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Invited Commentary
August 19, 2021

Recognizing the Complexity of Psychosocial Factors Associated With Children’s Development—the Case of Maternal Depression

Author Affiliations
  • 1Boston College School of Social Work, Chestnut Hill, Massachusetts
JAMA Netw Open. 2021;4(8):e2122310. doi:10.1001/jamanetworkopen.2021.22310

Maternal depression occurs in an estimated 7% to 15% of women in high income countries (HICs) and a staggering 19% to 25% of women in low and middle income countries (LMICs).1 In line with this geographic pattern, key risk factors associated with maternal postpartum depression include daily stress, trauma, illness, poverty, poor living conditions, domestic violence, lack of social support, and unplanned pregnancy. These risk factors tend to be more concentrated, and harder to cope with, among women with lower socioeconomic status.

Maternal depression during a child’s early years can be associated with long-lasting outcomes in the child’s developmental trajectory. Large, prospective studies in HICs found that maternal postpartum depression was associated with long-term outcomes among offspring, including socioemotional maladjustment, behavioral problems, and internalizing symptoms starting as early infancy and observed through adulthood.2 The intergenerational transmission of depression is believed to be associated with biological factors, including genetic factors and innate neuroendocrine dysregulation, as well as psychosocial factors. These psychosocial factors include negative maternal behaviors, decreased maternal engagement in sensitive responsive care, and the environmental stressors associated with maternal depression mentioned previously, including poverty, violence, and childcare responsibilities.3

The study by Orri and colleagues4 presents data from the Birth to Twenty Plus (BT20+) study, a unique longitudinal birth cohort from South Africa in which mothers and their offspring have been followed for more than 28 years. Orri et al found that maternal depression at 6 months post partum was associated with increased odds of offspring experiencing persistently high internalizing symptoms, characterized as a trajectory of increased levels of internalizing symptoms across repeated measures collected from ages 14 to 28 years. The authors also provide novel evidence that the increase in odds varies not only by socioeconomic risk, but also by an interaction between socioeconomic risks and offspring sex. The observed increase in odds of offspring internalizing symptoms with maternal depression was greater in male offspring from families with high vs low levels of socioeconomic adversity, but the increase was greater in female offspring from families with low vs high levels of socioeconomic adversity.

Analyses exploring potentially differential odds increases associated with adverse exposures across subgroups of a population are always admirable. They are also important to the advancement of our understanding of risk and disease profiles that, in turn, may inform the development of interventions and guide policy making to efficiently support children and families at increased risk of adverse outcomes. The finding of an interaction between socioeconomic adversity and maternal postpartum depression in the association with child outcomes is important but, as such, not surprising. It is well-known that socioeconomic status has interactions with a number of environmental risks in their associations with child outcomes. A common hypothesis is that socioeconomic adversity, including low income and low parental education levels, is associated with decreased family financial and psychosocial resources to cope with added challenges, such as postpartum depression. Such hypotheses have been pursued under a variety of labels but may be referred to as cumulative risk or double burden hypotheses and may explain the observed increase in odds of internalizing symptoms among male offspring exposed to high socioeconomic adversity. These hypotheses would suggest that efforts to support child development in the context of maternal postpartum depression may have the greatest positive outcomes among households in the lowest socioeconomic strata.

A cumulative risk or double burden hypothesis, however, does not explain the finding that female offspring had increased odds of internalizing symptoms if exposed to less socioeconomic adversity. A possible explanation, put forward by the authors, is that socioeconomic circumstances may interact differently with the association of maternal postnatal depression with offspring depression depending on broader circumstances and cultural practices and that certain correlates of socioeconomic risks may buffer against adverse outcomes associated with maternal postpartum depression differently in girls and boys. For example, the authors suggest that mothers with low levels of education may be more dependent on help raising their children and that childcare may be more likely to involve members of the extended family. These other individuals’ social interactions with the child may buffer against the adverse outcomes associated with postpartum depression that operate through psychosocial experiences of responsive caregiving. Previous studies have indeed found that having a healthy support person in the child’s life, including a father, nonparental caregiver, or childcare professional, may be associated with buffering against socioemotional and behavioral problems among offspring of mothers with depression.3

