305 ILCS 5/5-5.23) was passed

with the goal o improving birth outcomes or over

80,000 babies whose births are covered each year by

HFS. The law requires HFS to develop a plan to im-

prove birth outcomes. Addressing perinatal depres-

sion is among the strategies outlined in the plan.89

n Illinois participated in the ABCD II project with

support rom The Commonwealth Fund, the Na-

tional Academy or State Health Policy, the MichaelReese Health Trust, The Chicago Community Trust,

the Centers or Medicare & Medicaid Services, The

Ounce o Prevention Fund, provider organizations

(Illinois Chapter o the American Academy o Pe-

diatrics and the Academy o Family Physicians) and

many other partners.

n Public Act 095-0469, Perinatal Mental Health

Disorders Prevention and Treatment Act, eective


16/28


January 1, 2008, was enacted to increase awareness

and to promote early detection and treatment o

perinatal depression.90 This act requires that:

Women and their amilies be educated about peri-

natal mental health disorders in the prenatal and

hospital (labor/delivery) settings.

Women be invited to complete a questionnaire toassess whether they suer rom perinatal mental

health disorders in the prenatal, postnatal and

pediatric care settings.

Under the authority o Public Act 93-0536, and

through a collaborative eort involving public-private

partnerships, including the states human services agen-

cies, the Conerence o Women Legislators, the Univer-

sity o Illinois at Chicago Womens Mental Health Pro-

gram, and private oundations, Illinois has developed a

comprehensive perinatal depression initiative.

n Screening or perinatal depression using an approved

instrument is a reimbursable service to HFS-enrolled

providers, including community mental health

centers, or screening HFS-enrolled women. Screen-

ing is reimbursed both prenatally and up to one year

ater delivery.

n The Perinatal Mental Health Consultation Service

operated by the University o Illinois at Chicago

(UIC) is available to HFS-enrolled providers or

consultation on perinatal depression. The consul-tation service is toll-ree, provides consultation to

physicians by psychiatrists, and provides inormation

about medications.

n A 24-hour crisis hotline operated by Evanston

Northwestern Healthcare (ENH) Postpartum De-

pression Program is available to women experiencing

perinatal depression. The hotline is staed by trained

mental health proessionals. Callers receive psycho-

social assessment by phone and are reerred to local

mental health providers.

n Reerral and treatment resources are available state-

wide or reerral o women who call the hotline.

n Provider education and training on the healthy

development o young children, which includes ad-

dressing perinatal depression, is available rom the

Enhancing Developmentally Oriented Primary Care

(EDOPC) program operated by Advocate Health-

care, the Illinois Chapter o the American Academy

o Pediatrics and the Illinois Academy o Family

Physicians (web-based training), and the Mental

Health Consultation Service.

n A major initiative was undertaken with the Chicago

Department o Public Health to screen pregnant

women or depression.

n The Illinois Department o Human Services has

provided State Title V Maternal and Child HealthServices Block Grant unding to support the states

perinatal depression initiative and promotes perina-

tal depression screening and developmental screen-

ing o young children in the public health sector.

n HFS provides support o provider training on peri-

natal depression, telephone consultation and reerral

coordination or its participants with support rom

private oundations and ederal matching unds.

Perhaps most signicantly, cross-agency, public-private

collaboration has led to system-wide change at the s-

cal, policy, and practice levels.

n HFS provides reimbursement or screening perinatal

program participants and/or their inants who are

enrolled in the program.

n The state has created the expectation through

EPSDT that objective developmental screening will

occur, at a minimum, annually rom birth to age 3.

n Illinois has made it a priority to ocus on promoting

healthy social and emotional development in young

children, including addressing mental health needs o

their mothers to improve healthy early relationships.

n Inants and toddlers with a mother with a mental

health illness diagnosis (including depression) are

automatically eligible or the Early Intervention

program.

n Screening and identication o mothers experienc-

ing depression have increased in the HFS-enrolled

population.

n An eort to cross-walk and implement DC-0-3 is

under way.

n HFS began providing reimbursement or adult

preventive care services eective July 1, 2007. In

conjunction with this, an annual preconception visit

will also be allowed. The coverage o routine preven-

tive services and preconception/interconception care

or women allows greater opportunity or screening

or perinatal depression.


