(‘hr/d.-lhusc & ~A’glFrcf. Vol 16. pp. 345-358. 1992 Pnnted I” the U.S.A. All nghts reserved.

0145.2134/92 $5.00 + .OO CopyrIght 0 1992 Pergamon Press Ltd.

EARLY IDENTIFICATION OF MATERNAL DEPRESSION AS A STRATEGY IN THE

PREVENTION OF CHILD ABUSE

DOROTHYSCOTT

School of Social Work, University of Melbourne, Australia

Abstract-Maternal suicide and infanticide are merely the extreme tip of the iceberg of psychological and social morbidity associated with post-pat-turn depression. Despite research indicating an association between maternal depression and disturbed parent-child interaction, maternal depression has been largely ignored in the literature on child maltreatment and in child protection practice. Practitioners should be alert to the potential risks to the child associated with maternal depression. In cases where child abuse has occurred, they should consider the possibility that the mother is depressed and that this needs to be treated as a problem in its own right. In terms of prevention of child maltreatment, early identification of maternal depression is an important strategy in which primary health workers have an important role. This study investigates the feasibility of broadening the traditional infant health focus of the role of the Australian Maternal and Child Health Nurse or Public Health Nurse to encompass maternal emotional and social well-being. Using quantitative and qualitative methods, the conditions under which mothers would find this acceptable, and the factors that facilitate or constrain such role redefinition are analyzed.

Key Words-Maternal depression, Post-pat-turn depression, Early intervention, Prevention, Child abuse.

INTRODUCTION

TWO ISSUES EMERGE from the author’s experience as a psychiatric social worker involved in the treatment of women admitted to a psychiatric ward for depression in the post-pat-turn period. First, adult psychiatric services need to go beyond the mother’s mental state and include the mother-infant relationship and the marital relationship as foci of intervention. The implications of this for clinical intervention have been explored elsewhere (Scott, 1984).

Second, the potential of the service system for earlier identification of post-partum depres- sion needs to be tapped in order to develop strategies for the secondary prevention of maternal depression and the possible primary prevention of associated problems in marital and parent- child relationships. This paper presents the findings of a study that was developed to explore such a strategy in the State of Victoria in Australia.

Definition

Post-pat-turn depression (also referred to as post-natal depression and puerperal depression) should be distinguished from post-natal blues (also called maternity blues) and puerperal psychosis (also called post-pat-turn psychosis). In addition, the generic term maternal depres- sion is frequently used, particularly in the child psychiatry literature to describe chronically depressed mothers of dependent children.

Received for publication December 17, 1990; final revision received April 15, I99 I; accepted May 7, I99 I.

Requests for reprints may be sent to Dorothy Scott, School of Social Work, University of Melbourne, Parkville, Victoria, Australia, 3078.

345

346 Dorothy Scott

Post-natal blues is a very common state consisting of depressive mood, irritability, and labile emotions typically beginning 2-4 days following birth and generally abating within IO days of birth. Its estimated incidence ranges from 50% to 70% of all births (Hopkins, Marcus, & Campbell, 1984; Pitt, 1973; Yalom, Lundf, Hoas, & Hamburg, 1968). Some researchers have found an association between severe post-natal blues and the onset of post-partum depression (Cox, Connor, & Kendell, 1982; Kendell, 1985; Pitt, 1968).

Puerperal psychosis occurs in approximately l-2 in 1,000 births (Kendell, 1985; Oates, 1986) and is a very serious psychiatric disorder characterized by acute onset of major distur- bances in thinking and behavior in the days or weeks following birth.

Post-partum depression is a clinical depression experienced by approximately 10% of women in the weeks or months following birth (Cox, Connor, & Kendell, 1982; Hopkins, Marcus, &Campbell, 1984; Kendell, 1985; Pitt, 1968). Common symptoms include: appetite and sleep disturbance; fatigue; feelings of sadness, anxiety, and guilt; irritability: loss of libido; inability to cope with the baby: hypochondriasis, and suicidal ideation.

Isolated symptoms do not constitute a clinical depression and the severity of the depression is determined by the number of symptoms and the degree of impairment they entail for the individual. While a spontaneous remission occurs in most cases, a significant proportion of women who are depressed in the post-partum period continue to be depressed (Pitt, 1975; Williams & Carmichael, 199 1).

There are no agreed diagnostic criteria for post-partum depression and research in this area has used different de~nitions of the post-pa~um period and dilferent classification methods including a number of self-administered questionnaires and clinical diagnostic criteria. There is also some controversy as to whether post-pat-turn depression differs from other clinical depressions (Hopkins et al., 1984). Moreover, it is difficult to differentiate “normal” post-par- turn adjustment (which may include symptoms such as lowered libido or sleep disturbance) from mild post-pat-turn depression. The lack of clarity on the definition of post-pat-turn de- pression is compounded by the different ways in which the general term depression is used.

“Depression as a normal mood, is a universal phenomenon which is familiar to us all and from which no one escapes, Depression as symptom, or abnormal mood, is also common. The borderline between the normal and the pathological is here, as often in psychiatry, indistinct. The term syndrome is borrowed from medicine and refers to a cluster of symptoms and functional disturbances that usually have a common mechanism but a variety of causes. This is clinical depression” (Weissman & Paykel, 1974, p. 3).

The etiology of post-partum depression is unclear and probably involves a complex interac- tion of factors at the biochemical, intrapersonal, inte~ersonal, and sociocultural levels of analysis. The significance of factors may vary between individuals and post-pat-turn depres- sion, like depression at other points in the life cycle, is unlikely to be a single entity.

At the biochemical level, it is likely that endocrinological factors play a significant role, given the marked hormonal changes that are associated with pregnancy, birth, and lactation. While the precise relationship between endocrinological disturbances and post-partum dis- orders is unclear, recent research has yielded a number of theories (Dennerstein, Varnavides, & Burrows, 1986). Whether endocrinological factors are a necessary and/or a sufficient condi- tion for the development of post-natal depression is difficult to determine at this stage.

