Winnicott Research Unit, Department of Psychology, The University of Reading, Reading
Centre for Family Research, Faculty of Social and Political Science, Cambridge University
Winnicott Research Unit, Department of Psychology, University of Reading, Reading, UK
Correspondence: Professor Lynne Murray, Winnicott Research Unit, Department of Psychology, University of Reading, Whiteknights, 3 Earley Gate, Reading RG6 6AL, UK
Funding detailed in Acknowledgements.
See part 1 pp.
412419, this issue.
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ABSTRACT |
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Aims To evaluate the effect of three psychological treatments on the motherchild relationship and child outcome.
Method Women with post-partum depression (n=193) were assigned randomly to routine primary care, non-directive counselling, cognitivebehavioural therapy or psychodynamic therapy. The women and their children were assessed at 4.5, 18 and 60 months post-partum.
Results Indications of a positive benefit were limited. All three treatments had a significant benefit on maternal reports of early difficulties in relationships with the infants; counselling gave better infant emotional and behaviour ratings at 18 months and more sensitive early motherinfant interactions. The treatments had no significant impact on maternal management of early infant behaviour problems, security of infantmother attachment, infant cognitive development or any child outcome at 5 years.
Conclusions Early intervention was of short-term benefit to the motherchild relationship and infant behaviour problems. More-prolonged intervention may be needed. Health visitors could deliver this.
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INTRODUCTION |
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METHOD |
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Assessments
Assessments were made before treatment, immediately after treatment (i.e.
at 4.5 months post-partum) and at 18 months and 5 years post-partum by trained
assessors unaware of the treatment group to which the women had been assigned.
In addition to the assessment of maternal mood outlined in Cooper et
al (2003, this issue),
several assessments were made of the motherinfant relationship and of
the dimensions of child developmental progress.
Post-treatment outcomes
Four-month outcomes
Early maternal management of infant behaviour, and problems in the
motherinfant relationship. A checklist was devised specifically
for this project, covering the mother's experience of managing infant
behaviour difficulties (feeding, sleeping, crying) and problems in the
mother's relationship with the infant (infant demands for attention,
separation problems, difficulties with playing and general difficulties in
relating to the infant). The mothers rated possible difficulties on a
four-point severity scale (from not at all to a great
deal) before treatment and immediately after treatment.
Motherinfant interactions. Videotapes of the mother and infant interacting in a 5-min face-to-face play session at the 8- and 18-week post-partum assessments (i.e. before treatment and at the end of treatment) were rated by an independent assessor using the global rating scales devised by Murray et al (1996a). This rating system, in common with others used to assess the quality of engagement between mothers with depression and their infants (e.g. Tronick et al, 1980; Cohn et al, 1986; Field et al, 1990) includes micro-analytical assessment of maternal responsiveness to the infant's cues. The principal dimension assessed is that of general sensitivity (including consideration of maternal warmth, acceptance and responsiveness), a measure found to discriminate between women with and without depression in community samples in the UK (Murray et al, 1996a).
The face-to-face interactions were videotaped in the home. When the infant was in an alert and calm state, the mother sat opposite the infant and was asked to play with him or her. The video camera was positioned to film over the mother's shoulder in order to obtain a full-face image of the infant, and the mother's full-face image was filmed simultaneously, reflected in a mirror placed adjacent to the infant.
Eighteen-month outcomes
Later infant emotional and behavioural problems. At 18 months
post-partum all the women were interviewed using the Behavioural Screening
Questionnaire (BSQ; Richman & Graham,
1971), modified for use with this age group
(Murray, 1992). This measure
includes infant difficulties such as sleep disturbance, feeding problems,
separation problems and excessive temper tantrums, and it has been found to
distinguish between infants of mothers with and without depression
(Murray, 1992).
Infant attachment. Infant attachment to the mother was assessed at 18 months in the research unit using the Ainsworth Strange Situation Procedure (Ainsworth et al, 1978). Trained independent assessors made ratings using the ABCD system.
Infant cognitive development. Infant cognitive development was assessed at 18 months in the research unit using the Mental Development Index of the Bayley Scales of Infant Development (Bayley, 1969).
Five-year outcomes
Child emotional and behavioural problems
Child cognitive development. The McCarthy Scales of Children's Abilities (McCarthy, 1972), a general measure of children's cognitive development, were administered in the research unit.
