Childhood maltreatment exposure is differentially associated with transdiagnostic perinatal depression symptoms

History of childhood maltreatment (CM) is common and robustly associated with prenatal and postpartum (perinatal) depression. Given perinatal depression symptom heterogeneity, a transdiagnostic approach to measurement could enhance understanding of patterns between CM and perinatal depression.

METHODS

In two independently collected samples of women receiving care at perinatal psychiatry clinics (n = 523 and n = 134), we categorized longitudinal symptoms of perinatal depression, anxiety, stress, and sleep into transdiagnostic factors derived from the Research Domain Criteria and depression literatures. We split the perinatal period into four time points. We conducted a latent profile analysis of transdiagnostic factors in each period. We then used self-reported history of CM (total exposure and subtypes of abuse and neglect) to predict class membership.

RESULTS

A three-class solution best fit our data. In relation to positive adaptive functioning, one class had relatively more positive symptoms (high adaptive), one class had average values (middle adaptive), and one class had fewer adaptive symptoms (low adaptive). More total CM and specific subtypes associated with threat/abuse increased an individual's likelihood of being in the Low Adaptive class in both samples (ORs: 0.90-0.97, p < .05).

LIMITATIONS

Generalizability of our results was curtailed by 1) limited racial/ethnic diversity and 2) missing data.

CONCLUSIONS

Our results support taking a person-centered approach to characterize the relationship between perinatal depression and childhood maltreatment. Given evidence that increased exposure to childhood maltreatment is associated with worse overall symptoms, providers should consider incorporating preventative, transdiagnostic interventions for perinatal distress in individuals with a history of childhood maltreatment.

Satisfaction with parental responsibilities and disorganized attachment among infants of mothers at risk for depression

Growing attention has been placed on examining the family environment as antecedent of attachment, including the coparenting relationship. Parents' satisfaction with the coparenting relationship may be particularly of interest when parents are at heightened risk for depression, as depression has been consistently linked to negative coparenting, poor quality of parenting, and insecure infant attachment. However, no study has examined the effects of parents' satisfaction with the coparenting relationship on attachment. The present study examined mothers' satisfaction with division of childrearing responsibilities, a component of coparenting, and its longitudinal and cross-sectional links with infant disorganized attachment, examining the quality of mothering as a mediator, in a sample of infants and mothers at elevated risk for depression (N = 234). We assessed maternal depressive symptoms at 3, 6, and 12 months of infant age, mothers' satisfaction with the division of parental responsibilities at 3 and 12 months, the quality of mothering at 6 and 12 months, and infant disorganized attachment at 12 months. Mediation analyses revealed that at 12 months, mothers who were unsatisfied with fathers' childrearing responsibilities had poorer quality of mothering, which in turn was linked to disorganized attachment in their infants. However, the longitudinal indirect association between satisfaction with childrearing responsibilities at 3 months and disorganization at 12 months mediated by maternal parenting at 6 months was not significant. Findings emphasize the importance of partner support in childrearing for mothers at risk for depression in shaping a healthy relationship between mothers and their infants, particularly as infants get older. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Associations between mothers' and fathers' depression and anxiety prior to birth and infant temperament trajectories over the first year of life: Evidence from diagnoses and symptom severity

BACKGROUND

Developmental shifts in infant temperament predict distal outcomes including emerging symptoms of psychopathology in childhood. Thus, it is critical to gain insight into factors that shape these developmental shifts. Although parental depression and anxiety represent strong predictors of infant temperament in cross-sectional research, few studies have examined how these factors influence temperament trajectories across infancy.

METHODS

We used latent growth curve modeling to examine whether mothers' and fathers' anxiety and depression, measured in two ways - as diagnostic status and symptom severity - serve as unique predictors of developmental shifts in infant temperament from 3 to 12 months. Participants included mothers (N = 234) and a subset of fathers (N = 142). Prior to or during pregnancy, both parents were assessed for lifetime diagnoses of depression and anxiety as well as current severity levels. Mothers rated their infants' temperament at 3, 6, and 12 months of age.

RESULTS

Mothers' depression and anxiety primarily predicted initial levels of temperament at 3 months. Controlling for mothers' symptoms, fathers' depression and anxiety largely related to temperament trajectories across infancy. Lifetime diagnoses and symptom severities were associated with distinct patterns.

LIMITATIONS

Infant temperament was assessed using a parent-report measure. Including an observational measure would provide a more comprehensive picture of the infants' functioning.

CONCLUSIONS

These results indicate that mothers' and fathers' mental health are uniquely associated with infant temperament development when measured using diagnostic status and/or symptom severity. Future studies should examine whether these temperament trajectories mediate intergenerational transmission of risk for depression and anxiety.

Associations Between Direct and Indirect Forms of Racism Exposure and Stress-Induced Inflammatory Response and Health in Pregnancy

Theory and research suggest chronic direct and indirect exposures to racism impact health, and stress-responsive inflammation may play a role in these paths. This study examines links between forms of racism-related stress, salivary markers of inflammation during acute psychosocial stress, and perinatal mental and physical health in a racially heterogenous sample. Pregnant people (n = 108, 27% non-white) self-reported personal and vicarious exposure to racism (racial microaggressions, online racism, overt racial/ethnic discrimination) and racial collective self-esteem, as well as affective symptoms and general physical health. Five saliva samples collected before and after the Trier Social Stress Test were assayed for pro-inflammatory cytokines and C-reactive protein. Results revealed associations between racism-related stress and greater inflammatory reactivity/delayed recovery to acute stress, between racial collective self-esteem and lower levels of inflammation, and between profiles of inflammatory responses to stress and mental and physical symptoms. We discuss implications for understanding perinatal health disparities.

Positive affect improves a transdiagnostic model of perinatal depression symptoms

INTRODUCTION

Accurate measurement of perinatal depression is vital. We aimed to 1) test whether a factor that measured positive affect (PA) bettered a transdiagnostic model of depression symptoms and 2) replicate the model in a second sample.