At the intrapersonal level, motherhood has been conceptualized as a significant transition point in a woman’s identity. From a psychodynamic perspective, pregnancy is seen to be associated with a reawakening of issues related to the mother’s relationship with her own mother, and the intensification of issues related to gender identity. Selma Fraiberg (1980)

Early identification of maternal depression 347

coined the evocative phrase “ghosts in the nursery” to describe the process by which unre- solved conflicts in the parent’s childhood may resurface in the parent-infant relationship. The birth of a child can be seen to exacerbate pre-existing conflicts centered on unmet dependency needs or on an ambivalent internalized image of oneself as mother-the problems of “leaving mother” or “being mother” (Grunebaum, Weiss, Cohler, Hartman, & Gallant, 1975).

There is some evidence to suggest that post-par-turn psychiatric disorders may be more common among women who have poor relationships with their own mothers (Nilsson & Almgrem, 1970) and who had poor early parent-child relationships (Williams & Carmichael, 1983). This may also be the case for women who are depressed outside the puerperium (Birtchnell, 1988).

Another dimension at the intrapersonal level is the woman’s resolution of the possible incongruence between her fantasized image of motherhood and herself as a mother and her experience of the reality of motherhood. Both the fantasy and the reality may be socially constructed as well as idiosyncratic. If there is a major disjunction between the fantasy and reality the mother may experience this as a loss and as indicative of her failure. For many women the relinquishing of autonomy required by the maternal role may evoke considerable ambivalence. The intrapersonal processes involved in a first pregnancy have been explored by Breen (1975) who normalizes such ambivalence and sees it as an expression of the inherent conflicts relating to motherhood.

There may be a personality predisposition to post-par-turn depression which has a number of sources, both genetic and environmental. Cognitive and behavioral theories of depression focused on “learned helplessness” and “cognitive attributional style” have been applied to depression. However, the nature of the association between locus of control and depression is unclear and an external locus of control may be a symptom of depression rather than being an enduring trait of the woman’s personality (Hammon, Marks, de Mayo, & Mayol, 1985).

At the interpersonal level, the depressed mother can be seen to be part of a complex web of social interactions in the families of origin and procreation, as well as in her wider social network. The mother’s mood and behavior can simultaneously affect and be affected by these relationships. A family systems model of post-natal depression has been proposed by Kraus and Scott Redman (1986). The transition from a dyadic to a triadic family structure can be seen to constitute a family development crisis as well as an individual developmental crisis (Lewis, Owen, & Cox, 1988).

Whether pre-existing problems in the marital relationship may make the transition to parenthood more difficult and leave the mother more vulnerable to depression or whether depression in a spouse leads to marital conflict, or both, is unclear. In one semi-longitudinal study, impairment of the marital relationship has been found to occur after the onset of post-partum depression (Tonge, 1984). Evidence for the causal influence of depression on marital adjustment has also been presented by Ulrich-Jakubowski, Russell, and O’Hara (1988). The capacity of a person who is depressed to engage in a reciprocally supportive relationship or to even provide positive reinforcement for a spouse’s supportive behavior may be seriously diminished.

Infant temperament may also be a contributing factor in post-partum depression (Tonge, 1984). Stressors such as incessant crying or infant sleep disturbance may constitute significant provoking agents, particularly for women who carry the major burden of the child care role.

At the sociocultural level of analysis, a broad range of social factors have been found to be correlated with maternal depression in general. These factors include lower social class, social isolation, lack of social support, housing difficulties, nonparticipation in paid employment, and the full-time burden of caring for young children (Brown & Harris, 1978). Most studies have not found an association between post-partum depression and variables such as mater-

348 Dorothy Scott

nal age, parity, social class, or obstetric complications (Cox, Connor, & Kendell, 1982: Hop- kins, Marcus, & Campbell, 1984; Kendell. 1985).

Williams and Carmichael (1983) followed a cohort of babies born in a multi-ethnic urban working class area of Melbourne and found a strong association between recent migration (less than three years) and depression among the non-Australian born mothers and a strong association between deprived and disrupted childhood experiences and depression among the Australian born mothers.

The relationship between post-par-turn depression, life events, and social support is com- plex (O’Hara, 1986). “It is not clear whether depressive affect influences perceptions of social support in the face of additional stress. whether the decreased quality of social support in the face of additional stress increased the vulnerability to depression, or whether the interaction between a high level of stress and depressive affect led to the need for particularly high levels of support” (Hopkins et al., 1984. p. 303).

Ambivalence about the loss of an occupational identity and the acquisition of what is seen as a socially devalued maternal role may also be a significant factor in depression for some women. Hock and De Meis (1990) found that women who preferred employment but re- mained at home with their infants reported higher levels of depressive symptomatology. This group held conflicting sets of beliefs about the maternal role, separation from infants, careers, and employment. Goldsteen and Ross ( 1989) found that employed mothers perceived their children to be less of a burden than mothers at home and Umberson ( 1989) has reviewed the literature showing a general association between parenthood and diminished well-being.

Oakley ( 1980) had advanced a feminist perspective on post-partum depression, focusing on the disempowering impact of obstetric intervention, and the losses entailed in the transition into the socially constructed maternal role characterized by low status, social isolation, and the full-time burden of child care. From this perspective the emergence of what could be termed “the medicalization of maternal melancholy” is likely to obscure the structural origins of maternal stress and distress.

Paw&-Child Relationships and Parental Depression

The 1980s witnessed the publication of a considerable body of research on the children of depressed parents, starting with a collection of studies edited by Morrison ( 1983) and culmi- nating in the recent extensive reviews of Rutter ( 1990) and Downey and Coyne ( 1990). The earlier work on depressed women by Weissman and Paykel ( 1974) had opened the way for a more ecological perspective on the depressed woman in the context of her social relationships. This landmark research demonstrated that even when depressive symptoms pass, “social remission” in the areas of the mother-child and marital relationships does not necessarily spontaneously occur.