Data analysis
Initially, the effect of treatment on outcome was assessed. Generalised
linear models were used to analyse the individual measures of the
motherchild relationship and child outcome that were dichotomous or
normally distributed, controlling for pre-treatment measures of the outcome
variable where appropriate. The outcome measures that had distributions that
were positively skewed were analysed using KruskalWallis one-way
analysis by ranks, and the median differences between the controls and each of
the treated groups were calculated using the HodgesLehmann estimator.
Further models were fitted to explore the effect of treatment after
controlling for social adversity (which was possibly unbalanced between the
treatment groups, as well as being thought to be related to outcome) and other
potentially relevant baseline covariates: conflict concerning motherhood,
maternal age (under age 25 years defined as young) and education (up to
O level or GCSE defined as low), the gender of the child and,
for assessments at 4.5 months, the baseline Edinburgh Postnatal Depression
Scale (EPDS; Cox et al,
1987) score. Interactions between baseline covariates and
treatments also were considered. Covariates and their interactions were
retained in the model if they reached a significance of P<0.05.
Linear regression was used to analyse maternal sensitivity, which was assumed
to be normally distributed. The binary variables created for the measures of
emotional and behavioural development, early problems in the
motherinfant relationship and infant attachment were analysed using
logistic regression. The adjusted odds ratios from the logistic regression
models were converted to approximate relative risks using the method of Zhang
& Yu (1998), because the
rates of depression were common (i.e. >10%;
Davies et al, 1998).
The positively skewed distributions of the BSQ, Bayley, Rutter A2,
PBCL and McCarthy scales were assumed to follow a gamma distribution.
A subgroup analysis for those women who had received therapy was conducted to investigate the effect of receiving treatment from a specialist as opposed to a non-specialist therapist.
All statistical analyses were performed using the SAS program package (version 8.02, SAS Institute, Cary, NC).
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RESULTS |
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Early problems in the motherinfant relationship. Before therapy, the percentage of women reporting moderate or marked relationship problems (60-74%) was higher than the percentage reporting behavioural difficulties (see Table 1). After therapy, the percentage of women who were still experiencing relationship difficulties varied between the groups, with far fewer women in the control group reporting that they had resolved their relationship difficulties.
All three treatments were found to reduce significantly the risk of reporting a moderate or marked relationship problem, after the effect of reported pre-treatment relationship problems had been controlled for (see Table 2). The decreased risk associated with treatment remained after social adversity had been controlled for.
Motherinfant interactions
Motherinfant face-to-face interactions were assessed using the
measure of maternal sensitivity at 2 and 4.5 months post-partum. From
Fig. 1, it can be seen that for
all groups the levels of maternal sensitivity increased to a comparable
extent. In a regression analysis, the three treatments were found to be
comparable with the control condition after the level of maternal sensitivity
at 2 months had been controlled for. A secondary analysis that included the
main effects of treatment and level of social adversity, along with their
interaction (see Table 3),
revealed that for women with low levels of social adversity those in the
control condition had higher levels of sensitivity than women in the CBT or
psychodynamic therapy groups. The effects were estimated as -0.46 for CBT (95%
CI -0.76 to -0.15; 2=8.56; d.f.=1; P=0.003) and -0.39
for psychodynamic therapy (95% CI -0.68 to -0.11;
2=7.26;
d.f.=1; P=0.007). No significant difference was found between the
control condition and non-directive counselling (-0.23, 95% CI -0.53 to 0.07;
2=2.21; d.f.=1; P=0.14). For women with high social
adversity, those who received non-directive counselling were found to have
higher levels of maternal sensitivity than the women in the control condition
(0.46; 95% CI -0.03 to 0.89;
2=4.36; d.f.=1; P=0.04).
There were found to be no treatment effects for CBT (0.07; 95% CI -0.78 to
0.23;
2=1.14; d.f.=1; P=0.29) or psychodynamic
therapy (0.09; 95% CI -0.25 to 0.95;
2=1.33; d.f.=1;
P=0.25).
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Eighteen-month outcomes
Later infant emotional and behavioural problems
At 18 months post-partum the BSQ was administered to the mothers as an
interview. The BSQ scores showed an indication of the difference between the
groups (KruskalWallis=9.04; d.f.=3; P=0.03). The median
differences show that the infants of control mothers tended to score higher
than those of mothers in any of the three treatments (see
Table 4). A generalised linear
model was fitted, which assumed that the BSQ scores followed a gamma
distribution. Compared with the control group, after controlling for social
adversity and the significant effect of maternal age, the effect of treatment
was significant for non-directive counselling (2=12.19;
d.f.=1; P=0.001), with the psychodynamic therapy and CBT conditions
also showing some indication of an improvement compared with the control
condition (
2=4.06, d.f.=1, P=0.03 and
2=3.52, d.f.=1, P=0.06, respectively). Younger women
(under 25 years) reported more problematic behaviour in their infants than did
older women (
2=3.84; d.f.=1; P=0.05). For younger
women, the increased BSQ expected scores were estimated to be: 4.5 (95% CI
3.4-6.3) for non-directive counselling, 5.7 (95% CI 4.4-7.9) for psychodynamic
therapy, 6.1 (95% CI 4.7-8.4) for CBT and 8.3 (95% CI 6.2-12.2) for controls.