METHODS

We conducted secondary analyses from two samples (n's = 657 and 142) of women in treatment at perinatal psychiatric clinics. Data were derived from items from seven commonly used measures. We compared fit indices from our original factor model-one general and six specific factors derived from the Research Domain Criteria (Loss, Potential Threat, Frustrative Nonreward, and Sleep-Wakefulness) and depression literatures (Somatic and Coping)-to our novel factor model with a PA factor. The PA factor was created by recategorizing items that measured affective states with a positive valence into a new factor. Sample 1 data were split into six perinatal periods.

RESULTS

In both samples, the addition of a PA factor improved model fit. At least partial metric invariance was found between perinatal periods, with the exception of trimester 3 - postpartum period 1.

LIMITATIONS

Our measures did not operationalize PA in the same way as in the positive valence system in RDoC and we were unable to perform longitudinal analyses on our cross-validation sample.

CONCLUSIONS

Clinicians and researchers are encouraged to consider these findings as a template for understanding symptoms of depression in perinatal patients, which can be used to guide treatment planning and the development of more effective screening, prevention, and intervention tools to prevent deleterious outcomes.

Unique Characteristics of Women and Infants Moderate the Association between Depression and Mother-Infant Interaction

Research has shown mixed results regarding the association between women's postpartum depression and mother-infant interactions, suggesting that a woman's unique experience and context may moderate how depression shapes these interactions. We examined the extent to which a woman's comorbid anxiety, her exposure to adversity, and infant characteristics moderate the relationship between depressive symptoms of women and interactions with their infants at 6 (n = 647) and 12 months (n = 346) postpartum. The methods included standardized coding of mother-infant interactions and structural regression modeling. The results at 6 months of infant age indicated that infant male sex and infant negative affectivity were risk factors for mothers' depression being associated with less optimal interactions. At 12 months of infant age, two moderators appeared to buffer the influence of depression: a woman's history of trauma and infant preterm birth (≤37 weeks gestation). The results reinforce the salience of infant characteristics in the relationship between maternal depression and mother-infant interactions. The findings also suggest that experiences of trauma may offer opportunities for psychological growth that foster constructive management of depression's potential effect on mother-infant interactions. Further research is needed to clarify the underlying processes and mechanisms that explain the influence of these moderators. The ultimate goals are to reduce the risk of suboptimal interactions and reinforce healthy dyadic relations.

A positive parenting program to enhance positive affect in children of previously depressed mothers

Children of mothers with a history of depression are at heightened risk for developing depression and other maladaptive outcomes. Deficits in parenting are one putative mechanism underlying this transmission of risk from mother to child. The present study evaluated whether a brief intervention with mothers with a history of depression produced greater use of positive parenting behaviors and an increase in observed positive affect in their 8- to 10-year-old children. Mothers with a history of depression (n = 65) were randomly assigned to either a positive parenting intervention or an attention control intervention condition. In addition, a comparison group of 66 mothers with no history of depression was evaluated one time. Results revealed significant increases in positive parenting behaviors (e.g., active listening, praise) immediately postintervention in mothers randomized to the positive parenting intervention as compared to those in the attention control condition. Children of mothers in the positive parenting intervention showed increases in positive affect as compared to children of mothers in the attention control intervention. Increases in mothers' active listening and smiling/laughing significantly predicted increases in children's positive affect. The intervention did not increase the rate of children's moment-by-moment positive affect contingent on mothers' positive parenting behaviors. This study showed the short-term effectiveness of a brief parenting intervention for enhancing interactions between mothers with a history of depression and their children by directly targeting mothers' positive parenting and, indirectly, children's expressions of positive affect. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Using machine learning to understand age and gender classification based on infant temperament

Age and gender differences are prominent in the temperament literature, with the former particularly salient in infancy and the latter noted as early as the first year of life. This study represents a meta-analysis utilizing Infant Behavior Questionnaire-Revised (IBQ-R) data collected across multiple laboratories (N = 4438) to overcome limitations of smaller samples in elucidating links among temperament, age, and gender in early childhood. Algorithmic modeling techniques were leveraged to discern the extent to which the 14 IBQ-R subscale scores accurately classified participating children as boys (n = 2,298) and girls (n = 2,093), and into three age groups: youngest (< 24 weeks; n = 1,102), mid-range (24 to 48 weeks; n = 2,557), and oldest (> 48 weeks; n = 779). Additionally, simultaneous classification into age and gender categories was performed, providing an opportunity to consider the extent to which gender differences in temperament are informed by infant age. Results indicated that overall age group classification was more accurate than child gender models, suggesting that age-related changes are more salient than gender differences in early childhood with respect to temperament attributes. However, gender-based classification was superior in the oldest age group, suggesting temperament differences between boys and girls are accentuated with development. Fear emerged as the subscale contributing to accurate classifications most notably overall. This study leads infancy research and meta-analytic investigations more broadly in a new direction as a methodological demonstration, and also provides most optimal comparative data for the IBQ-R based on the largest and most representative dataset to date.

Maternal Interaction With Infants Among Women at Elevated Risk for Postpartum Depression

Ample research links mothers’ postpartum depression (PPD) to adverse interactions with their infants. However, most studies relied on general population samples, whereas a substantial number of women are at elevated depression risk. The purpose of this study was to describe mothers’ interactions with their 6- and 12-month-old infants among women at elevated risk, although with a range of symptom severity. We also identified higher-order factors that best characterized the interactions and tested longitudinal consistency of these factors from 6 to 12 months of infant age. We leveraged data from eight projects across the United States (n = 647), using standardized depression measures and an adaptation of the NICHD Mother-Infant Interaction Scales. Overall, these depression-vulnerable mothers showed high levels of sensitivity and positive regard and low levels of intrusiveness, detachment, and negative regard with their infants. Factor analyses of maternal behaviors identified two overarching factors—“positive engagement” and “negative intrusiveness” that were comparable at 6 and 12 months of infant age. Mothers’ ability to regulate depressed mood was a key behavior that defined “positive engagement” in factor loadings. An exceptionally strong loading of intrusiveness on the second factor suggested its central importance for women at elevated depression risk. Mothers with severe depressive symptoms had significantly more “negative intrusiveness” and less “positive engagement” with their 6-month-old infants than women with moderate or fewer depressive symptoms, suggesting a potential tipping point at which symptoms may interfere with the quality of care. Results provide the foundation for further research into predictors and moderators of women’s interactions with their infant among women at elevated risk for PPD. They also indicate a need for evidence-based interventions that can support more severely depressed women in providing optimal care.