Much of the most recent research has focussed on depressed mothers of infants. A general finding has been that depressed mothers show more negative affect toward their infants (Cohn, Campbell, & Matias, & Hopkins, 1990; Field, Healy, Goldstein, & Guthertz, 1990) although Rutter ( 1990) notes that these findings are based on very short period of observation of mother-infant interaction. Cox, Puckering, Pound, and Mills (1987) found that depressed mothers of 2-year-olds were less responsive to the child’s overtures and cues and more likely to respond with control when the child was distressed. Tonge (1984) found that women suffering from post-partum depression were far more likely to report that they physically abused their infant. Accidental injury to the child has also been found to be associated with maternal depression (Brown & Davidson, 1978) as has language delay (Williams & Carmi-

Early identification of maternal depression 349

chael, 199 1) and behavioral disorders (Lee & Gotlib, 1989; Richman, 1976; Williams & Carmichael, 199 1).

Contradictory findings have emerged on whether the risk to the child is the result of paren- tal psychopathology per se (Fendrich, Warner, & Weissman, 1990) or more the result of poor parenting (Goodman & Brumley, 1990). In their integrative review of the research on the children of depressed parents Downey and Coyne (1990) question the hypothesis that child adjustment problems result directly from living with a depressed mother. They pose the possibility that both parental depression and the associated child problems are a function of pre-existing marital conflict and family stress, and that genetic and other biological vulnerabil- ities may also be significant in child adjustment. They conclude that depressed parents and their children are heterogeneous groups and call for a more contextual view of parental depression and child adjustment, while also warning of the dangers of “mother-bashing.”

Clearly, the relationships between parental psychopathology, family conflict, child tempera- ment, and social stress are very complex. Given current knowledge, an ecological framework that recognizes the dynamic interaction of biological, psychological, and social factors would appear to be appropriate.

The Service System

Early intervention depends on early identification. A precondition of early identification is an increased awareness by primary health professionals of the prevalence and potential seriousness of maternal depression. Cox (1986) has identified five possible factors which explain the low level of recognition of post-partum depression by primary health workers: difficulty in differentiating depression from a normal low mood, fear of being “out of their depth” with psychiatric problems, women’s reluctance to divulge their emotional state, the belief that depression “is what most women go through,” and the problem of coordinating different community workers.

In examining the Australian service system, it appeared that the universal maternal and child health service has enormous potential for early intervention. In the State of Victoria, this service is subsidized by the State Government, administered by local government, and deliv- ered through baby health centres at the neighborhood level. These are typically staffed by solo maternal and child health nurses (formerly called infant welfare sisters) and are used by more than 90% of the population for immunization and regular monitoring of the child’s physical growth and development during infancy and the preschool years.

This service, like similar services elsewhere in the world, was established early in the twen- tieth century to combat the problems of infant mortality and morbidity. This study specifi- cally sought to assess the capacity of the maternal and child health nurse to identify cases of maternal depression and generally sought to explore the potential of the service to broaden its role from infant health focus to include maternal emotional and social well-being. It did not attempt to evaluate the effectiveness of maternal and child health nurse intervention in the treatment of post-par-turn depression.

Concern was expressed by nurses about whether it would be acceptable to mothers to explore their emotional health, and they rejected the idea of using nurse- or self-administered instruments to identify depression. In an earlier New South Wales study on post-partum anxiety and depression conducted in baby health centres, there was a high level of resistance by mothers to the suggestion of a psychiatric referral and the nurses discontinued the use of the self-rating scale after the research was completed (Robinson & Young, 1982). The Edin- burgh Post-Natal Depression Scale (Cox, Holden, & Sagovsky, 1987) a self-administered instrument specifically designed for use by primary health workers, has been reported to be used by Health Visitors in the U.K., but this scale was not available at the time of this study.

350 Dorothy Scott

METHOD

This study addresses the following questions:

1. How do maternal and child health nurses who are respected by their colleagues for their interpersonal skills, assess and intervene in relation to the emotional and social well-being of mothers?

2. How do nurses’ assessments of the depression of mothers compare with the mothers’ self-assessments, and how do both of these compare with reported symptoms of clinical depression?

3. How do mothers using the maternal and child health service perceive the symptoms and causes of depression among women with infants?

4. What are the attitudes of mothers to the role of the maternal and child health nurse in relation to maternal emotional and social well-being?

5. What appear to be the norms which can be observed to govern the interaction of maternal and child health nurses and mothers in regard to exploring maternal emotional and social well-being?

6. What are the intra- and inter-organizational factors that affect the potential of the mater- nal and child health service to broaden its traditional infant health focus to encompass maternal emotional and social well-being?

A triangulated research design utilizing quantitative and qualitative methods was em- ployed. A purposively selected sample of maternal and child health nurses in three Melbourne centres and a random sample of mothers using these three centres were used. In order to test the potential of the maternal and child health nurse to operate in the domain of “maternal emotional and social well-being,” nurses who already possessed a high level of interpersonal skills were chosen on the basis of peer recommendation via the Infant Welfare Special Interest Group of the Royal Australian Nursing Federation. While such a purposively selected sample is appropriate for exploring the clinical judgment of maternal and child health nurses and their role in maternal depression under “ideal nurse” conditions, it constrains the generalisa- bility of these findings.

A pilot study was undertaken at an inner city maternal and child health centre. The diverse socioeconomic composition of families using this centre facilitated the testing of the survey- questionnaire items for comprehension and acceptance.

