Chapter 1 BACKGROUND & INTRODUCTION
The health and well-being of children is intimately connected with their early social, emotional and inter-personal experiences. This paper describes an analysis of the Growing Up in Scotland ( GUS) longitudinal data-set over four sweeps, to explore the impacts of maternal mental health 1 on their children at ages 3-4.
1.1 The policy context
"Equally Well", 2 the report of the ministerial task force of the Scottish Government on health inequalities, emphasised the well-established and persistent damaging effects of low income and poverty on physical health and mental health. The report made it clear that the Government is committed to reducing "unfair and unjust inequalities in health": the early years are identified by the Scottish Government as a priority area for action.
A mentally healthy childhood can be a precursor to a healthy and productive adulthood. Children's development can be affected by their socio-economic circumstances, but also by the emotional climate within the home. This can include the quality of relationships between a child's parents, the supports that are available to a family and by the health and well-being of the child's primary care-givers. Longitudinal evidence suggests that conduct problems in childhood are associated with a range of adverse outcomes in adulthood, including crime, substance abuse, poor mental health, and poor educational attainment. "Equally Well" noted that:
Children's earliest experiences shape how their brains develop. Very young children need secure and consistent relationships with other people, or else they will not thrive, learn and adapt to their surroundings [page 2].
In a similar vein, "Towards a Mentally Flourishing Scotland" 3 notes that:
Concentrating efforts on the early years of life, from before birth to up to 8 years old, and more generally on the mental well-being of children and young people, is likely to bring the best long-term outcomes of improved population mental health [page 8]
The health, well-being and development of children is jeopardised directly and indirectly by poverty (Marmot, 2005) but also, in complex ways, by poor parental health which, in turn, is affected by socio-economic factors. There is a higher incidence of depression and anxiety in women with young children, particularly among those who are young, unsupported and living in socio-economically disadvantaged circumstances (Brown and Harris, 1978; Petterson et al., 2001).
1.2 Pregnancy, childbirth and mental health
A woman is more likely to be admitted to a psychiatric hospital in the three month period following childbirth than at any other time in her life (Kumar, 1982). While only a very small number of women - approximately 1-2 per thousand - will experience a severe postpartum psychosis (Kendall et al., 1981), surveys suggest that between 10-17% of all deliveries are followed by a depressive episode that would be regarded as indicative of clinical depression, although this may never come to the attention of health professionals (Cox et al., 1982; Kumar and Robson, 1984).
There are competing schools of thought about the factors that may cause or be associated with depression in the period after childbirth: that depression is caused by biological changes associated with pregnancy and childbirth or that it is the social context surrounding a pregnancy or birth that is the significant trigger or causal factor.
Brown and Harris (1978) showed that depression in women was very strongly associated with their psycho-social environment. In particular, women who had experienced a stressful life event but did not have supportive relationships, had three or more young children and/or were not employed outside the home were more likely to become depressed after a stress event. In addition, women who had experienced an early (before the age of 11) loss of their own mother were also more vulnerable in the face of adversity.
Using the same methodology as Brown and Harris, Martin et al., (1989) explored the role of stress events among women who had recently given birth. This study suggested that depression during pregnancy and in the six months after childbirth was common, affecting up to 1 in 5 women at some point in that period. It was shown that most depression observed after childbirth actually began in pregnancy. While there were some cases of severe psychiatric illnesses which began very shortly after childbirth and appeared to occur without any other trigger, the less severe cases were very much associated with social conditions. For example, it was found that women who were unsupported by a partner (either lone parents or in troubled relationships) and/or who experienced socio-economic adversity were much more likely to be depressed - both in the antenatal and postnatal periods - than women who remained emotionally well throughout pregnancy and after the birth.
1.3 Maternal mental health and child outcomes
Maternal mental health can affect children's emotional well-being and their cognitive and behavioural development in particular ways. There is consistent evidence that depressed mothers may be less responsive than mentally healthy mothers to their infants' efforts to engage with them and that this, in turn, affects the strength of infants' attachment to the mother (Murray et al., 1991). Poor attachment, in turn, has been shown to be related to impaired cognitive functioning at 18 months (Murray et al., 1996). There is also evidence to suggest that there may be different developmental outcomes for children exposed briefly to a mother with poor mental health compared with those exposed over a prolonged period. While brief exposure to a mother with poor mental health has been associated with adverse emotional and cognitive outcomes for the child (Murray et al., 1996, and Wachs et al., 2009), long-term exposure may additionally be associated with adverse behavioural outcomes (Lyons-Ruth et al., 1993 and Chang et al, 2007). Understanding the possible causal mechanisms is, however, not straightforward as the factors associated with poor maternal health may also be those associated with less favourable developmental outcomes for children.
1.4 Longitudinal research
Longitudinal surveys afford a unique opportunity to study change over time for the same individuals, and to explore the impact of prior circumstances on long-term outcomes. Using longitudinal data over four sweeps of the Growing Up in Scotland ( GUS) survey this paper explores the impacts of poor maternal mental health on children's emotional, cognitive and behavioural development and on their relationships with peers at ages three to four.
We do not have a clear picture of the ways in which maternal mental health may change over the course of their child's early years in Scotland and how poor maternal mental health at one point in time may impact on children's longer-term development and well-being. Nor too do we have an understanding of the factors - including service interventions and social and/or family support - that may moderate or ameliorate the negative impacts of exposure to a mother with poor mental health. This analysis of GUS data, for children born in 2004 and 2005 and now on the cusp of starting primary school, is intended to address this topic.
1.5 How the study will contribute to the evidence base
Longitudinal data afford valuable opportunities to explore change over time and possible causal relationships between circumstances or events and outcomes which are less likely to be subject to the reporting biases associated with one-off cross-sectional surveys. The GUS survey to date comprises information collected for mothers and their children at discrete points over a four year period and it is now possible to assess whether early social and inter-personal experiences may have impacted on children's development and well-being.
The analysis reported here uses statistical techniques which allow us to assess the extent to which broader psycho-social and socio-economic factors influence both maternal mental health and child outcomes. The analysis considers whether and in what ways maternal mental health may affect a child and, in particular, whether brief or repeated exposure to an emotionally compromised mother might have differential impacts on child development and sociability. Finally, we consider the implications of the findings, on the one hand, to identify and support mothers with mental health problems and, on the other hand, to ameliorate the deleterious impacts of maternal mental health problems on young children.
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