A Review of Associations between Externalizing Behaviors and Prenatal Cannabis Exposure: Limitations & Future Directions

In utero cannabis exposure can disrupt fetal development and increase risk for various behavioral disruptions, including hyperactivity, inattention, delinquent behaviors, and later substance abuse, among others. This review summarizes the findings from contemporary investigations linking prenatal cannabis exposure to the development of psychopathology and identifies the limitations within the literature, which constrain our interpretations and generalizability. These limitations include a lack of genetic/familial control for confounding and limited data examining real world products, the full range of cannabinoids, and motives for use specifically in pregnant women. Taken together, our review reveals the need to continue to improve upon study designs in order to allow researchers to accurately draw conclusions about the development of behavioral consequences of prenatal cannabis exposure. Findings from such studies would inform policy and practices regarding cannabis use during pregnancy and move the field toward developing a comprehensive teratogenic profile of cannabis similar to what is characterized in the prenatal alcohol and tobacco literature.

Prenatal origins of temperament: Fetal cardiac development & infant surgency, negative affectivity, and regulation/orienting

Temperament, i.e. individual differences in reactivity and self-regulation, emerges early in infancy; might temperament originate during fetal development? Mixed findings and methodological issues in the literature examining this consideration limit our understanding of the continuity between these fetal indices and infant temperament. The primary aims of the current study were to improve on published studies by (a) using standardized and well-accepted fetal cardiac (actocardiograph) and infant temperament measures (the Infant Behavior Questionnaire-Revised; IBQ-R) (b) expanding fetal assessments to include coupling (the cross correlation of heart rate with movement), and (c) examining a diverse sample to determine if findings of associations between fetal neurobehavior and infant temperament generalize beyond cohorts that are demographically well-resourced and predominantly white. Building on theory and empirical findings, we hypothesized that (1) FHR would be positively associated with Surgency and Negative Affectivity, (2) FHRV would be positively associated with Surgency, and Regulation/Orienting and inversely associated with Negative Affectivity, and (3) fetal coupling would be positively associated with Regulation/Orienting and Surgency and inversely associated with Negative Affectivity. We collected 20 min of fetal data (m gestational age = 34.42 weeks) and mothers completed the IBQ-R (n = 90 women; 60 % non-Caucasian race; 63 % Latina ethnicity). We found that FHR was positively associated with Negative Affectivity but not associated with Surgency (or Regulation/Orienting). FHRV was inversely associated with Surgency but not associated with Negative Affectivity or Regulation/Orienting. Coupling was positively associated with Regulation/Orienting and Surgency but not associated with Negative Affectivity. Our findings, from a more diverse sample and with established measures, provide further evidence that individual differences in reactivity and regulation can be identified in the in-utero period and show theory-based continuity to specific infant temperament constructs.

The Journal of Psychopathology and Clinical Science is the future of the Journal of Abnormal Psychology: An editorial

This editorial describes the rationale behind changing this journal's title beginning in 2022. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Depression in mothers and the externalizing and internalizing behavior of children: An attempt to go beyond association

Hundreds of studies have documented an association between depression in mothers and behavior problems in children. Theory and empirical findings suggest this association may be confounded by other factors, but little attention has been paid to this issue. We used propensity score methods in a sample of 731 low-income families assessed repeatedly from child age 2 through 14 years to produce a weighted sample of families that were similar at child age 3 years except for mothers' depression. Depressive symptomatology was measured via self-report rating scale. Mothers were categorized as having clinically-elevated versus non-clinically-elevated scores based on an established threshold. Mothers with elevated versus nonelevated scores were equated on 89 other relevant characteristics (e.g., SES, child behavior, marital conflict). We then compared the equated groups on mother, secondary caregiver, and teacher ratings of child externalizing and internalizing behavior from child ages 4 to 14 years. Prior to equating, the mean prima facie effect of exposure to clinically-elevated mothers' depression scores at child age 3 years was d = 0.45 per mothers, d = 0.26 per secondary caregivers, and d = 0.13 per teachers. After equating, the mean adjusted effect was d = 0.07 per mothers, d = 0.01 per secondary caregivers, and d = 0.03 per teachers. Findings suggest that a substantial portion of the prima facie association between mothers' depression and later child behavior problems is accounted for by confounding variables rather than a causal effect of depressive symptoms per se. To fully understand why children of depressed mothers exhibit more behavior problems, a multicausal theory is needed that jointly considers the cluster of co-occurring clinical features that often accompany maternal depression. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Consistency of EEG asymmetry patterns in infants of depressed mothers

We evaluated frontal electroencephalogram (EEG) asymmetry across multiple contexts as an index of a general affective response predisposition in 12-month-old infants whose mothers were at elevated risk for perinatal depression due to their mother's history of depression. We further examined mothers' prenatal, postnatal, and concurrent depressive symptom levels in relation to infants' frontal EEG asymmetry consistency. Mothers (n = 132) with a history of depression prior to pregnancy completed depressive symptom scales repeatedly during pregnancy and the first year postpartum. Their 12-month-old infants' frontal EEG asymmetry was recorded across five contexts (baseline/bubbles, peek-a-boo, play, feeding, and distract). Frontal EEG asymmetries showed small to moderate correlations across contexts. Mothers' prenatal depression symptom levels (not postnatal or concurrent) were associated with infants having consistent right, rather than left, frontal EEG asymmetry, even after controlling for infants' observed affect. These findings demonstrate the consistency of EEG asymmetry scores across contexts in 12-month-old infants at risk for the development of psychopathology, providing support for relative right frontal EEG asymmetry as a trait marker of vulnerability to depression. Findings also suggest the importance of mothers' prenatal, rather than postnatal or concurrent depression, in predicting infants' consistent patterns of relative right frontal EEG asymmetry across contexts.