Subsequently, a number of modifications were made, including the discontinuation of the Pitt (1968) scale of puerperal depression which was perceived by mothers and nurses as too intrusive. A checklist of interviewer-administered questions about depressive symptoms based on research diagnostic criteria by Feighner et al. ( 1972) was adopted instead. The nurse at the pilot centre was also used to refine the qualitative methods of observation and focused interviewing chosen to describe the nurses’ cognitive schema and conceptualize their practice. A sample consisting of 45 mothers using three centres in a given week was selected, and following introduction by their maternal and child health nurse, all the mothers agreed to be interviewed in their home. Each nurse was observed in her daily work for a period of 1 week.

RESULTS

The majority of the women were Australian born, married and aged 25-39 years with one or two children, the youngest of whom was under 12 months of age. Most were not involved

Early identification of maternal depression

Table 1. Preferred Sources of Help in Problem Situations

351

Hypothetical Problem Situations

Source of Help Mild Worse

Feeding Sleeping Depression Depression

Relative 9 12 21 16 Doctor 5 2 2 14 Friend 3 6 7 3 NUrX 24 25 13 10 Others 4 0 0 2 Nobody 0 0 2 0 Total 45 45 45 45

in any paid employment, and their previous occupational status ranged from professional to unskilled.

Attitudes to Maternal and Child Health Service

Mothers were asked to nominate the person with whom they would most prefer to consult in relation to a number of hypothetical problems. The maternal and child health nurse was more than twice as likely to be cited as the most preferred source of help regarding infant feeding and sleeping problems and was second only to relatives (predominantly husband) in relation to “mild maternal depression.” The nurse was the third most frequently cited source of help in relation to “worsening maternal depression” with a relative being the most fre- quently mentioned and local doctor the second most frequently cited source of assistance (see Table 1). These results were supported by other questionnaire items which asked respondents to rate the relative importance of a number of functions of the Maternal and Child Health Service using a Likert scale. The percentage of mothers rating the following functions as very important or important is set out in Table 2.

Table 2 demonstrates how less traditional “mother-focused functions” are perceived to be nearly as important as the traditional “child-focused functions” with the exception of the domain of marital and family relationships which is clearly not perceived as an important function of the service. Open-ended comments reflected the view that the latter would be regarded as intrusive and beyond the domain of the service.

Using a similar Likert scale, mothers were also asked to indicate how acceptable they would

Table 2. Attitudes to the Importance of Different Service Functions

Function Importance Rating

To assist new mothers wanting instruction and reassurance with the baby

To check on children’s physical growth and development

To advise on children’s emotional and social development

To offer assistance to mothers experiencing emotional problems

To provide social contact with other mothers

To provide information about community services and activities

To offer assistance with problems in marital and familv relationshios

100%

100%

87%

87%

80%

80%

20%

352 Dorothy Scott

Table 3. Acceptability Ratings of Nurse Inquiries About Mother

Questions

Nurse asking mother how she is coping with the baby.

Nurse asking mother “How do you find being at home compared with how you imagined it would be?’

Nurse asking mother if she had experienced feeling depressed in the first week after the birth.

Nurse commenting that a mother looked “rundown” and “weary” and asking “How have you been feeling lately?’

Nurse asking mother if she had had any marked changes in mood since the baby was born.

Nurse asking mother if she had been feeling lonely or isolated since the birth of the baby.

Acceptability Rating

98%

96T

96%8

93%’

9 1 B

89%

find it if the maternal and child health nurse asked certain questions about their own well-be- ing (see Table 3).

These high acceptability ratings were frequently qualified by respondents indicating that they would find this acceptable from their own nurse whom they knew well and trusted but would not generalize this to other nurses. Interestingly, the nurses themselves gave lower acceptability ratings on these items than the mothers, indicating their reservation about their mandate to move into this area.

In strong contrast to mothers’ liberal attitudinal norms to hypothetical instances of the maternal and child health nurse moving into the domain of maternal emotional and social well-being, the behavioral norms observed in the actual interaction of nurses and mothers were quite conservative. The latter were found to be more congruent with the cautious attitu- dinal norms expressed by the nurses. The interaction between nurses and mothers appeared tentative when issues relating to maternal emotional well-being were actually initiated by the nurse. The nurse readily retreated to the safer, traditional child-focused issues if the mother seemed to perceive this as intrusive. While this may have been an artifact of the observer’s presence, it was the opinion of the nurses that the interactions observed were not affected by the researcher and that they were typical of what normally occurred.

Maternal Experience and Understanding Qf Depression

Of the 45 mothers, 30 (66%) reported that they had experienced a depressive episode following the birth of their child, while only 4 considered themselves to be currently de- pressed. Of those reporting that they had been or were currently depressed, 15 (50%, 33% of the total sample) reported having or having had four or more symptoms of clinical depression. In the four cases in which women reported currently experiencing four or more symptoms of a clinical depression, their maternal and child health nurses independently rated them de- pressed. The nurses did not rate as depressed those mothers who perceived themselves as having been depressed but who did not report having had four or more symptoms of clinical depression.

Factors that may have affected the incidence of reported experiences of depression include: retrospectivity of data and the accuracy of recall, social desirability effects, and differing

Early identification of maternal depression 353

perceptions of the construct “depression” with mothers regarding depression as a mood and the nurses defining it more stringently at the clinical level.

The mothers were also asked how they might recognize a depressed mother, and they typically cited affective and behavioral symptoms such as crying, irritability, and inability to cope with childrearing and domestic tasks. They saw the causes as situational rather than as physical or psychological. Frequently cited sources of situational stress included the frustra- tions of caring for young children, lack of support from husband, financial worries, housing problems, and loneliness.

There were no differences between those mothers who perceived themselves to have been (or be) depressed and those who did not identify themselves as having been depressed, in regard to their attitudes to the maternal and child health service. An analysis of the reasons given by mothers who perceived themselves as having been depressed but who chose not to consult their maternal and child health nurse about this is illuminating and casts doubt on the validity of the stated liberal attitudinal norms obtained from the questionnaire. The following were typical:

“I didn’t think of talking to the infant welfare sister. I felt she was only there for the children and not for the other problem.”

