Keeping the infant in mind in the presence of maternal mental illness

• Author: Kathryn Thornton, Psychologist Perinatal Psychiatry Service, Child and Adolescent Mental Health Service, Hunter New England Health
• Series editors: Andrea Reupert and Darryl Maybery (Monash University) on behalf of the Australian COPMI national initiative.

Quick facts

• In order to survive, infants need to form a relationship with another person, and are born with the capacity to do so.
• Maternal mental illness may impact on the infant’s relationship with his/her mother and the infant’s development so clinicians need to keep the infant and his/her needs in mind.
• It is not sufficient to only treat the mother’s mental illness.
• If a mother is physically or emotionally unavailable to her infant, care from another responsive caregiver e.g. father may be protective for the infant.
• If a mother requires hospitalisation, a joint admission with her infant will allow for the needs of both mother and infant to be addressed and the fostering of the motherinfant relationship.
• There are a range of interventions that are available to target relationship difficulties if they occur.

Research summary

Infants, to survive, need to form a relationship with another person, and are born with the capacity to do so. At birth they show preference for their mother’s voice and smell and can engage in mutual gaze and imitate facial expressions.^1-4 The quality of this early relationship impacts on the infant’s physiological, neurobiological, emotional and social development.^1,2 Infants who experience sensitive and responsive care giving are more likely to develop a secure attachment with their primary caregiver, usually the mother, which lays the foundation for

“optimal behavioural, social and emotional development, including a greater capacity for emotion regulation, positive social interactions and better coping skills” (p.4, 5).

Impact of maternal mental illness

Postnatal mental illness affects a significant number of women, with numerous studies indicating that postnatal depression alone affects around 10-15% of women.^2,6,7 Mental illnesses may impact on parenting. Some mothers with a mental illness may experience difficulty registering or attending to their infants’ needs or being consistent and available; some may be overly intrusive or at times threaten the survival of their infant e.g. when the infant is incorporated into a mother’s delusions or hallucinations.⁷ In the face of maternal mental illness, infants may indicate distress by withdrawing or

“incessant crying, inability to be soothed, feeding problems, sleep disturbances, hyper-arousal and hyper-vigilance and intense distress during transitions” (p. 5, 5).⁸

Addressing the infant’s needs

While it is essential that a mother’s mental illness is identified early, properly diagnosed and treated effectively this is not sufficient.⁹

“Someone must hold the infant, her particular experiences and her needs in the centre of their mind” (p. 162, 10).

If a mother is emotionally or physically unavailable, research suggests that the presence of another available caregiver e.g. father may buffer the impact on the infant.^{7, 11} However, research is contradictory; one study suggests that non-depressed fathers may be less available to their infants when their partners are depressed.¹¹ In comparison, another case study indicates that supporting the father in the presence of his partner’s depression can result in improved father-infant relationship and have a flow on effect to the mother-infant relationship.⁶ If the mother requires hospitalisation, admission to a mother-baby unit is preferable as staff can promote the relationship between mother and infant and address the needs of both.¹² If this is not possible, clinicians need to be aware that an infant can experience “distress, emotional and physical pain” (p. 5, 5) on separation from his/her mother.

In these cases it is preferable that the infant be cared for by someone he/she knows and who can be available to the infant e.g. father, grandparent. Baby care plans can be a meaningful way to ensure that the infant experiences as fewer disruptions as possible. The book, ‘The Best for Me and My Baby’ provides practical information about how to reduce stress on infants and promote their sense of safety and security. It is essential that mothers and infants have regular contact as soon as possible and that the infants are adequately supported at this time.

For mothers with depression, infant massage has been shown to have a positive impact on both the mother’s and the infant’s well being.¹³ Mothers and infants can also benefit from the support offered through home visiting programs.^{14, 15} Quality day care may be appropriate for infants by providing a consistent, caring and stimulating environment as well as providing opportunities for the mothers to access treatment and/ or obtain respite, crucial for their recovery.⁷ When the mother-infant relationship has been compromised, programs with an emerging evidence base such as Watch Wait Wonder, Interaction Guidance and mother-infant groups can be considered.^16,17,18 In such interventions, both mother and infant are present and issues or behaviours that negatively impact on the relationship are processed.