17/28


To make these eorts work, there is close and requent

communication among a core group o leaders, which

promotes leveraging o dollars toward achieving a com-

mon vision.

Federal Eorts

To date there has been a limited explicit ederal response

to maternal depression. At the agency level, over the past

three years, in response to a Congressional appropriation,

MCHB-HRSA has given 16 states one-year grants to

promote awareness o and address perinatal depression.

n In Fiscal Years 2004 and 2005, 10 State MCH

programs (AK, CT, DC, IL, IN, MD, MA, NE, NY,

VA) received money to launch multilingual public

education programs to promote mental wellness ormothers and amilies, and to increase public aware-

ness and understanding o maternal depression to

reduce stigma and encourage treatment. The initia-

tive also required states to decrease barriers to care

or low-income amilies.

n In 2006, the program awarded grants to six states (IL,

IA, LA, KY, MA, PA) to provide comprehensive, co-

ordinated services or maternal depression and other

mental health problems during pregnancy and at least

through the rst year ater pregnancy. In this program,

maternal mental health services must be combined with

services or inant mental health within a service system

model that ocuses care on the mother-inant pair.93

While the rst round o grants have been useul, states

do not seem to be able to sustain the public awareness

strategies.

Pending Federal Legislation as o Winter 2007

n t Melanie Blocker-Stokes Postpartum Depression

Research and Care Act as passd by hs n

ob 15, 2007. Spnsd by Bbby rs (il),

and spnsd by 130 rpsnas, hr

20 nd sa, snn, amn, and d-

an ms pspam dpssn and

psyss, fsa yas 2008-2010. t b, fs

ndd n 2001, as passd by a 382

3. i as bn sn Sna.

n Moms Opportunity to Access Health, Education,

Research, and Support or Postpartum Depression Act

(MOTHERS Act), as ndd by Sna rb

Mnndz (Nj) and spnsd by Babaa Bx

(cA), Sd Bn (oh), csp Ddd (ct),

rad Dbn (D-il), Fank lanb (Nj), Baak

obama (il), Bnad Sands (vt), oympa j. Sn

(Me), and Sdn ws (ri). ts sa-

n d asss a a pds da-

n, dnfan, and amn, and ns a

n ms and ams a dad ab

pspam dpssn, snd sympms, and

pdd ssna ss.91 i as as

nasd sa a Nana inss ha

n pspam dpssn amns and dans

s. t b as ndd n jn 2006, as

ndd n May 2007, and as bn d

Sna cmm n ha, edan, lab,

& Pnsns. in ak passn Man

Bk-Sks Pspam Dpssn rsa and

ca A, pspam dpssn adas a bn

anzn nsn spp, ndn a nana

day an a snas and b ab a. 92

n Ps hs san passd n 2000, House

Resolution 163, xpssn sns hs

rpsnas sp pspam dps-

sn nad and mmndd mana

dpssn snn, pd dan, and pb

aanss, b dd n manda any ans.

Update: in Nmb 2007, hs and Sna bs

mbnd and namd as The Melanie Blocker

Stokes MOTHERS Act. As Fbay, 2008, A s

Sna cmm n ha, edan, lab,

and Pnsns, aan mak p and psnan

Sna dn nx sa sssn.