For women aged 25 years and over, the expected BSQ scores were estimated to be
3.7 for the non-directive counselling group (95% CI 3.0-4.7), 4.6 for the
psychodynamic therapy group (95% CI 3.8-5.8), 4.9 for the CBT group (95% CI
4.0-6.1) and 6.3 for the control group (95% CI 5.1-8.0).
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Infant attachment
The rates of secure (B) and insecure (A, C and D) attachment were similar
for all four groups and no significant differences were found between the
treated groups and the control condition (see
Table 2). After controlling for
social adversity, the treatment effects remained insignificant.
Cognitive development
At 18 months post-partum, scores on the measure of child cognitive
development, the Mental Development Index of the Bayley Scales (see
Table 4), were similar for the
four groups (KruskalWallis=0.78; d.f.=3; P=0.85). A
generalised linear model, which assumed that the scores followed a gamma
distribution, revealed there to be no significant treatment effects after
controlling for social adversity and the significant adverse effects of young
maternal age (2=6.13; d.f.=1; P=0.01), low maternal
education (
2=7.67; d.f.=1; P=0.006) and male gender
(
2=7.73; d.f.=1; P=0.005).
Five-year outcomes
Emotional and behavioural difficulties
At 5 years, child emotional and behavioural difficulties were assessed
using maternal reports on the Rutter A2 Scale and teacher reports
on the PBCL. The distribution of the Rutter A2 Scale scores was
found not to differ between the four groups (KruskalWallis=7.19;
d.f.=3; P=0.07). However, there was some evidence from the median
differences (see Table 4) that
infants whose mothers had received CBT had lower scores compared with the
infants of control mothers. A generalised linear model was fitted that assumed
that the Rutter A2 Scale scores followed a gamma distribution.
After controlling for the significant adverse effect of social adversity
(2=9.55; d.f.=1; P=0.002), only an indication of a
CBT treatment effect was found (
2=3.61; d.f.=1;
P=0.06). For women who did not experience a high level of social
adversity, the mean Rutter A2 Scale scores were estimated to be 7.7
for the CBT group (95% CI 6.5-9.4), 9.5 for the non-directive counselling
group (95% CI 8.0-11.6), 9.8 for the control group (95% CI 8.2-12.0) and 11.2
for the psychodynamic therapy group (95% CI 9.4-13.8). For women who had a
high level of social adversity, the Rutter A2 Scale scores were
estimated to be 10.2 for the CBT group (95% CI 7.8-14.4), 13.4 for the
non-directive counselling group (95% CI 10.7-17.7), 13.9 for the controls (95%
CI 11.1-18.6) and 16.8 for the psychodynamic therapy group (95% CI
12.1-26.5).
The distribution of scores on the teacher reports of child behavioural difficulties (PBCL), treated as a continuous measure (see Table 4), did not differ between the four groups (KruskalWallis=0.10; d.f.=3; P=0.99). A generalised linear model, which assumed that the scores followed a gamma distribution, revealed there to be no significant treatment effects after controlling for the level of social adversity.
Cognitive development
At 5 years post-partum, scores on the measure of child cognitive
development, the General Cognitive Index of the McCarthy Scales (see
Table 4), similarly failed to
differ between the four groups (KruskalWallis=0.55; d.f.=3;
P=0.91). A generalised linear model, which assumed that the scores
followed a gamma distribution, showed no significant treatment effects after
controlling for social adversity and the adverse effects of antenatal
motherhood issues (2=3.60; d.f.=1; P=0.06) and a low
level of maternal education (
2=8.61; d.f.=1;
P=0.003).
Specialist therapist effects
After controlling for pre-treatment measures, at 4 months there were found
to be no specialist therapist effects for behavioural problems (relative
risk=1.34; P=0.24; 95% CI 0.80-1.91), relationship problems (relative
risk=1.23; P=0.36; 95% CI 0.76-1.68) or maternal sensitivity
(specialist effect=-0.18; P=0.15; 95% CI-0.42 to 0.07).