A transdiagnostic approach to conceptualizing depression across the perinatal period in a high-risk sample

Clinical guidelines recommend assessing depression during pregnancy and postpartum but often overlook potential changes in symptoms across this developmental period. Such changes contribute to difficulties in conceptualizing maternal depression. This study aimed to situate depressive symptoms and related concerns (anxiety, stress, sleep) across the perinatal period within a transdiagnostic framework and to use this framework to better understand how depressive symptoms change across the perinatal period. First, items from seven symptom scales were a priori categorized into six transdiagnostic factors: four based on Research Domain Criteria (loss, potential threat, frustrative nonreward, and sleep-wakefulness) and two based on the depression literature (somatic and coping symptoms). Second, using prospective data from women with a history of an affective disorder (n = 657) in an observational study of neuropsychiatric illness, factor analyses were performed in seven periods (three trimesters of pregnancy and four quarters of first year postpartum). For each period, a bifactor model with six transdiagnostic factors and a general factor fit data better than models that combined or dropped a factor (p < .003). Except around delivery, item loadings and intercepts could be fixed between consecutive periods and still adequately fit data from both periods. Means of sleep-wakefulness and somatic factors increased significantly from second to third trimester (p < .01), with trends reversing early postpartum. In conclusion, depressive symptoms and related concerns exhibit factor structures that are only partly congruent across the perinatal period. This conclusion suggests that greater attention to specific life phases is warranted in the conceptualization of depression during this time in women's lives. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Correction to: Parenting as a Mediator of Associations between Depression in Mothers and Children's Functioning: A Systematic Review and Meta-Analysis

The original version of the article requires a correction to one of the sentences. Under the section 'Limitations', the last sentence 'Findings of no support for mediation was also deemed important as, for example, our findings suggest..' should read as below. Also important were where we found no support for moderation of the mediation model; for example, our findings suggest that parenting as a mediator of associations between depression and child functioning is concerning regardless of the ages of the children, for both sons and daughters, and for a broad range of aspects of children's functioning.

The Future of Women in Psychological Science

There has been extensive discussion about gender gaps in representation and career advancement in the sciences. However, psychological science itself has yet to be the focus of discussion or systematic review, despite our field's investment in questions of equity, status, well-being, gender bias, and gender disparities. In the present article, we consider 10 topics relevant for women's career advancement in psychological science. We focus on issues that have been the subject of empirical study, discuss relevant evidence within and outside of psychological science, and draw on established psychological theory and social-science research to begin to chart a path forward. We hope that better understanding of these issues within the field will shed light on areas of existing gender gaps in the discipline and areas where positive change has happened, and spark conversation within our field about how to create lasting change to mitigate remaining gender differences in psychological science.

Protocol for a mechanistic study of mindfulness based cognitive therapy during pregnancy

OBJECTIVE

Preventive interventions for postpartum depression (PPD) are critical for women at elevated risk of PPD. Mindfulness based cognitive therapy - perinatal depression (MBCT-PD) is a preventive intervention that has been shown to reduce risk for PPD in women with a prior history of depression. The objective of this clinical trial is to examine two potential mechanisms of action of MBCT-PD, emotion regulation and cognitive control, using behavioral and neuroimaging methods.

METHOD

This baseline protocol describes a randomized control trial (RCT) with two arms, MBCT-PD and treatment as usual (TAU). We plan on enrolling 74 females with a prior history of a major depressive episode, with 37 participants randomized to each arm. Participants in the MBCT-PD arm will receive MBCT-PD during pregnancy, and the TAU group will receive standard prenatal care. All participants will complete the Center for Epidemiological Studies Depression Scale - Revised (CESD-R), Emotion Regulation Questionnaire (ERQ), and classic Stroop task at multiple points from pregnancy through six months postpartum. Participants will also complete an fMRI scan at six weeks postpartum.

RESULTS

All primary outcomes are collected at six weeks postpartum. Primary behavioral outcomes include: depressive symptoms on the CESD-R, cognitive reappraisal on the ERQ, and Stroop task performance. In parallel, the primary neurobiological outcomes include whole-brain activation during fMRI tasks when participants 1) regulate emotional responding and 2) engage cognitive control.

CONCLUSIONS

This results of this innovative RCT will help identify potential behavioral and neurobiological mechanisms of action of preventive interventions for PPD for in-depth examination in larger scale RCTs. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Intergenerational Transmission of Depression

The study of depression in mothers in relation to transmission of risk for the development of psychopathology in their children relies on solid foundations in the understanding of psychopathology, of development, and of developmental psychopathology per se. This article begins with a description of the scope of the problem, including a summary of knowledge of how mothers’ depression is associated with outcomes in children and of moderators of those associations. The sense of scope then informs a theoretical and empirical perspective on knowledge of mechanisms in those associations, with a focus on what has been learned in the past 20 years. Throughout the article, and in conclusions at the end, are suggestions for next steps in research and practice.

Studying the Intergenerational Transmission of Risk for Depression: Current Status and Future Directions

Studying offspring of depressed mothers is a promising strategy for elucidating factors that contribute to depression onset, given that these offspring are three to six times more likely to develop depression than are their low-risk peers. In this paper we briefly describe representative findings from studies of younger and older offspring of depressed mothers and identify factors that have garnered the most consistent empirical support across development. We discuss what these studies can and cannot tell us about mechanisms that might underlie the intergenerational transmission of risk for depression, regardless of the age of offspring being studied. Finally, in light of limitations of this literature, we offer recommendations for future research.