Innovative Coverage or Depression Screening

hFS-nd pds pd pmay a s-

s an b mana dpssn snn sn

an appd snn nsmn (ednb Psnaa

Dpssn Sa, Bk Dpssn inny, Pmay

ca eaan Mna Dsds Pan ha

Qsnna, Pspam Dpssn Snn Sa,cn epdm Sds Dpssn Sa). t

snns an b pmd as many ms as ns-

say, p n ya a b. Bas pna

na mpas mana dpssn n dn,

snn s d as a sk assssmn and an

b mpd dn pnaa and pspam ss, as

as dn nan -d and psd ss. D-

n pspam pd, pds b nd m-

ans a, s s d by hFS. F sn-

ns a ak pa dn a -d psd s,

hFS mbs nans a. en-

n ra cns, Fday Qafd ha cns,

and ra ha cns d n mbsmn

snn bas y a pad by nn a, s a ss p s. on a man s d-

ansd dpssn, hFS mbs and-

pssans pamaa amn mn

d nd s mda pams.


18/28


There have also been eorts to introduce legislation to

promote public awareness and a more coherent set o

services or pre-natal depression. However, none has

been successul. (See box.) Nor has there been any exec-

utive order or Congressional mandate to bring together

health, mental health and child development agencies

to maximize the impact o scattered research projects.

Recommendations

Addressing and targeting resources to maternal depression

as a barrier to early healthy development and early school

success is complex undertaking that will require the in-

volvement o programs, community leaders, state policy-

makers and legislators and amilies and researchers at local

and state levels, as well as some national leadership. At the

same time it is clear rom this report that approaches are

emerging, both at the practice level and the policy level.To move this agenda orward, below is a set o strategic

actions or those at the local, state and ederal levels.

At the local level, communities can:

n conduct a community scan to assess local capacity

or screening and ollowing-up or pregnant women

and parents o babies and young children and to

identiy how existing resources are used;

n engage local unders, including community ounda-

tions, to develop a strategic plan and implementa-

tion steps to help local early childhood programs test

and/or replicate evidence-based, eective amily-

ocused practices to address maternal depression and

its impact on young children (See Appendix or con-

tacts or approaches mentioned in this issue brie.);

n assess and strengthen community capacity to ad-

dress depression in athers as well as mothers, and in

others who care or young children on a daily basis,

whether in amilies or in child care settings;

n engage leaders o low-income communities in de-

signing and evaluating public awareness campaignsand culturally and linguistically responsive outreach

and program strategies;

n document disparities and implement strategies to

track and improve access to culturally and linguisti-

cally responsive instructions; and

n combine public and private dollars to support early

childhood mental health consultants to work with

home-visitors and other caregivers.

At the state level, public ofcials and advocates

can:

n use ECCS grants to help health care providers and

systems implement a developmental multi-genera-

tional amily health/mental health perspective, in-

cluding attention to prenatal depression and related

risks as part o implementing the medical/dentalhome vision;

n dedicate a sta person to coordinating interagency

screening, prevention and treatment eorts to ad-

dress depression through a amily lens, paralleling

positions that have been created or to coordinate

cross-agency activities around womens health or

HIV/AIDS;

n develop a cross-agency strategic action plan to

reduce maternal depression and its impact on young

children that identies what each system will do

separately and together, such as:

build on medical home initiatives and perinatal

screening initiatives, making sure there is appro-

priate ollow-up treatment;

support cross-training eorts or primary care pro-

viders in health and early care and learning settings;

expand early childhood mental health strategies to

include attention to depression in sta and amilies;

provide support to expand access to screening and

ollow-up treatment or pregnant and parentingmothers through both health practices and early

childhood programs;

train and identiy mental health consultants with

documented expertise in dealing with depression

through a amily lens to work with pediatricians,

early care and learning programs and womens

health agencies; and

embed attention to depression beyondhealth andearly childhood systems and programs (especially

TANF, marriage initiatives, WIC, child welare, etc.)

in developing program initiatives, regulations, etc.

n Maximize the use o Medicaid to prevent and treat

depression and related risk actors in the context o

promoting healthy early child development, such as:

use Medicaid waivers (or i that is prohibited,

state unds) to extend health insurance coverage

to mothers with young children at least to the

eligibility levels that the children are covered or


19/28


the rst two years ollowing birth or use the childs

access to Medicaid to cover parents;

promote public awareness campaigns and educa-

tional materials that show the links between early

school success and addressing maternal depression.

