Perinatal and infant mental health: Further fruitful twists of Rubik’s cube

Judd et al. (2017) propose a new direction for perinatal and infant mental health (PIMH) in Australia. Their article begins with a broad summary of the main focus of this field during the last three decades, funded both at Federal and State levels through Medicare and the National Perinatal Depression Initiative (2009–2015). Work has been centred around depression and anxiety, targeting screening, some pathways to care, and the development of teaching packages and National Perinatal Guidelines. They then provide an overview of the intergenerational transfer of problems from mother to infant when there is maternal childhood trauma, compromised attachment and/or borderline personality disorder (BPD) often compounded by substance abuse, depression and anxiety, interpersonal violence and relationship difficulties. The effects on infants are substantial and include neurodevelopmental and psychological problems, perhaps via several mechanisms including attachment disorganisation and trauma, ultimately leading to mental health difficulties for those offspring in childhood and the potential for personality disorder themselves when they become young adults. Not surprisingly, these families are frequently involved in the child protection space.

Finally, with clarity and wisdom, they provide a compelling case for a new focus in PIMH on these ‘high risk’ mothers with complex problems and compromised early relationships with their infants, in order to better disrupt the intergenerational transfer of problems to the offspring. Proposals include early identification of such ‘high risk’ mothers, preferably in the antenatal period, and wider introduction of high-quality therapeutic interventions for the mother–infant relationship.

Their proposal makes sense from many points of view and has already been supported to some extent with the introduction of new perinatal mental health federally funded guidelines (published subsequent to the writing of Judd et al.’s submission) which include schizophrenia and BPD albeit without the breadth of Judd et al.’s proposals in high-risk situations.

Most mothers want to do the best they can for their infants but for high-risk mothers, their previous life experiences and tendency to dysregulate under stress – and what parenting experience is not stressful? – make parenting a difficult task with the likely problems of poor outcomes. Thus, offering therapy perinatally is likely to be welcomed by many affected women, hopefully with flow-on effects to their offspring.

It is clear however that identification and then treatment of families with perinatal BPD will challenge. The stigma and seeming untreatability of BPD has of course led to clinicians worldwide pretending not to see the raw nakedness of the symptoms and distress of this condition, a modern Emperor’s New Clothes phenomenon. Thus, these problems have been systematically ignored in families until very recently, leading to a paucity of knowledge regarding prevalence and interventions which could help the mother with BPD and successfully help her steer her infant(s) in healthy directions.

There are for instance no prospective studies regarding the prevalence of BPD in antenatal clinics and effects on the woman during pregnancy, including birth outcomes for her and her infant, although some retrospective studies of cases have been published. Data in mother-baby units show that many women with BPD personality traits will decompensate postnatally with the multiple stressors of sleep deprivation, role changes, financial pressures, concerns about parenting competence and often increased relationship stress. Nevertheless, there have been no systematic attempts to define community prevalence rates of postnatal BPD, nor any screening for this condition. Searches of databases reveal hundreds of references for perinatal depression and anxiety and effects on infants, and almost none for similar searches for perinatal BPD. Rates of postnatal depression (PND) are generally quoted as 15%, but as there are no studies of BPD prevalence postnatally, one must turn to general population rates of BPD for guidance. While community studies vary widely in their findings of BPD prevalence between 1% and as high as 6.5%, most settle around 2.5%, making PND six times more common using these figures as a guide, yet incomparably more studied. Many doctoral theses are out there beckoning.

Grenyer et al. (2017) outline many of the problems regarding management of BPD in the adolescent and adult populations, including lack of data and lack of access to trained therapists. Perinatally, where the mother–infant relationship is in focus, there is currently an almost complete vacuum in the intervention space. Judd et al. outline promising Australian interventions which attempt to help mothers with BPD change their parenting; however, these studies are as yet unpublished in peer-reviewed journals, are of small scale and their results need replication. Changing the intergenerational pathways requires a great deal of sophisticated work over many months – clearly well worth doing but the long-term success of these new therapies will not be known for another generation. There has recently been a surge in interest in the related field of trauma, with increasing recognition of its damaging long-term effects and ensuring that care is trauma-informed. Emotional dysregulation has become a more widely used term and therapies which focus on the need to help better regulation, including mindfulness-based practices are more ubiquitous. Trauma and emotional dysregulation are part of the BPD picture and clearly addressing these issues is helpful, but generally insufficient for high-risk mothers and their babies.