At 18 months, specialists and non-specialists were found not to differ for BSQ score (median difference=0; P=0.82; 95% CI -1 to 1) or attachment (relative risk=0.97; P=0.90; 95% CI 0.61-1.36). Infants of mothers receiving treatment by specialists were found to have higher Bayley scores (median difference=14, P=0.0001; 95% CI 7-21).
At 5 years, no specialist effect was found for Rutter A2 (median difference=-1; P=0.18; 95% CI -3 to 1) or PBCL scores (median difference=0; P=0.92; 95% CI -1 to 2). Children of mothers receiving treatment by specialists were found to have higher McCarthy scores (median difference=10; P=0.002; 95% CI 4-15).
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DISCUSSION |
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Different treatment approaches
Clinical practice that deals specifically with the motherinfant
relationship has developed into two distinct lines of work: (a)
cognitivebehavioural approaches with an emphasis on here and
now observed behaviour and difficulties, at times combined with a
problem-solving approach, aim to promote maternal feelings of competence in
infant caretaking as well as to improve maternal sensitivity and the quality
of motherinfant interactions, for example, through modelling or
positive feedback (Gelfand et al,
1996; Field,
1997); and (b) psychodynamic approaches focus on the
motherinfant relationship in terms of the mother's past history of
relationships as the source of current problems (e.g.
Fraiberg, 1981;
Cramer et al, 1990).
Theoretically, the mother's history of relationships is particularly relevant
to the infant's developing attachment to the mother because it deals with the
mother's representation of her own early attachment relationships
itself a strong predictor of infant attachment quality
(van Izendoorn et al,
1995; Steele et al,
1996). Nevertheless, in studies aimed at preventing the
development of insecure attachments, the modest positive results that have
been achieved have come from short-term behaviourally focused treatments
rather than from more intensive, long-term therapies working at the level of
maternal representations (van Ijzendoorn et al, 1995). This is
important because establishing whether different treatments are differentially
effective not only is theoretically interesting but also has significant
practical implications in terms of the skills, and therefore personnel and
National Health Service resources, required to deliver the intervention. Any
treatment that demands a high level of training in psychotherapy, and
particularly psychodynamic work, will be limited in its availability. However,
important practical implications would follow if it were shown that treatments
deliverable by health visitors, found to be effective in bringing about early
remission from depression (e.g. counselling), were also of benefit in terms of
the motherinfant relationship and child development.
The current study
The current study addressed these questions by evaluating the impact of
three brief psychological treatments, delivered in the home from 8 to 18 weeks
post-partum, to a representative community sample of primiparous mothers with
postnatal depresion. The study therapists included health visitors who
received training in the CBT and counselling treatments, as well as specialist
professional therapists representing each of the three treatment approaches.
Assessments were made of the child's behavioural, emotional and cognitive
development through infancy and at 5 years. The three study treatments
non-directive counselling, CBT and psychodynamic therapy were found to
bring about an early improvement in the EPDS measure of maternal mood (see
Cooper et al, 2003,
this issue).
Findings of the current study
Positive findings
Treatment showed some short-term benefits in relation to the
motherchild relationship and child outcome. First, at 4.5 months,
compared with those who received routine primary care, mothers who received
any of the interventions reported significantly fewer difficulties in their
relationship with their infant, experiencing play, separation issues and the
management of the infant's needs for their attention as being less
problematic. In addition, in mothers who experienced social adversity, whose
interactions with their infants were particularly poor, non-directive
counselling produced a more sensitive pattern of motherinfant
interactions than was apparent among those in the control group. There was
evidence also of a positive benefit of non-directive counselling at 18 months
in terms of maternal reports of infant emotional and behavioural problems, and
some indication also of a possible benefit for the other two treatments.
It is worth noting that the outcomes that showed the clearest evidence for a beneficial effect of treatment (i.e. relationship problems at 4.5 months and emotional and behavioural problems at 18 months) were those that relied on maternal reports.