Patterns of Positivity: Positive Affect Trajectories Among Infants of Mothers with a History of Depression

This study examined positive affect (PA) trajectories over the first year of life among infants of mothers with a history of depression (N = 191) as well as predictors (i.e., maternal prenatal and postpartum depression symptoms, maternal parenting behaviors) of those trajectories. Infant PA was observed in play and feeding tasks during lab visits at 3, 6, and 12 months of age; parenting behaviors were observed at 3 months. Mothers completed questionnaires regarding their symptoms of depression throughout the prenatal period and during the first 3 months postpartum. Growth curve analyses indicated that infant PA increased across time, and this finding replicated across both the play and feeding tasks, though increases slowed over time. Neither maternal prenatal nor postpartum depression symptoms predicted infants' PA trajectories, but mothers' PA, positive parenting, and disengaged parenting were associated with infant PA during the play task. Our finding that infant PA increased over the first year postpartum suggests PA trajectories among infants of mothers with a history of depression may be indices of resilience, despite risks associated with their mothers' history of depression. Furthermore, this study highlights parenting behaviors that may be important targets of prevention and early intervention efforts to bolster infant PA.

A multimethod, multi-informant investigation of maternal validation and invalidation of female adolescents who engage in self-inflicted injury

OBJECTIVE

This study aimed to characterize parenting behaviors of mothers of adolescent daughters who engage in repetitive self-inflicted injury (SII) and to test hypothesized associations between parenting behaviors and adolescent psychopathology.

METHOD

Participants were mothers and their 14- to 18-year-old daughters (N = 51 dyads), including 24 (47%) adolescents with a history of SII and 27 (53%) with no history of SII. Dyads completed questionnaires assessing perceived maternal validation and invalidation and participated in face-to-face interactions, which were later rated for parenting behaviors.

RESULTS

The two groups did not significantly differ on validation and invalidation across all informants and methods of assessment. For the sample as a whole, adolescent perceptions of maternal parenting behaviors interacted to predict adolescent psychopathology. In particular, adolescent perceptions of high maternal invalidation in interaction with perceptions of low validation were associated with higher levels of self-reported borderline pathology and externalizing problems and mother-reported adolescent internalizing and externalizing problems.

CONCLUSIONS

We failed to find support for the hypothesized parenting deficits in mothers of female adolescents engaging in SII. Adolescent perceptions of their mothers' high levels of invalidation and low levels of validation were associated with higher levels of adolescent psychopathology. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The effect of content and tone of maternal evaluative feedback on self-cognitions and affect in young children

Feedback that young children receive from others can affect their emotions and emerging self-views. The current experiment tested the effect of negative content (criticism) and negative tone (hostile) of the feedback on children's affect, self-evaluations, and attributions. We also explored whether maternal history of depression and children's temperament moderated these relations. Participants were 152 mothers and children (48% girls) aged 4 and 5 years (M = 61.6 months, SD = 6.83). The task involved three scenarios enacted by dolls; a child doll made something (e.g., picture, house, numbers) that had a mistake (e.g., no windows on the house) and proudly showed it to the mother doll, who then gave feedback (standardized, audio recorded) to the child. Children were randomized to one of four maternal feedback conditions: negative or neutral content in either a negative or neutral tone. Negative content (criticism) produced significantly more negative affect and lower self-evaluations than neutral content. When the tone of the feedback was hostile, children of mothers who had been depressed during the children's lifetimes were significantly more likely to make internal attributions for mistakes than children of nondepressed mothers. In addition, among children with low temperamental negative affectivity, in the presence of negative tone, negative content significantly predicted more internal attributions for the errors. Findings are discussed in terms of understanding the role of evaluative feedback in children's emerging social cognitions and affect.

Couples' treatment preferences for insomnia experienced during pregnancy

INTRODUCTION

Insomnia during pregnancy is prevalent, yet little is known about preferred treatments for the disorder. The current study investigated both pregnant women's and their partners' preferences for treatment of maternal insomnia, comparing the two most empirically supported therapies: cognitive-behavioral therapy for insomnia (CBT-I) and pharmacotherapy.

METHOD

We recruited pregnant women and their partners (N = 212) from a low-risk maternity clinic in Calgary, AB, Canada. Participants read expert validated treatment descriptions of pharmacotherapy and CBT-I and indicated their preference for treatment of maternal insomnia. Participants also completed the Insomnia Severity Index and Edinburgh Postnatal Depression Scale.

RESULTS

The majority of pregnant women (72.6%) and their partners (73.6%) selected CBT-I as their preferred choice for treatment of maternal insomnia, with a high concordance between partners. Correlates of maternal treatment choice included previous use of treatment and partner preference.

DISCUSSION

Findings suggest that pregnant women and their partners prefer CBT-I to pharmacotherapy as a treatment for maternal insomnia. Partners' preference may be an important consideration for women selecting treatment for insomnia. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Course of ante- and postnatal depressive symptoms related to mothers' HPA axis regulation

Given high health costs of depression during pregnancy and the first postnatal year, it is important to understand mechanisms involved in the emergence and perpetuation of symptoms during this time. In a series of 2 studies, we aim to clarify bidirectional relations between mothers' physiological stress regulation-stress-related activation of the hypothalamic-pituitary-adrenal (HPA) axis-and their course of depressive symptoms. In Study 1, 230 pregnant women recruited from a women's mental health program gave 3 saliva samples in the context of psychosocial stress at 24, 30, and 36-weeks gestation. They self-reported depressive symptoms across the three trimesters of pregnancy and first year postpartum. Multilevel models revealed women with elevated salivary cortisol during pregnancy showed a course of escalating ante- and postnatal symptoms, implicating HPA hyperactivation as a precursor to worsening mood problems. In Study 2, 54 mothers from a community sample self-reported depressive symptoms at 3, 6, 12, and 18 months postnatal. At 18 months, they participated in a dyadic stress task with their infant and gave 4 saliva samples for cortisol assay. For mothers with a lifetime depression diagnosis, an escalating course of postnatal symptoms predicted a higher, flatter cortisol response profile. Together, the results of these studies suggest that for high-risk mothers, a trajectory of worsening depression may both follow from and give rise to neuroendocrine stress hyperactivation. These findings suggest greater attention is warranted to course of depressive symptoms across the ante- and postnatal period, rather than symptom levels at any given time, to characterize health risks. (PsycINFO Database Record