Limitations

Postnatal depression has been the focus of much research with the impact on infants well documented and the identification of some effective interventions.^2,3,6,8,13 There is comparatively less research regarding the impact of other maternal mental illnesses on infants, a gap that needs to be addressed. The role of fathers in enhancing infants’ development in the presence of maternal mental illness needs further research, particularly for illnesses such as schizophrenia and bipolar disorder. Ensuring infants’ emotional wellbeing is one of the major challenges for parents, clinicians and researchers and is an area in urgent need of study.

1. Cozolino L. The neuroscience of human relationships. New York, USA: W.W.Norton & Company; 2006
2. Mears S, Newman L, Warren B, Cornish K. Clinical skills in infant mental health Camberwell, Australia: ACER Press; 2005.
3. Field T, R. W, Greenberg R, Cohen D. Discrimination and imitation of facial expressions by Neonates. Science, 1982; 218:179-81.
4. Murray L, Andrews L. Your social baby: Understanding babies’ communication from birth. Melbourne: ACER Press; 2001.
5. Jordan B, Sketchley RA. A stitch in time saves nine: Prevention and responding to the abuse and neglect of infants. Child Abuse and Prevention Issues, 2009; (30):1-12.
6. Fletcher R. Promoting infant well-being in the context of maternal depression by supporting the father. Infant Mental Health Journal, 2009;30(1):95-102.
7. Williams AS. Infants of mothers with mental illness. In: Cowling V, editor. Children of parents with mental illness: Personal and clinical perspectives. Melbourne, Australia: ACER Press; 2004.
8. Luby JL. Depression. In: Zeanah CH, editor. Handbook of Infant Mental Health. 3rd ed. New York: The Guilford Press; 2009.
9. Kowalenko N, Barnett B, Fowler C, Matthey S. The perinatal period: Early interventions for mental health. In: Kosky R, O’Hanlon A, Martin G, Davis C, editors. Clinical approaches to early intervention in child and adolescent mental health. Adelaide: Australian Early Intervention Network for Mental Health in Young People; 2000.
10. Stone J. Mummy has an illness Called schizophrenia. In: Sved Williams A, Cowling V, editors. Infants of Parents with Mental Illness: Developmental, Clinical, Cultural and Personal Perspectives. Bowen Hills: Australian Academic Press; 2008. p. 161-75.
11. Goodman JH. Influences of maternal pospartum depression on fathers and on father-infant interaction. Infant Mental Health Journal, 2008;29(6):624 – 43.
12. Williams AS, Ellershaw S, Mader L, Seyfang M. Working with severely ill mothers and their infants in a mother-baby inpatient unit. In: Sved Williams A, Cowling V, editors. Infants of parents with mental illness. Bowen Hills: Australian Academic Press; 2008. p. 176-94.
13. Field T, Gizzle N, Scafidi F, Abrams S, Richardson S, Kuhn Cea. Massage therapy for infants of depressed mothers. Infant Behaviour and Development, 1996;9:415-21.
14. Olds DL, Robinson J, Pettitt L, Luckey DW, Holmberg J, Rosanna K, et al. Effects of Home visits by paraprofessional and by nurses: Age 4 follow-up results of a randomized trial. Pediatrics. 2004;114(6):1560-9.
15. Walker AM, Johnson R, Banner C, Delaney J, Farley R, Ford M, et al. Target home visiting interventions: the impact on the mother-infant relationship. Community Practioner, 2008;81(3):31-4.
16. Muir E. Watching, Waiting and Wondering: Applying psychosomatic principal to mother-infant intervention. Infant Mental Health Journal, 1992;13(4):319-28.
17. McDonough SC. Interaction Guidance: An approach for difficult-to-engage families. In: Zeanah CH, editor. Handbook of Infant Mental Health. New York: Guildford Press; 2000. p. 472-85.
18. Paul C, Salo FT. Infant-led innovations in a mother-baby therapy group. In: Salo FT, Paul C, editors. The baby as subject. 2nd ed. Caufield, Australia: Stonnington Press; 2007.

Resources

• Book: Zeanah CH, editor. Handbook of Infant Mental Health. 3rd ed. New York: The Guildford Press; 2009.