“I feel that the nurse is mainly concerned with the baby. I wouldn’t like her to probe too much, but I would like her to be there to go to when I want. I’d rather go to friends. I feel she doesn’t know my situation well enough to be able to assist.”

“I couldn’t admit feeling depressed and not coping even though I have a very good relationship with her. 1 talked about the baby’s colic but not how I felt. I’d never considered her role as covering the mother’s emotional well-being. 1 never thought I had a right to talk about emotional problems as I was never told what the role of the nurse covers.”

“If I had thought it [the depression] was because of the baby I would have talked to the nurse but not otherwise.”

“I would have preferred to have talked about it but I couldn’t because this would have been an admission that I was anxious about my ability to cope.”

A few mothers had spoken to their maternal and child health nurse about how they were feeling and made the following comments:

“I spoke to the nurse, my mother and also went to the doctor. the nurse was the first one to ask if I’d been eating and to show concern for me as well as the baby . it’s very necessary to have her there she doesn’t make you feel silly or that you’re worrying about nothing and she always asks how you are . ”

“She’s a supplement to my own mother. She’s easy to talk to. I depend on her. She’s not just there to take care of the baby but for the mothers too. She started a group for us new mothers.”

A number of themes emerged from a content analysis of comments made in the open- ended sections of the questionnaire: anxiety about exposing feelings of inadequacy; uncer- tainty about the legitimacy of talking about oneself to the nurse; the importance of the nurse directly expressing her interest in the mother; and the significance of the transference reaction of the nurse as a supportive “good mother” or a critical “bad mother.”

Cognitive Schema of the Nurse

Through observation and focused interviewing, the cognitive schema used by the nurses to assess the social functioning of mothers was identified. They made their assessment, or as one evocatively described it, “built up a picture of the mother,” through a process of unobtrusive data collection and observation.

The variables to which they appeared to attend were:

354 Dorothy Scott

l The characteristics of the baby and the degree to which the baby’s behavior constituted a stressor

0 The mother’s background and personality as these were seen to shape her adaptation to the maternal role

l The availability and capacity of significant others, in particular her husband and her mother, to perform a sup~~ive role

l Her integration into neighborhood social networks l Other situational stressors impinging on the family

This schema was not presented in an explicit way but existed in a tacit form and was inductively extracted by the researcher through a process of reflecting upon the researcher’s observations of the nurses and the impticit generalizations in the case illustrations provided by them.

The three nurses studied appeared to be highly skilled in successfully engaging mothers, although they had not received any formal interpersonal skills training and were generally unaware of the techniques which they employed to do this. They adopted a personalized rather than a remote style of professionalism, and displayed what has been called the profes- sional virtue of hospitality (Elliot, 1984), warmly welcoming mothers into the centre and recalling them and referring to them by name.

When they ventured into the domain of “maternal emotional and social well-being,” they did so skillfully, using the baby as a focus and building a supportive and trusting reiationship around this core role function. In cases in which the mother expressed frustration with the baby, they avoided colluding with the mother against the baby (“aren’t you a naughty baby then?“) or colluding with the baby against the mother (“what has Mummy been doing to you then dear?‘). Instead, they were skillful in expressing concern and empathy for the suffering of both mother and baby. Babies were warmly praised for their beauty and their growth in a manner which positively reflected upon the mother rather than displacing her as the focus of attention.

One nurse consistently and effectively soothed obviously anxious mothers by continuing to slowly stroke the baby in the mother’s arms, although she was unaware that she selectively did this. This is indicative of the “intuitive” nature of the clinical judgment that was observed- the result of “natural” interpersonal skills and clinical experience rather than formal learning. The nature of inductively derived clinical judgment has been described by Feinstein ( 1967) and Schon (1983), and the potential for transforming “practice wisdom” into “practice theory” has been explored by Scott (1990).

In any cases of subclinical and mild post-par-turn depression, support of the mother by her nurse and her family appeared to be sufficient. In some instances mothers were responsive to being linked with a post-partum depression self-help group such as P.A.N.D.A. (Post and Ante-Natal Depression Association) which has grown considerably over the past decade and now exists on a State-wide basis in Victoria. In cases of post-partum depression requiring psychiatric referral, the maternal and health nurse was well located to facilitate this and this occurred in several cases in this sample.

Playgroups and New-Mothers Groups were also subtly and unobtrusively used to help women reflect upon the impact of motherhood on their life and to express ambivalence about their loss of autonomy and changed identity. Such groups also appeared to be an effective means of facilitating mutual support and the creation of social networks which may act as a buffer in the face of the stresses of parenthood.

Certain factors such as heavy workload pressures and poor interprofessional collaboration were found to limit the ability of the Maternal and Child Health Nurse to fulfill her potential

Early identification of maternal depression 355

role in relation to maternal emotional and social well-being. When the time available per consultation was reduced it was observed that the nurse was only able to perform the infant- focused core role function. There was also a tendency to retreat to this role when the nurse was stressed by the emotional dependency of some of the mothers. This appeared to be associated with the isolated work setting, lack of peer support and clinical consultation and the number of emotionally vulnerable women for whom the nurse acted as a mother substitute.

In cases in which it was important for the maternal and child health nurse to interface closely with other services, poor interprofessional and interorganizational interaction ob- structed delivery of appropriate services. An analysis of cases identified by the nurses as “problem situations” revealed a pattern of communication difficulties with other profes- sionals and services. Breakdowns in referrals and poor coordination of services characterized interactions between the maternal and child health service and obstetric, pediatric, and psychi- atric hospitals as well as child welfare services. Personnel in these service systems seemed to disregard the importance of the maternal and child health nurse.

The following case vignettes were typical of the poor collaboration observed in this study.