Validating parent and child forms of the Parent Perception Inventory

Understanding parenting from both parent and child perspectives is critical to child clinical and developmental research. Similarities and differences between parents' and children's reports can be highly informative, but only if they derive from psychometrically sound measures that assess the same parenting constructs. We examined the psychometric properties of the child and parent forms of the Parenting Perception Inventory (Bruce et al., 2006), which measures perceptions of two higher-order dimensions: positive, warm, supportive parenting; and negative, harsh, critical parenting. Data from a four-wave, longitudinal study of community children and adolescents (n = 876, Mage = 9.5 at the beginning), and data from a study of children (n = 131, Mage = 9.35) of depressed and nondepressed mothers provided psychometric support for both measures. Factor analyses revealed the existence of two factors in both the child and parent forms, and showed strong congruence across the two forms. Other analyses examined longitudinal structure, item difficulty, item discriminations, and scale coverage of the child form. Parents' and children's perceptions of parenting were related to children's affect, emotionality, and depressive symptoms. Parents' perceptions of parenting were related to parents' depressive symptoms and to parenting self-efficacy. (PsycINFO Database Record

Clinical Considerations When Treating Adults Who Are Parents

When providing mental health services to adults, we are often treating individuals who, among their other roles, are also parents. The goal of this article was to provide practitioners with the state of the science about both the impact of parental psychopathology on children and the role that children's well-being has in parental psychopathology. We discuss the benefits of integrated care for adult clients who are parents, as well as the barriers to providing integrated care for both parents and children in psychotherapy, and provide recommendations for practice. With this information, practitioners will gain greater awareness of their opportunities to treat adults in their parenting roles as well as to contribute to prevention of mental disorders in children.

Insomnia Treatment Preferences During Pregnancy

OBJECTIVE

To determine pregnant women's preferences for the treatment of insomnia: cognitive behavioral therapy (CBT-I), pharmacotherapy, or acupuncture.

DESIGN

A cross-sectional survey of pregnant women.

SETTING

We recruited participants in person at a low-risk maternity clinic and a pregnancy and infant trade show and invited them to complete an online questionnaire.

PARTICIPANTS

The sample (N = 187) was primarily White (70%), married or common-law married (96%), and on average 31 years of age; the mean gestational age was 28 weeks.

METHODS

Participants read expert-validated descriptions of CBT-I, pharmacotherapy, and acupuncture and then indicated their preferences and perceptions of each approach.

RESULTS

Participants indicated that if they experienced insomnia, they preferred CBT-I to other approaches, χ²(2) = 38.10, p < .001. They rated CBT-I as the most credible treatment (η²_partial = .22, p < .001) and had stronger positive reactions to it than to the other two approaches (η²_partial = .37, p < .001).

CONCLUSION

Participants preferred CBT-I for insomnia during pregnancy. This preference is similar to previously reported preferences for psychotherapy for treatment of depression and anxiety during pregnancy. It is important for clinicians to consider women's preferences when discussing possible treatment for insomnia.

Evidence-Based Interventions for Depressed Mothers and Their Young Children

Depression in mothers is a significant risk factor for the development of maladjustment in children. This article focuses on modifiable risk processes linking depression in mothers and adaptation in their young children (i.e., infancy through preschool age). First, the authors present evidence of the efficacy of interventions for reducing the primary source of risk: maternal depression. Second, they describe a central mechanism-parenting behaviors-underlying the relation between maternal depression and children's adjustment. Third, the authors recommend two different integrated interventions that successfully treat mothers' depression and enhance parenting skills with infants and young children. Finally, the authors note the possible need for supplementary interventions to address severity and comorbidity of mothers' depression, barriers to engaging in treatment, and the sustainability of program benefits.

Extending Models of Sensitive Parenting of Infants to Women at Risk for Perinatal Depression

OBJECTIVE

Recognizing that not all mothers at risk for depression engage in insensitive parenting, this study examined predictors of individual differences in sensitive parenting of infants by mothers with histories of depression, who are at elevated risk for depression during the perinatal period.

DESIGN

We examined maternal personal characteristics, context, and early infant temperament as predictors of sensitive parenting. Seventy-six women with a history of major depression were followed through pregnancy and postpartum and observed during play and feeding interactions with their 12-month-old infants.

RESULTS

Maternal personal characteristics (recurrence of clinically significant depression symptom levels during pregnancy or postpartum and higher trait anxiety), context (lower social context and lower income), and early infant temperament (higher negative affectivity, surgency/extraversion, and orienting/regulation) are often associated with less sensitive parenting, with stronger and clearer associations for play than feeding and with some differences based on whether sensitivity was defined as affective matching or rated sensitivity.

CONCLUSIONS

The findings extend support for multi-determination of sensitive parenting of infants to women with histories of depression, albeit with small to medium effect sizes, and suggest ways to identify those who may be most at risk for insensitive parenting and the potential value of intervening in pregnancy to enhance subsequent sensitivity of parenting.

A pragmatic randomized clinical trial of behavioral activation for depressed pregnant women

OBJECTIVE

Depression among pregnant women is a prevalent public health problem associated with poor maternal and offspring development. Behavioral activation (BA) is a scalable intervention aligned with pregnant women's preference for nonpharmacological depression care. This is the first test of the effectiveness of BA for depression among pregnant women, which aimed to evaluate the effectiveness of BA as compared with treatment as usual (TAU).