Negative findings
The majority of outcomes failed to show any benefit of the study
interventions. The first concerned the mother's experience, immediately after
treatment, of difficulties in the practical management of her infant
(sleeping, feeding and crying problems), where there was a similar level of
improvement over time for both the control and the treated groups. There are a
number of possible explanations for this lack of treatment effect. First, it
is possible that any initial problems the mothers experienced with their
infants resolved spontaneously over time. This is particularly likely to be
the case with crying problems. The peak age for persistent crying in UK
populations is between 3 and 6 weeks, with a steady decline in the amount of
time that infants cry thereafter (St
James-Roberts & Plewis, 1996). By 4.5 months, when the first
post-treatment assessment was made, it is likely that infant crying would have
shown a significant spontaneous decline. Initial feeding problems also are
likely to have settled down by this time. An alternative explanation is that
the routine care provided by health visitors was effective in these particular
areas of infant behaviour. The principal focus of routine health visiting is
advice on the practical difficulties that women experience in the management
of such infant problems, and it may be that in these particular respects the
study interventions offered no significant advantage over routine health
visitor practice.
With regard to infant attachment also there was no benefit of any of the treatments compared with the control condition. Influencing the nature of child attachment to the mother has generally proved difficult to achieve, even in samples without depression. A meta-analysis by van Ijzendoorn et al (1995) showed the overall effect size for 12 treatment studies to be only 0.17; and a subsequent study by Gelfand et al (1996) with a clinically referred depression sample showed that treatment conferred no benefit in terms of overall rates of child security of attachment. The fact that the current treatments were brief and delivered early on in development, before the setting up of clear attachment responses, may have made the promotion of security particularly difficult to achieve.
Finally, with regard to infant and child cognitive development and child emotional and behavioural adjustment at both home and school at 5 years, no significant benefit of any of the treatments was evident. The apparently negative finding regarding cognitive development should, possibly, be viewed with caution. Reports of significant adverse effects of postnatal depression on cognitive development have been derived generally from high-risk samples (e.g. Lyons-Ruth et al, 1986; Hay et al, 2001). In the current study sample, drawn from a relatively low-risk population, the children's IQ scores at 18 months and 5 years among both controls and treated groups were within the range expected for a general population sample, and thus it can be argued that the issue of treatment preventing cognitive deficits did not obtain. This same argument cannot be made in relation to child emotional and behavioural adjustment: in this domain, adverse outcome in terms of increased rates of both internalising and externalising problems have been found to be associated with postnatal depression in low-risk as well as high-risk samples (Sinclair & Murray, 1998; Murray et al, 1999; Essex et al, 2001). It appears, therefore, that although the intervention may have been of some benefit to the early motherinfant relationship and to the emotional and behavioural adjustment of the infant at 18 months, this benefit did not persist.
The question of whether treatment delivered by specialist therapists would be of greater benefit than that provided by non-specialists (including trained health visitors) was addressed in the current study. For none of the outcomes showing a significant benefit of treatment was there a difference between specialists and non-specialists. With regard to the other outcomes, an expertise effect was apparent only for cognitive performance (Bayley and McCarthy scales). The case for an overall benefit of specialist therapists is therefore not substantial.
Clinical implications
The fact that only limited, short-term benefits to the motherinfant
relationships and child development accrued from the interventions suggests
that, despite symptomatic improvement and initial gains in maternal care,
underlying maternal vulnerabilities persisted. In order to prevent longer-term
difficulties in child functioning, therefore, more-prolonged interventions may
be required. Nevertheless, such treatment may not require high-level
psychological expertise. Thus, we found no substantial evidence that
specialist therapists were more effective than non-specialists; and although
the study was not designed to compare the three interventions with each other,
the clearest evidence to emerge for a benefit of treatment compared with
routine care was for the counselling condition. On both these counts, as well
as for reasons of availability and cost, health visitors appear to be
well-placed to deliver such support.
Two further clinical implications of the current study should be noted. First, although the treatments were, in general, highly acceptable to the women concerned, a minority of mothers were reluctant to receive the home visiting support. Inspection of the outcomes and background characteristics of those refusing such interventions indicates that this population may be particularly at risk (Murray et al, 2003). Related research suggests that forging positive relationships with those who may be distrustful of established professional services is a key therapeutic challenge that may be resolved ultimately only through the use of non-statutory volunteer or community support routes (Egeland & Erickson, 1990; Harris et al, 2000). Second, any intervention that is delivered only when women have already become depressed falls short of ideal practice. To date, studies aiming to prevent depression have, by and large, been unsuccessful, not least because take-up rates by vulnerable women have been poor (Stamp et al, 1995; Buist et al, 1999; Brugha et al, 2000; Elliott et al, 2000). The development and evaluation of preventive interventions therefore represents a further major challenge for researchers engaged in this clinical area.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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Received for publication March 21, 2002. Revision received November 5, 2002. Accepted for publication December 3, 2002.
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