At the ederal level ederal ofcials, includingCongress can:

n ensure that Medicaid acilitates, rather than impedes,

states ability to pay or depression reduction and

prevention strategies that are designed to improve

outcomes or young children;

n provide incentives to the states to cover parents o

young children through Medicaid up to 200 percent

o the poverty level to ensure access to treatment or

depression as well as health conditions that impair

parenting;

n create a ederal interagency work group, either

through legislation or executive order, including

health, mental health and childrens agencies that

can develop a strategic action plan, and potentially

pool unds to support state eorts to design compre-

hensive approaches to prevent and reduce parental

depression and improve outcomes in young children;

n embed attention to depression beyondhealth andearly childhood systems and programs (especially

TANF, marriage initiatives, child welare, etc.) in

developing program initiatives, regulations, etc.; and

n develop a strategic NIH research agenda that

includes support to develop and test a range o in-

terventions to address maternal depression, promote

more eective parenting strategies and improve

outcomes or young children, particularly or low-

income women experiencing depression along with

other risk actors.

Conclusion

This issue brie calls or policymakers to include much

more serious attention to maternal depression as part o

the larger eorts across the country to improve healthy

developmental and school-readiness outcomes in young

children.

The argument is simple: particularly or low-income

children, maternal depression is a known barrier to

ensuring that young children experience the kinds o

relationships that will acilitate their success in the

early school years. Investing in treatment and support

or one generation will promote healthy development

and school readiness or the next. Addressing maternal

depression through a parenting and early childhood lens

is in eect a two-er: it can help parents, but impor-

tantly, it will also pay o or their children, both in

the short term and in the longer term. There are tough

barriers, particularly scal barriers, to creating amily-

ocused interventions. It requires a ramework shit that

provides public incentives or a amily-ocused, namely

multi-generational, culturally responsive, approach that

brings together resources rom multiple public systems.

There is also a critical role as a catalyst and seeder o

initiatives or private philanthropy.

The real message rom this brie is clear. While there

is much more to be known, we already have enoughevidence about eective approaches to address a damag-

ing condition that ripples throughout a amily and a

community, with lielong implications or everyone it

touches. We simply cannot aord not to respond with

resources and commitment.


20/28


Endnotes

1. Putnam, Frank. Reducing Maternal Depression and Its Impact onYoung Children: Building a Policy Framework. Policy Roundtable.June 22, 2006. New York NY: National Center or Children inPoverty.

2. Ibid.

3. Gaynes, B. N.; Gavin, N.; Meltzer-Brody, S.; Lohr, K. N.;Swinson, T.; Gartlehner, G.; Brody, S.; Miller, W. C. 2005. PerinatalDepression: Prevalence, Screening Accuracy, and Screening Outcomes.Rockville, MD: Prepared by the RTI-University o North CarolinaEvidence-based Practice Center, under Contract No. 290-02-0016.

Isaacs, Maresa. 2004. Community Care Networks for Depression inLow-Income Communities and Communities of Color: A Review of theLiterature. Submitted to Annie E. Casey Foundation. Washington,DC: Howard University School o Social Work and the National

Alliance o Multiethnic Behavioral Health Associations (NAMBHA).

Roca, Catherine. National Institute o Mental Health. 2007.Personal communication.

4. Isaacs, Maresa. 2004. Community Care Networks for Depression inLow-Income Communities and Communities of Color: A Review of theLiterature. Submitted to Annie E. Casey Foundation. Washington,DC: Howard University School o Social Work and the National


5. Ibid.

6. Ibid.

7. Ibid.

8. Lanzi, R. G.; Pascoe, J. M.; Keltner, B.; Ramey, S. L. 1999.Correlates o Maternal Depressive Symptoms in a National HeadStart Program Sample.Archive of Pediatric Adolescent Medicine153(8): 801-807.