Case Vignette l-Psychiatric Hospital Liaison

An obviously sedated woman, unknown to the maternal and child health nurse and unescorted, walked into the

centre with her baby. She was a patient at a nearby small private psychiatric hospital where she had been for 2 weeks.

She said she was anxious about the baby’s weight and asked the nurse to weigh her 6-week-old baby, producing the

booklet from her local centre which recorded her previous weight. The baby appeared to have lost a significant

amount of weight in the past 2 weeks and in the presence of the researcher and nurse had a severe apnea episode. The

mother said this had occurred on a number of occasions. The baby appeared very hungry but the mother did not seem

able to recognize and respond to this need. The nurse contacted the psychiatric nursing staff and met considerable

resistance to her suggestion that an urgent pediatric examination be arranged and that closely supervised feeding of

the baby be instituted. The psychiatric nurses claimed the baby was a boarder and that infant feeding was not one of

their duties, and that the mother’s psychiatrist would have to be approached regarding a pediatric referral. The

maternal and child health nurse repeatedly attempted to contact the psychiatrist who did not return her calls over a

number ofdays. Eventually she managed to speak with him and he rejected the need for a pediatric assessment on the

grounds that the mother was irrationally preoccupied with the health of the baby. This case is an example of how the

mother infant dyad can be seriously ignored in an adult psychiatric setting, as well as an example of the failure to

provide information on the mother’s mental state to the nurse and to respect and respond to her professional expertise

relating to the baby’s health.

Case Vignette 2-Obstetric Hospital Liaison

The maternal and child health nurse received the usual birth notification notice from a major obstetric hospital,

detailing the name and address of the parents and the baby’s sex and birthdate. The researcher and nurse visited the

small bungalow in the backyard of an inner urban house and found an adolescent mother and her young partner very

distressed. The baby girl had severe congenital abnormalities and was dying in the hospital. The nurse was unprepared

to deal with this and no follow-up had been arranged by the hospital. The birth notification notice was merely an

administrative process and did not act as a professional referral facilitating coordinated service delivery.

Case Vignette 3-Pediatric Hospital Liaison

A l-month-old baby boy was admitted to a major pediatric hospital for “social” reasons following presentation in

Casualty for croup. The parents, both aged 20 and with a 2-year-old daughter visited infrequently and there appeared

to be little attachment to the infant. The mother was reluctant for the baby to be discharged and after 4 weeks the baby

was transferred on his own to a mother and baby aftercare hospital close to where the parents lived. After 2 months,

the baby was sent home. Because of concerns that the child was “at risk,” staff at both hospitals organized home help and a family aide to “monitor” the situation. The parents were angry about this intrusion, and the maternal and child

health nurse who had a supportive relationship with the mother was not consulted. As well as the lost opportunities to

therapeutically address the problems in the parent-child relationships in the hospital, the plan of intervention failed

due to the mother’s resistance. If the nurse had been consulted she would have been able to describe how the mother was an obsessive housekeeper and predict that home help would usurp the mother in the one area of her role in which

she felt competent. Moreover, the supportive relationship that the nurse had developed could have been used to

356 Dorothy Scott

engage the family and act as a vehicle of clinical intervention (with appropriate support and ~onsuitatio~) in the face of resistance to other services.

DISCIJSSION

In addition to more research on the complex association between maternal depression, parent-child interaction. and child adjustment problems, there is a need for further applied social research on effective forms of service delivery. This needs to go beyond the traditional clinical evaluation studies and include research at the primary and secondary prevention end of the service delivery system. An ecological persperctive on research in the area of child abuse and neglect (Garbarino, 1977) should lead us to explore the potential for prevention and early intervention at the points of transaction between the microsystems of the family and the exosystem, or forma1 service delivery systems. This will require a rethinking in our research priorities and a reconceptualization of the ecology of families.

This study did not evaluate the effectiveness of the Maternal and Child Health Service in the prevention or treatment of post-par-turn depression. Rather, it addressed the prior ques- tions of whether maternal and child health nurses can identify depressed mothers, how they go about exploring maternal emotional and social well-being, and under what conditions, including considerations of consumer acceptance, this is possible.

The findings indicate that it is possible for the maternal and child health nurse to identify depressed mothers and through her traditional infant-focused role, to develop a supportive and trusting relationship which allows her to enter the domain of maternal emotional and social well-being. The behavioral norms identified in this study would suggest that this re- quires a sensitive and subtle approach on behalfof the nurse. This has implications for the sort of professional education, secondary consultation, and peer support that might facilitate the development of a high level of interpersonal skills and the maintenance of competent profes- sional practice.

The potential of the nurse to play an important role in the primary and secondary preven- tion of maternal depression goes beyond direct one-to-one interactions with mothers to en- compass a community development strategy. In one maternal and child health centre, an innovative program was developed by the nurse and social workers in a local family support agency to link all new mothers with an experienced mother in the same neighborhood who volunteered to visit her, offering support and introducing her to other women in the neighbor- hood. The volunteer mothers, or “Mums’ Chums” as they called themselves, also reported positive outcomes of this experience for themselves (Schwarz & Begg, 1980). Such a program is a good example of interprofessional and interorganizational collaboration. It also illustrates an ecological approach to the promotion of healthy parenthood in which professionals facili- tate natural helping networks rather than placing themselves center stage in the helping relationship.

The study also found that the broadening ofthe maternal and child health service from an infant-health focus to encompass the broader social well-being of the family depends upon certain organizational prerequisites. Under conditions of resource scarcity in which the nurse carries a high caseload. or one that is more demanding because of the needs of the particular population she serves, there is a danger of the nurse being overwhelmed and retreating to an exclusively infant health focus. The potential of the service is thus dependent upon adequate funding and support which minimizes the level of work-related stress for maternal and child health nurses.