The evidence that other caregivers may be associated with protective buffering against the adverse outcomes associated with maternal postpartum depression casts light on strengths that may be leveraged within the family and wider local community. This especially includes the need to extend the view of the early caregiving environment to male and female caregivers and to issues in the immediate household that are known to shape maternal depression, such as violence. While environmental buffers, such as high-quality daycare and childcare from the extended family, are important to consider, much can of course be done to support women experiencing postpartum depressive symptoms to relieve the depression and other stressors and factors that are associated with depressive outcomes, including violence and daily stressors, such as housing and food insecurity. Various interventions exist to address maternal depression directly, but these typically require identification of women as at risk of depression before they are referred, as well as access to a well-trained workforce to deliver the intervention. Given high rates of depression and distress among women at risk of socioeconomic adversity, more widely available support to address social determinants of depression and risks associated with depression would have the potential to reach and support the development of millions of children worldwide. Parenting interventions focused on early childhood development that work to support caregivers in engaging in sensitive and responsive caregiving practices, with very basic support for problem-solving and coping skills, have been found to decrease caregiver depression in LMICs and HICs. In our own work involving a home visit–based parenting intervention to promote sensitive care, decrease violence, and engage fathers in childcare among poor families in Rwanda, we studied participation in a lay worker–facilitated parenting intervention focused on active coaching of male and female caregivers in playful and responsive interactions with their young children. We found that participation in this intervention was associated with decreased depressive symptoms in male and female caregivers of children aged 6 to 36 months.5 Similar buffering outcomes associated with parenting interventions have been observed among poor families in other LMICs.6

The association of maternal depression with offspring depression varied by socioeconomic adversity and child sex (3-way interaction), showing that these associations are complex and deserve further investigation. It is well-known that girls and women, in general, are at increased risk of depression.7 This increased risk is associated with biological and environmental factors. Social factors like parental decisions regarding childcare options may interact in the association of socioeconomic risks with offspring depression in a sex-associated manner, but understanding the exact mechanisms of these associations necessitates much more research attention across cultures and settings. In particular, the study by Orri et al4 makes an excellent contribution to the literature with its rare longitudinal cohort sampled over multiple time points from birth to adulthood. More work of this nature using culturally sensitive approaches is needed to illuminate such dynamics in a range of cultures and settings. Future work should examine interactions of violence in the home and family composition with the association between caregiver depression and child outcomes by child sex.

In summary, the study by Orri and colleagues4 contributes to the literature showing the complexity by which environmental factors interact with intergenerational transmission of risk of depression. While all children living with caregivers who have depression may benefit from various forms of intervention to resolve or buffer against depression among caregivers, some children are at increased risk of internalizing symptoms and may benefit more from intervention, depending on patterns of socioeconomic disadvantage and sex. Knowledge of specific risk profiles and factors that interact with risks and protective factors have important clinical and public health implications. In the future, more work is needed to explore interindividual variability in susceptibility to psychosocial risk like maternal depression in LMICs, where maternal depression and interacting risk factors are concentrated. Our own findings and the findings of others suggest that parenting interventions that use coaching to improve responsive caregiving among male and female caregivers may be associated with decreased depression among caregivers. These findings may highlight an important opportunity to decrease intergenerational transmission of depression within standard early childhood development work.

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Article Information

Published: August 19, 2021. doi:10.1001/jamanetworkopen.2021.22310

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Jensen SKG et al. JAMA Network Open.

Corresponding Author: Theresa S. Betancourt, ScD, MA, Boston College School of Social Work, 140 Commonwealth Ave, Chestnut Hill, MA 02467 (theresa.betancourt@bc.edu).

Conflict of Interest Disclosures: None reported.

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Stein  A, Pearson  RM, Goodman  SH,  et al.  Effects of perinatal mental disorders on the fetus and child.   Lancet. 2014;384(9956):1800-1819. doi:10.1016/S0140-6736(14)61277-0PubMedGoogle ScholarCrossref
Goodman  SH, Gotlib  IH.  Risk for psychopathology in the children of depressed mothers: a developmental model for understanding mechanisms of transmission.   Psychol Rev. 1999;106(3):458-490. doi:10.1037/0033-295X.106.3.458PubMedGoogle ScholarCrossref
Orri  M, Besharati  S, Ahun  MN, Richter  LM.  Analysis of maternal postnatal depression, socioeconomic factors, and offspring internalizing symptoms in a longitudinal cohort in South Africa.   JAMA Netw Open. 2021;4(8):e2121667. doi:10.1001/jamanetworkopen.2021.21667Google Scholar
Betancourt  TS, Jensen  SKG, Barnhart  DA,  et al.  Promoting parent-child relationships and preventing violence via home-visiting: a pre-post cluster randomised trial among Rwandan families linked to social protection programmes.   BMC Public Health. 2020;20(1):621. doi:10.1186/s12889-020-08693-7PubMedGoogle ScholarCrossref
Herba  CM, Glover  V, Ramchandani  PG, Rondon  MB.  Maternal depression and mental health in early childhood: an examination of underlying mechanisms in low-income and middle-income countries.   Lancet Psychiatry. 2016;3(10):983-992. doi:10.1016/S2215-0366(16)30148-1PubMedGoogle ScholarCrossref
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