Miranda, Jeanne; Green, Bonnie L. 1999. The Need or MentalHealth Services Research Focusing on Poor Young Women. The

Journal of Mental Health Policy and Economics2(2): 73-80.

Onunaku, Ngozi. 2005. Improving Maternal and Infant MentalHealth: Focus on Maternal Depression. National Center or Inantand Early Childhood Health Policy at UCLA.

Riley, A. W.; Broitman, M. 2003. The Effects of Maternal Depressionon the School Readiness of Low-Income Children. Baltimore, MD:Report or the Annie E. Casey Foundation, Johns HopkinsBloomberg School o Public Health.

Sieert, K.; Bowman, P. J.; Hefin, C. M.; Danziger, S.; Williams,D. R. 2000. Social and Environmental Predictors o MaternalDepression in Current and Recent Welare Recipients.American

Journal of Orthopsychiatry70(4): 510-522.

9. Gaynes, B. N.; Gavin, N.; Meltzer-Brody, S.; Lohr, K. N.;Swinson, T.; Gartlehner, G.; Brody, S.; Miller, W. C. 2005. PerinatalDepression: Prevalence, Screening Accuracy, and Screening Outcomes.

Rockville, MD: Prepared by the RTI-University o North CarolinaEvidence-based Practice Center, under Contract No. 290-02-0016.

10. Research to Practice: Depression in the Lives of Early Head StartFamilies. April 2006. Administration or Children and Families,U.S. Department o Health and Human Services.

11. Kahn, Robert S.; Wise, Paul H.; Finkelstein, Jonathan A.;Bernstein, Henry H.; Lowe, Janice A.; Homer, Charles J. 1999.The Scope o Unmet Maternal Health Needs in Pediatric Settings.Pediatrics103(3): 576-581.

12. Sieert, K.; Bowman, P. J.; Hefin, C. M.; Danziger, S.;Williams, D. R. 2000. Social and Environmental Predictors oMaternal Depression in Current and Recent Welare Recipients.

American Journal of Orthopsychiatry70(4): 510-522.



14. Isaacs, Maresa R. 2006.Maternal Depression: The Silent Epidemicin Poor Communities. Baltimore: MD: Annie E. Casey Foundation.

15. Belle, Deborah; Doucet, Joanne. 2003. Poverty, Inequality, andDiscrimination as Sources o Depression Among U.S. Women.Psychology of Women Quarterly27(2): 101-113.

Hoboll, Stevan E.; Ritter, Christian; Lavin, Justin; Hulsizer,Michael R.; Cameron, Rebecca P. 1995. Depression Prevalence andIncidence Among Inner-City Pregnant and Postpartum Women.

Journal of Consulting and Clinical Psychology63(3): 445-453.

Richardson, Phil. 2002. Depression and Other Mental Health BarriersAmong Welfare Recipients Results from Three States. Reston, VA:Maximus.

16. Hoboll, Stevan E.; Ritter, Christian; Lavin, Justin; Hulsizer,Michael R.; Cameron, Rebecca P. 1995. Depression Prevalence andIncidence Among Inner-City Pregnant and Postpartum Women.

Journal of Consulting and Clinical Psychology63(3): 445-453.

17. Essex, Marilyn J.; Klein, Marjorie H.; Miech, Richard;Smider, Nancy A. 2001. Timing o Initial Exposure to MaternalMajor Depression and Childrens Mental Health Symptoms inKindergarten. British Journal of Psychiatry179(2): 151-156.

Hammen, Constance; Brennan, Patricia A. 2003. Severity,Chronicity, and Timing o Maternal Depression and Risk or

Adolescent Ospring Diagnoses in a Community Sample.Archivesof General Psychiatry60(3): 253-258.

18. For more detailed syntheses o research see Bonari, Lori; Pinto,Natasha; Ahn, Eric; Einarson, Adrienne; Steiner, Meir; Koren,Gideon. 2004. Perinatal Risks o Untreated Depression DuringPregnancy. Canadian Journal of Psychiatry49(11): 726-735.