It is important that the key features of the present service be maintained-pa~icularly the neighborhood base which makes it easily accessible, and the universalism which preserves its

Early identification of maternal depression 357

non-stigmatized image. The latter is particularly pertinent for child protection services to recognize. It is the accessibility and the non-stigmatized public image of the maternal and child health service that has enabled regular and routine attendance at the local baby health centre to become so firmly established as a norm of Australian parenthood over the last 70 years. Service restructu~ng in a context of economic restraint and a preoccupation with child abuse detection rather than prevention run the risk of killing the goose that lays the golden egg.

If primary health workers are to fulfill their potential role in the prevention of child abuse and neglect, services developed at the beginning of this century to deal with infant mortality and morbidity will need to be imaginatively transformed to meet the psychosocial problems experienced by families at the end of this century.

REFERENCES

Birtchnell, J. (1988). Depression and family relationships. British Jortrnal ~fRyvchiafry, 153. 758-769. Breen, D. (1975). Psychological aspects ofafirst pregnancy. London: Tavistock Publications. Brown, G. W., & Davidson, S. (1978). Social class and psychiatric disorder of mother and accidents to children.

Lance& 1, 378-380. Brown, G. W., & Harris, T. (1978). The social origins of depression, a study ofpsychiatric disorder among women.

London: Tavistock Publications. Cohn, J., Campbell, S., Matias, R., & Hopkins, J. (1990). Face to face interactions of postpartum depressed and

nondepr~d mother-infant pairs at 2 months. D~~ve/~~p~~enfal Ps~~cho~ogy, 26( I ), 15-23. Cox, A., Puckering, C., Pound, A., & Mills, M. ($987). The impact of maternal depression on young children. Jozunul

qf Child Psychology and Psychiatry, 28.917-928. Cox, J. L. (1986). Postnatal depression, a guide for health professionals. Edinburgh: Churchill-Livingstone. Cox, J. L., Conner, Y., & Kendell, R. E. (1982). Prospective study of the psychiatric disorders of childbirth. British

Journal ofPsychiatry, 140, I1 l-l 17. Cox, J. L., Holden, J. M., & Sagovsky, R. (1987). Detection of postnatal depression, development of the IO item

Edinburgh postnatal depression scale. British Jonrnal ofPsychiatry, 150, 782-786. Dennerstein, L., Vamavides, K., & Burrows, G. (I 986). Postpartum depression: A review ofthe literature. Australian

Family Physician, 15, 1470- 1472. Downey, G., & Coyne, J. (1990). Children of depressed parents: An integrative review. Psych~~l~~gical Bz~llet~n, 108.

50-76. Elliot, M. W. (1984). Hospitality as a virtue. Social Casework, 65, 109-l 12. Feighner, J. I’., Robins, E., Guze, S., Woodruff, R., Winokur, G., & Munoz. R. ( 1972). Diagnostic criteria for use in

psychiatric research. Archives of General Psychiatry. 26, 56-73. Feinstein, A. R. (1967). Clinical judgment. New York: Krueger Co. Fendrich, M., Warner, V., & Weissman, M. (1990). Family risk factors, parental depression and childhood psychopa-

thology. Developmental Psychology, 26,40-50. Field, T., Healy, B., Goldstein, S., & Guthertz, M. (I 990). Behavior state matching and synchrony in mother-infant

interactions of nondepressed versus depressed dyads. Developmental P.sychology, 26. 7-14. Fraiberg, S. (Ed.) (1980). The.firsl year qf I@: Studies itz inane mental hea~fh. New York: Basic Books. Garbarino, J. (1977). The human ecology of child maltreatment: A conceptual model for research. J(~z~rna/ of

h4arriage and the Family, 39, 72 l-735. Goldsteen, K., & Ross. (I 989). The perceived burden of children. Journa/ ofFamity Issues, IO, 504-526. Goodman, S., & Brumley, E. (1990). Schizophrenic and depressed mothers: Relational deficits in parenting. Devr/q~-

mental Psychology, 26, 31-39. Grunebaum. H.. Weiss. J.. Cohler. B.. Hartman, C.. & Gallant, D. (1975). Mentallv ill mothers and their children.

Chicago, IL: University of Chicago Press. Hammon, C., Marks, T., de Mayo, R., & Mayol, A. ( 1985). Self-schemas and risk for depression: A prospective study.

Jottrnal of Personality and Social Psychology, 49, 1147-l 159. Hock, E., & De Meis, D. (1990). Depression in mothers of infants: The role of maternal employment. Deve/op~nefftal

Psychology, 26,285-29 1. Hopkins, K. J., Marcus, M., &Campbell, S. (1984). Postpartum depression: A critical review. Ps~~c~z~~~~~gica~ B~fileti??,

95,498-5 15. Kendell, R. E. (1985). Emotional and physical factors in the genesis of puerperal mental disorders. Journal of

Psychosomatic Research, 29, 3- 11. Kraus, M., &Scott Redman, E. (1986). Postpartum depression: An interactional view. JournulofMarital and Fami/y

Therapy, 12, 63-74. Lee, C. M., & Gotlib, H. (1989). Maternal depression and child adjustment: A longitudinal analysis. Jotrmul of

Abnormal Psychology, 98, 78-85.

358 Dorothy Scott

Lewis. J. M., Owen. M. T., & Cox, M. J. (1988). The transition to parenthood: III, Incorporation ofthe child into the family. Family Procrss. 27, 4 1 I-42 I.

Morrison, H. L. (Ed.) (1983). Children ufd~pr~.s.s~d uarenf.s: Risk. id~~?ti~~ati(~ff und i~ter~,e~~ti~~~. New York: Grune & Stratton.

Nilsson, A., & Almgren. P. (1970). Paranatal emotional adjustment-a prospective investigation of I65 women. .4CTA P.sychiatrica Scandinavia, Suppl. 220, 1- I4 1.