METHOD

Pregnant women (mean age = 28.75 years; SD = 5.67) with depression symptoms were randomly assigned to BA (n = 86) or TAU (n = 77). Exclusion criteria included known bipolar or psychotic disorder or immediate self-harm risk. Follow-up assessment occurred 5 and 10 weeks postrandomization and 3 months postpartum using self-report measures of primary and secondary outcomes and putative targets.

RESULTS

Compared with TAU, BA was associated with significantly lower depressive symptoms (d = 0.34, p = .04) and higher remission (56.3% vs. 30.3%, p = .003). BA also demonstrated significant advantage on anxiety and perceived stress. Participants attended most BA sessions and reported high satisfaction. Participants in BA reported significantly higher levels of activation (d = 0.69, p < .0002) and environmental reward (d = 0.54, p < .003) than those who received TAU, and early change in both of these putative targets significantly mediated subsequent depression outcomes.

CONCLUSIONS

BA is effective for pregnant women, offering significant depression, anxiety, and stress benefits, with mediation analyses supporting the importance of putative targets of activation and environmental reward. (PsycINFO Database Record

Positively Biased Processing of Mother's Emotions Predicts Children's Social and Emotional Functioning

Risk for internalizing problems and social skills deficits likely emerges in early childhood when emotion processing and social competencies are developing. Positively biased processing of social information is typical during early childhood and may be protective against poorer psychosocial outcomes. We tested the hypothesis that young children with relatively less positively biased attention to, interpretations of, and attributions for their mother's emotions would exhibit poorer prosocial skills and more internalizing problems. A sample of 4- to 6-year-old children (N=82) observed their mothers express happiness, sadness and anger during a simulated emotional phone conversation. Children's attention to their mother when she expressed each emotion was rated from video. Immediately following the phone conversation, children were asked questions about the conversation to assess their interpretations of the intensity of mother's emotions and misattributions of personal responsibility for her emotions. Children's prosocial skills and internalizing problems were assessed using mother-report rating scales. Interpretations of mother's positive emotions as relatively less intense than her negative emotions, misattributions of personal responsibility for her negative emotions, and lack of misattributions of personal responsibility for her positive emotions were associated with poorer prosocial skills. Children who attended relatively less to mother's positive than her negative emotions had higher levels of internalizing problems. These findings suggest that children's attention to, interpretations of, and attributions for their mother's emotions may be important targets of early interventions for preventing prosocial skills deficits and internalizing problems.

Development of the Perinatal Depression Inventory (PDI)-14 using item response theory: a comparison of the BDI-II, EPDS, PDI, and PHQ-9

The objective of this study is to develop a simple, brief, self-report perinatal depression inventory that accurately measures severity in a number of populations. Our team developed 159 Likert-scale perinatal depression items using simple sentences with a fifth-grade reading level. Based on iterative cognitive interviewing (CI), an expert panel improved and winnowed the item pool based on pre-determined criteria. The resulting 67 items were administered to a sample of 628 pregnant and 251 postpartum women with different levels of depression at private and public sector obstetrics clinics, together with the Beck Depression Inventory (BDI-II), Edinburg Postpartum Depression Scale (EPDS), and the Patient Health Questionnaire (PHQ-9), as well as Module A of the Structured Clinical Interview for DSM-IV Diagnoses (SCID). Responses were evaluated using Item Response Theory (IRT). The Perinatal Depression Inventory (PDI)-14 items are highly informative regarding depression severity and function similarly and informatively across pregnant/postpartum, white/non-white, and private-clinic/public-clinic populations. PDI-14 scores correlate well with the PHQ-9, EPDS, and BDI-II, but the PDI-14 provides a more precise measure of severity using far fewer words. The PDI-14 is a brief depression assessment that excels at accurately measuring depression severity across a wide range of severity and perinatal populations.

Staying well during pregnancy and the postpartum: A pilot randomized trial of mindfulness-based cognitive therapy for the prevention of depressive relapse/recurrence

OBJECTIVE

Clinical decision-making regarding the prevention of depression is complex for pregnant women with histories of depression and their health care providers. Pregnant women with histories of depression report preference for nonpharmacological care, but few evidence-based options exist. Mindfulness-based cognitive therapy has strong evidence in the prevention of depressive relapse/recurrence among general populations and indications of promise as adapted for perinatal depression (MBCT-PD). With a pilot randomized clinical trial, our aim was to evaluate treatment acceptability and efficacy of MBCT-PD relative to treatment as usual (TAU).

METHOD

Pregnant adult women with depression histories were recruited from obstetric clinics at 2 sites and randomized to MBCT-PD (N = 43) or TAU (N = 43). Treatment acceptability was measured by assessing completion of sessions, at-home practice, and satisfaction. Clinical outcomes were interview-based depression relapse/recurrence status and self-reported depressive symptoms through 6 months postpartum.

RESULTS

Consistent with predictions, MBCT-PD for at-risk pregnant women was acceptable based on rates of completion of sessions and at-home practice assignments, and satisfaction with services was significantly higher for MBCT-PD than TAU. Moreover, at-risk women randomly assigned to MBCT-PD reported significantly improved depressive outcomes compared with participants receiving TAU, including significantly lower rates of depressive relapse/recurrence and lower depressive symptom severity during the course of the study.

CONCLUSIONS

MBCT-PD is an acceptable and clinically beneficial program for pregnant women with histories of depression; teaching the skills and practices of mindfulness meditation and cognitive-behavioral therapy during pregnancy may help to reduce the risk of depression during an important transition in many women's lives.

Reward function: a promising but (still) underexamined dimension in developmental psychopathology

The goal of this Special Section is to explore the ways that investigation of reward function can shed light on the development and pathophysiology of psychopathology. Reward function provides a promising starting point for clinical affective neuroscience research because, thanks to the extensive literature on the neural mechanisms of addiction, the functional neuroanatomy, cellular mechanisms, and genetic contributions to reward circuitry have been well delineated (see Russo & Nestler, 2013, for details).