19. Neggers, Yasmin; Goldenberg, Robert; Cliver, Suzanne; Hauth,John. 2006. The Relationship between Psychosocial Prole, HealthPractices, and Pregnancy Outcomes.Acta Obstetrica et GynecologicaScandinavica85(3): 277-285.



21. Ashman, Sharon B.; Dawson, Geraldine; Panagiotides, Heracles;Yamada, Emily; Wilkinson, Charles W. 2002. Stress HormoneLevels o Children o Depressed Mothers. Development andPsychopathology14(2): 333-349.

Essex, Marilyn J.; Klein, Marjorie H.; Cho, Eunsuk; Kalin, Ned H.2002. Maternal Stress Beginning in Inancy May Sensitize Children

to Later Stress Exposure: Eects on Cortisol and Behavior. BiologicalPsychiatry52(8): 776-784.

22. Huang, Larke N.; Freed, Rachel. 2006. The Spiraling Effects ofMaternal Depression on Mothers, Children, Families and Communities.Issue Brie #2. Annie E. Casey Foundation.

Lyons-Ruth, K.; Connell, D. B.; Grunebaum, H. U.; Botein, S.1990. Inants at Social Risk: Maternal Depression and FamilySupport Services as Mediators o Inant Development and Securityo Attachment. Child Development61(1): 85-98.

23. NICHD Early Child Care Research Network. 1999. Chronicityo Maternal Depressive Symptoms, Maternal Sensitivity, and ChildFunctioning at 36 Months. Developmental Psychology35(5): 1297-1310.


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Paulson, James F.; Dauber, Sarah; Leierman, Jenn A. 2006. Individualand Combined Eects o Postpartum Depression in Mothers andFathers on Parenting Behavior. Pediatrics118(2): 659-668.

25. Beardslee, W. R.; Bemporad, J.; Keller, M. B.; Klerman, G. L.1983. Children o Parents with Major Aective Disorder: A Review.

American Journal of Psychiatry140(7): 825-832.

Essex, Marilyn J.; Klein, Marjorie H.; Miech, Richard; Smider,Nancy A. 2001. Timing o Initial Exposure to MaternalMajor Depression and Childrens Mental Health Symptoms inKindergarten. British Journal of Psychiatry179(2): 151-156.

26. Henderson, Jennier J.; Evans, Sharon F.; Straton, Judith A.Y.;Priest, Susan R.; Hagan, Ronald. 2003. Impact o PostnatalDepression on Breasteeding Duration. Birth 30(3): 175-180.


27. Chung, Esther K.; McCollum, Kelly F.; Elo, Irma T.; Lee, HelenJ.; Culhane, Jennier F. 2004. Maternal Depressive Symptoms andInant Health Practices among Low-Income Women. Pediatrics

113(6): 523-529.Kavanaugh, Megan; Halterman, Jill S.; Montes, Guillermo; Epstein,Mike; Hightower, A. Dirk; Weitzman, Michael. 2006. MaternalDepressive Symptoms Are Adversely Associated with PreventionPractices and Parenting Behaviors or Preschool Children.

Ambulatory Pediatrics6(1): 32-37.

McLennan, John D.; Kotelchuck, Milton. 2000. Parental PreventionPractices or Young Children in the Context o Maternal Depression.Pediatrics105(5): 1090-1095.



Kavanaugh, Megan; Halterman, Jill S.; Montes, Guillermo; Epstein,Mike; Hightower, A. Dirk; Weitzman, Michael. 2006. MaternalDepressive Symptoms Are Adversely Associated with PreventionPractices and Parenting Behaviors or Preschool Children.

Ambulatory Pediatrics6(1):32-37.

Sills, Marion R.; Shetterly, Susan; Xu, Stanley; Magid, David;Kempe, Allison. 2007. Association between Parental Depression andChildrens Health Care Use. Pediatrics119(4): 829-836.

