The shadow of perinatal illness on the developing child
Theme: Perinatal mental health
Perinatal psychiatry is an area of growing interest and importance within psychiatry. It has to do with the mental health of parents during pregnancy and the first year after the birth of a baby. This area of work requires that the psychiatrist is not only concerned about the wellbeing of the parents, but also about the wellbeing of the infant, and the parent’s capacity to provide good enough care for the infant for optimal development and wellbeing of the baby. We now know that pregnancy and the first year of life is a very important developmental period for the infant and that adversities during this time can have a lasting effect on future health and wellbeing of the individual.
Perinatal Psychiatry and Infant Psychiatry are therefore intertwined specialties, and in fact it has become increasingly evident in the last decades from neurodevelopmental research, that healthy attachment based on nurturing and supportive relationship with caregivers from the very beginning of life (even before birth) is a crucial part of becoming a healthy and productive adult.
Pregnancy, childbirth and the first years after birth is an extremely important time in a child´s life. It is a very sensitive period because of the rapid brain development of the baby during this time. From conception and the first 2-3 years, the infant's brain undergoes tremendous growth with the proliferation of brain cells and the formation of nerve cell connections. This period is crucial for the development of important features and senses, e.g., vision, hearing, emotion regulation, language development and social skills. Brain-development is experience-dependent and deeply affected by the child´s relational environment. The infant's relationship with the caregiver and the response and care the child receives during this period forms habitual responses to situations, e.g., what the child expects from other people. Thus, the child's experiences play a major role in shaping core attitudes towards himself and others.
Parents´ mental illness can negatively affect their capacity to respond sensitively and appropriately to the infant. This can have a profound effect on the baby´s development and increase the likelihood of insecure attachment. It has become evident that when parents struggle with psychiatric illness, trauma and adversities during the perinatal period it can have a negative impact on the growth, behavior and psychological development and wellbeing of the baby. Therefore, babies need to be included in the assessment and treatment in perinatal services.
Postnatal depression in the mother has been shown to have an adverse effect on the child´s development. It is also evident that treating the depression in the mother alone is not sufficient to change the baby´s developmental trajectory for the better. To improve the baby’s´ outcome, it is necessary to incorporate interventions that target the mothers´ interactions with her infant to enhance the mothers´ sensitivity and attunement to the needs of her infant and help her respond in a positively and appropriate way with her infant. Improving the quality of interactions between parents and their infants in turn increases the likelihood of secure parent-infant and infant-parent attachment.
Research has shown that attachment problems can have negative consequences throughout life, e.g. behavioral and anxiety problems in school and adolescence and mental illness in adulthood. If parents are dealing with stress, trauma, mental or emotional problems, this can negatively affect their ability to read the infant's signals and respond appropriately. Children of parents who struggle with depression and anxiety are at increased risk of developing relational, behavioral and attention problems, learning difficulties and impaired social skills, and are more likely to become depressed and anxious.
Parental mental health illness is not only a familial burden, but it also holds a great societal cost. London School of Economics produced a report in 2014 where the cost of perinatal mental health problems was calculated to be 8,2 billion pounds every year in the UK. The report showed that every pound invested in services for this target group could give up to 30-fold return in savings in health care, schools, social care and the justice system up until the 18th birthday of the child. 28% of the costs relate to the mother and 72% relate to the child throughout their lifespan.
Providing early interventions with specialized perinatal care for parents and infants is a vital aspect of the wellbeing of future generations. Research indicates that a minority of parents who suffer mental illness receive adequate help. It is urgent that perinatal mental health services are systematically made available across the Nordic countries and that psychiatrists are sensitive to the needs of this vulnerable group and can offer appropriate referrals and interventions when needed.
In Iceland programs to address attachment issues in infants have been developed since 2008. Parent Infant Psychotherapy services are now available when needed for parents during pregnancy and the first two years after birth within primary healthcare. The main treatment modalities are Parent Infant Psychotherapy (PIP), Watch Wait and Wonder (WWW), Solihull Approach (SA), Circle of Security (COS) and Newborn Behavioural Observation (NBO).
For more serious mental health illness in the parent, acute admission to a psychiatric unit (Landspitali – the National University Hospital in Reykjavik) with specialised facilities to meet the needs of both parents and baby have been available in Iceland since 2011.
It is important to be able to meet the needs of parents and infants in a tiered specialised service with timely interventions at different levels of the health service. Puerperal psychiatric admissions to tertiary services in Iceland in recent years have been fewer and shorter in duration since the Parent Infant Primary Care Services were developed. This highlights the importance of providing early attachment focused interventions for parents with mental illness and their baby, thereby preventing more serious illness in the parent and minimising the risk of emotional, behavioural and psychiatric problems for the child. □