Oakley, A. (1980). Women cor$ned. &ford: Martin Robertson. Oates, M. R. (I 986). The treatment ofpsychiatric disorders in pregnancy and the puerperium. Cliniu in Obstetrics &

Gynecology, 13, 385-395. O’Hara, W. (1986). Social supports, life events. and depression during pregnancy and the puerperium. Arcf7ive.s o/

Geni>ral PsychiaZry. 43. 569-573. Pitt, B. (1968). “Atypical” depression following ~hi~dbi~h. British ,~~~t~r~a~ ~~~~.sy~~iatr~, 114. 132% 1335. Pitt, B. (1973). Maternity blues. British Journal ofP.sychiatry, 114. 1325-l 335. Pitt, B. (1975). Psychiatric illness following childbirth. Brifi.rh Journal o/‘P.sychiofr~~. (Special) 9, 409-4 14. Richman, N. (1976). Depression in mothers of pre-school children. .Journa/ of Child P.~~rho/o~,~y CC Pc,vchra/rj: 17.

75-78. Robinson, S., & Young, J. (1982). Screening for depression and anxiety in the post-natal period: Acceptance or

rejection of a subsequent treatment oiler. if~sfralian and JVEIV Z<,aland Journal t$P.sjrhiatry, 16, 47-S 1. Rutter, M. (1990). Commentary: Some focus and process considerations regarding effects of parental depression on

children. ~~velopr~l~~ntai P.s~*~~z~~i~~~~, 26, 60-67. Schon, D. (1983). 7%7e r~~e~fiv~practitiunt’r: How professionals think in action. London: Temple Smith. Schwartz. R., & Begg, P. (1980). The “Mum’s Chums” project. Australian Child and Fami/>s U’&UY~. S. 19-21. Scott, D. A. ( 1984). Nursing the impaired mother-infant relationship in puerperal depression. .4cc.stra/ian .Joumal o/

Advanced Nursing, 1, 50-56. Scott. D. A. (1990). Practice wisdom: The neglected source of practice research. SociaL Work, 36. 564-568. Tonge, B. f 1984). Postnatal mood states, mother-child interaction and child development. M.D. Thesis, University of

MeIbourne. Australia. Ul~ch-Jakubowski, D., Russell, D. W., & O’Hara, M. W. (1988). Marital adjustment difficulties: Cause or conse-

quence of depressive symptomatology. Journal ofSocial and Clinical Psychokgy. 7, 3 12-3 18. Ilmberson, D. ( 1989). Parenting and well-being. Journal qfFamily 1ssue.s. 10, 427-439. Weissman. M. M., & Paykel. E. S. (1974). The depressed woman: d study qfsocial rekation.ships. Chicago, IL:

University of Chicago Press. Williams, H., & Carmichael, A. (1983). Depression in mothers in a multi-ethnic urban industrial municipality in

Melbourne. Journal of Child Prvchokxv and Ps~~chiatrv, 26, 277-288. Williams, H.. &Carmichael, A. (t99 1). Depression-in mothers and behavior problems with their pi-e-school children.

Paediatks and Child Heaiih, 127, 74-82. Yalom, I., Lundf, D., Hoas. R., & Hamburg, D. (1968). Post-partum “blues” syndrome: A description and related

variables. Archivu of Gutera P.sychiatry, 18, 16-27.

Resume-Le suicide matemel et l’infanticide constituent la pointe de I’iceberg de la morbidit& psychologique et sociale, Ii&e a la depression du post-pa~um. Malgre les recherches indiquant I’association de la depression maternelle et des interactions mere-enfant pertubees, la depression maternelle acependant et& largement ignoree, non seulement dans la litterature mais aussi dans la pratique concemant la protection de I’enfant. Les cliniciens devraient itre attentifs aux risques potentiels present& par I’enfant dont la mere est depressive. Darts les cas oh I’enfant a ete vichme de mauvais traitements, I’eventualite de la depression maternelle devrait Ptre prise en consideration et Ctre trait&e comme un probleme a part entiere. En terme de prevention des mauvais traitements a I’enfant; I’identification precoce de la depression maternelle constitue une strattgie importante dans laquelle les travailleurs de santt de premiere ligne ont un role a jouer. Cette etude analyse la possibilitt d’tlargir Ies objectifs des infirmiPres de la Protection Maternelle et Infantile Australienne afin d’y inciure le bien-etre social et psycholo~que des meres. Les conditions dans lesquelles un tel projet serait juge acceptable par les meres ainsi que les facteurs qui faciliteraient ou empecheraient une telle redefinition des roles sont analyses a I’aide de methodes quantitatives et qualitatives.

Resumen-El suicidio materno y el infanticidio son solo 10s picas del iceberg de la morbilidad psicolbgica y social asociada con la depresibn post-parto. A pesar de 10s hallazgos cientihcos que indican una relacibn entre depresibn materna y una interaction perturbada padre-hijo, la depresibn maternal ha sido muy ignorada en la literatura que estuida et maltrato a 10s nifios yen las pmcticas de protection al menor. Los que atienden a 10s niiios deben estar alertas al riesgo potenciai asociado con la depresibn matema. En 10s cases en que ha ocurrido abuso contra 10s niiios d&e considerarse la posibilidad de que la madre es3 depresiva y sea necesario tratar ese problema por si mismo. La identificaci6n temprana de la depresion materna es una estrategia importante en la que tienen un papel importante 10s que trabajan en salud mental; para lograr la prevention de1 maltrato a 10s niiios. Este estudio investiga la factibilidad de amphar et enfoque de salud traditional de la Enfermera Australiana de la Salud Materno-Infantil 6 de la Enfermera de Saiud Publica para que incluya el bienestar emotional y social de la madre. Se analizan las condi- ciones bajo las cuales las madres considerarian esto aceptable y 10s factores que facilitan o entorpecen esa redetinicion de rol, usando metodos cualitativos y cuantitativos.