29. Whitaker, Robert C.; Orzol, Sean M.; Kahn, Robert S. 2006.Maternal Mental Health, Substance Use, and Domestic Violencein the Year ater Delivery and Subsequent Behavior Problems inChildren at Age 3 Years.Archives of General Psychiatry63(5): 551-560.

30. Ibid.31. Isaacs, Maresa R. 2006.Maternal Depression: The Silent Epidemicin Poor Communities. Baltimore, MD: Annie E. Casey Foundation.

32. Goodman, Janice H. 2004. Paternal Postpartum Depression, ItsRelationship to Maternal Postpartum Depression, and Implicationsor Family Health.Journal of Advanced Nursing45(1): 26-35.

33. Research to Practice: Depression in the Lives of Early Head StartFamilies. April 2006. Administration or Children and Families,U.S. Department o Health and Human Services.

34. Goodman, Janice H. 2004. Paternal Postpartum Depression, ItsRelationship to Maternal Postpartum Depression, and Implications

or Family Health.Journal of Advanced Nursing45(1): 26-35.

35. Kahn, Robert S.; Brandt, Dominique; Whitaker, Robert C.2004. Combined Eect o Mothers and Fathers Mental HealthSymptoms on Childrens Behavioral and Emotional Well-Being.

Archives of Pediatric & Adolescent Medicine158(8): 721-729.


Ramchandani, Paul; Stein, Alan; Evans, Jonathan; OConnor,Thomas G. 2005. Paternal Depression in the Postnatal Periodand Child Development: A Prospective Population Study. Lancet365(9478): 2201-2205.

36. OBrien, R. W.; DElio, M. A.; Vaden-Kiernan, M.; Magee,C.; Younoszai, T.; Keane, M. J.; Connell, D. C.; Hailey, L. 2002.

A Descriptive Study of Head Start Families: Faces Technical Report I.Washington, DC: U.S. Administration on Children, Youth, andFamilies. Department o Health and Human Services.

37. Smithgall, Cheryl; Mason, Sally; Michels, Lisa; Licalsi,Christina; Goerge, Robert. 2006. Caring for Their ChildrensChildren: Assessing the Mental Health Needs and Service Experiences ofGrandparent Caregiver Families. Chapin Hall Center or Children atthe University o Chicago.

38. Whitebook, Marcy; Phillips, Deborah; Bellm, Dan; Crowell,Nancy; Almaraz, Mirella; Jo, Joon Yong. 2004. Two Years in EarlyCare and Education: A Community Portrait of Quality and WorkforceStability. Center or the Study o Child Care Employment,University o Caliornia at Berkeley.

39. Ibid.

40. Hamre, Bridget K.; Pianta, Robert C. 2004. Sel-ReportedDepression in Nonamilial Caregivers: Prevalence and Associations

with Caregiver Behavior in Child-Care Settings. Early ChildhoodResearch Quarterly19(2): 297-318.

41. Gilliam, Walter S.; Shabar, Golan. 2006. Preschool and ChildCare Expulsion and Suspension: Rates and Predictors in One State.Infants & Young Children: An Interdisciplinary Journal of Special CarePractices19(3): 228-245.

42. Miranda, Jeanne; Chung, Joyce Y.; Green, Bonnie L.; Krupnick,Janice; Siddique, Juned; Revicki, Dennis A.; Belin, Tom. 2003.Treating Depression in Predominantly Low-Income Young Minority

Women: A Randomized Controlled Trial.JAMA 290(1): 57-65.

Perry, Deborah F. 2006. What Works in Preventing and TreatingMaternal Depression in Low-Income Communities of Color. Issue Brie#3. Annie E. Casey Foundation.



44. Knitzer, Jane. 2000. Promoting Resilience: Helping Young Children

and Parents Affected by Substance Abuse, Domestic Violence, andDepression in the Context of Welfare Reform. New York, NY: NationalCenter or Children in Poverty, Mailman School o Public Health,Columbia University.

45. Beardslee, William R. Reducing Maternal Depression and ItsImpact

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