As Judd et al. discuss, there is a significant overlap between ‘high risk’ mothers receiving mental health interventions and child protection programmes. The Australian Institute of Family Studies (AIFS, 2017) has explored the economic costs of child protection, finding that $4.3 billion was spent across Australia in 2014–2015 on child protection, with the biggest proportion by far going towards out-of-home care. Those working in child psychiatry frequently see children who are in long-term placements, perhaps because of damage prior to removal from their family of origin or perhaps out-of-home care is not a preferred home for the children themselves who act out accordingly. AIFS attempted to provide information on money spent preventing child abuse and neglect but because of the complexity of fields which could be involved (they include inter alia maternal and child health, parenting education and support; mental health and substance use programmes; and domestic violence prevention) they concluded accurate information was unavailable. Those managing PIMH or child psychiatry services are struggling to employ sufficient trained clinicians to treat the large numbers of families seen. Sadly, the recent Child Protection Royal Commission in South Australia (2016), despite a clear theoretical acknowledgement of the value of prevention and early intervention, failed to recommend a move to wider employment of highly trained therapists focusing specifically on infants and their families, and working across agencies. This lost opportunity is likely to perpetuate the identification of problems downstream after the flooding has begun, rather than channelling and managing problems upstream in far less damaging ways. Perhaps redirecting funds for out-of-home care to early intervention services (after a period of double funding) would see a fall in these unsatisfactory placements. It is clear that, given the enormous costs, financial and personal, of out-of-home care, better solutions need to be found and some may exist in PIMH, particularly where skills can be shared, taught and integrated. So although the long-term effects of interventions are unproven, common sense suggests treating the mother and mother–infant dyad offers better hope than continuing to turn the blind eye. Economic modelling regarding each dollar spent in the early years also highlights massive additional savings in forensic and unemployment costs.

So far the case has been argued for better identification and interventions for ‘high risk’ mothers and their babies. Clearly implied is that parenting is the task of the mother alone. What information is there about the role of the father, the extended family and society? Literature searches produce a markedly lower yield of studies focusing on fathers as parents to infants, either as partners to unwell women or with mental health difficulties in their own right. Longitudinal studies of the effects of mentally ill parents on their offspring, even though the search term ‘parent’ is used, either focus only on women or have a much smaller cohort of fathers than of mothers, making conclusions less valid. Some Australian researchers have begun to focus on fathers and perhaps there would be more such research if more men worked clinically in the PIMH field with a focus on fathers – yes female therapists CAN and do work with men but many men may engage better with other men. While it is known that children have poorer outcomes when an antisocial father lives in the house, rather than out of it, there is far too little yet to guide us in the answers to many questions (Music, 2017). These include what is the role of the absent father generally in mental health outcomes for his offspring, how much does a father with a secure attachment style and good parenting models moderate the intergenerational transfer of problems from high-risk mother to child, and what interventions with domestically violent men, often from very complex traumatic backgrounds themselves, are successful in helping the mental health of their children?

When considering families at the vital times of procreation, the African dictum popularised by Hillary Clinton ‘it takes a village to raise a baby’ may complete the picture of what PIMH may become with more turns of Rubik’s cube. Bronfenbrenner provides a more sophisticated explanation in his bioecological model of development, which clearly sets out the interactions between the multiple systems surrounding an individual, including parents and early learning environments, the social environment including economic factors, and finally belief and values systems within the community. Many societal factors impinge on the complexity of infant development and parenting, which in turn impact on foetal and infant neurobiological and psychological development perhaps through epigenetics. Clearly, problems at one level, mother–infant interaction, are impacted by many other layers.

It seems likely that rates of children with identified mental health problems are rising in Western countries and although better screening (in some circumstances) and identification may account for this finding, many believe that the problems stem from further breakdown of traditional societies. Many nuclear families find themselves without extended family support, and rates of single parenthood are also on the increase, leaving parenting to fall generally still to women, perhaps intensifying the likelihood of emotional dysregulation in those mothers faced with the never-ending challenges of parenthood. Kindly and appropriate partner, extended family and community support make a difference to mothers and their babies, as do sufficient income for stable accommodation, good quality diet and education (Music, 2017).

Perhaps these latter social factors lie outside the realm of psychiatry except in our role as advocates, but in supporting the expansion of perinatal and infant psychiatry beyond depression and anxiety to areas which may potentially make profound changes for mother and infant, not only identifying and helping ‘high risk’ mothers and their babies, but including fathers and extended families will potentially provide better outcomes. Research that drills down to the minutiae of mother–infant interaction is necessary but better outcomes are likely to be reached when both figure and ground are understood and interventions offered where possible which focus on partner, adult relationships and wider family as well. Child protection and domestic violence programmes have been in the public eye and have attracted some improved funding, not always working together with PIMH clinicians. Integrating these fields with PIMH and ensuring that each family has unified and tailored preventive therapies for all families in high-risk situations is a dream worth pursuing.