A randomized controlled trial of yoga for pregnant women with symptoms of depression and anxiety

BACKGROUND

Yoga may be well suited for depressed and anxious pregnant women, given reported benefits of meditation and physical activity and pregnant women's preference for nonpharmacological treatments.

METHODS

We randomly assigned 46 pregnant women with symptoms of depression and anxiety to an 8-week yoga intervention or treatment-as-usual (TAU) in order to examine feasibility and preliminary outcomes.

RESULTS

Yoga was associated with high levels of credibility and satisfaction as an intervention for depression and anxiety during pregnancy. Participants in both conditions reported significant improvement in symptoms of depression and anxiety over time; and yoga was associated with significantly greater reduction in negative affect as compared to TAU (β = -0.53, SE = 0.20, p = .011).

CONCLUSION

Prenatal yoga was found to be a feasible and acceptable intervention and was associated with reductions in symptoms of anxiety and depression; however, prenatal yoga only significantly outperformed TAU on reduction of negative affect.

An open trial of mindfulness-based cognitive therapy for the prevention of perinatal depressive relapse/recurrence

Pregnant women with histories of depression are at high risk of depressive relapse/recurrence during the perinatal period, and options for relapse/recurrence prevention are limited. Mindfulness-based cognitive therapy (MBCT) has strong evidence among general populations but has not been studied among at-risk pregnant women to prevent depression. We examined the feasibility, acceptability, and clinical outcomes of depression symptom severity and relapse/recurrence associated with MBCT adapted for perinatal women (MBCT-PD). Pregnant women with depression histories were recruited from obstetrics clinics in a large health maintenance organization at two sites and enrolled in MBCT-PD (N = 49). Self-reported depressive symptoms and interview-based assessments of depression relapse/recurrence status were measured at baseline, during MBCT-PD, and through 6-months postpartum. Pregnant women reported interest, engagement, and satisfaction with the program. Retention rates were high, as were rates of completion of daily homework practices. Intent to treat analyses indicated a significant improvement in depression symptom levels and an 18 % rate of relapse/recurrence through 6 months postpartum. MBCT-PD shows promise as an acceptable, feasible, and clinically beneficial brief psychosocial prevention option for pregnant women with histories of depression. Randomized controlled trials are needed to examine the efficacy of MBCT-PD for the prevention of depressive relapse/recurrence during pregnancy and postpartum.

Effects of perinatal mental disorders on the fetus and child

Perinatal mental disorders are associated with increased risk of psychological and developmental disturbances in children. However, these disturbances are not inevitable. In this Series paper, we summarise evidence for associations between parental disorders and offspring outcomes from fetal development to adolescence in high-income, middle-income, and low-income countries. We assess evidence for mechanisms underlying transmission of disturbance, the role of mediating variables (underlying links between parent psychopathology and offspring outcomes) and possible moderators (which change the strength of any association), and focus on factors that are potentially modifiable, including parenting quality, social (including partner) and material support, and duration of the parental disorder. We review research of interventions, which are mostly about maternal depression, and emphasise the need to both treat the parent's disorder and help with associated caregiving difficulties. We conclude with policy implications and underline the need for early identification of those parents at high risk and for more early interventions and prevention research, especially in socioeconomically disadvantaged populations and low-income countries.

Perinatal depression influences on infant negative affectivity: timing, severity, and co-morbid anxiety

Accumulating evidence suggests that antenatal depression predicts infants' negative affectivity, albeit with variable effect sizes. With a prospective longitudinal design, we sought to explain that variability by addressing questions about timing of the depression across pregnancy and the early postpartum, the role of high symptom levels relative to diagnosed depression, comorbidity with anxiety, and the potential mediating role of neuroendocrine functioning. Primiparous women (n=77) with histories of depression prior to pregnancy were assessed for cortisol levels monthly beginning by mid-pregnancy. Depression symptom levels and diagnostic status were similarly assessed monthly in pregnancy and also until infants reached three months of age, when mothers completed the Infant Behavior Questionnaire-Revised to measure infant negative affectivity. Antenatal depression symptoms and infant negative affectivity were positively associated (r=.39). Controlling for depression symptom levels in other trimesters, only second trimester depression symptoms predicted higher infant negative affectivity (β=.44). With postpartum depression symptom levels in the model, only antenatal depression symptoms predicted infant negative affectivity (β=.45). In the context of depression, neither antenatal anxiety symptoms nor anxiety disorder diagnosis were associated with infant NA scores. The hypothesized role of elevated maternal cortisol as a mechanism for the association between antenatal depression and infant NA was not supported. Our findings contribute to efforts to more precisely identify infants of perinatally depressed mothers who are at greater risk for elevated negative affectivity, suggesting a window of vulnerability in mid pregnancy and the need for further study of potential mechanisms.

Preferences and attitudes toward approaches to depression relapse/recurrence prevention among pregnant women

Patient preferences are increasingly recognized as important in clinical research and the delivery of evidence based practice in psychology. Although the prevention of depressive relapse/recurrence among perinatal women is an important public health goal, little is known about pregnant women's preferences and attitudes toward relapse/recurrence prevention interventions. Such information is important given low rates of care seeking among this population, and the potential for a relapse/recurrence prevention to avert negative outcomes among both vulnerable women and their offspring. Pregnant women seeking routine prenatal care in obstetric clinics (n = 200) were surveyed to assess their preferences for and attitudes about psychotherapy and pharmacological approaches to relapse/recurrence prevention. Women preferred psychotherapy (mindfulness based cognitive therapy and interpersonal therapy) more so than pharmacotherapy and reported significantly more favorable perceptions of the psychotherapy as compared to pharmacotherapy approaches to depression relapse/recurrence prevention. Results suggest also that depression history is important to consider in evaluating women's preferences and attitudes. Clinical and research implications of these findings are discussed.

Electroencephalogram patterns in infants of depressed mothers

Electroencephalogram (EEG) patterns may reflect a vulnerability to depression. In an effort to understand their earliest origin, we examined their stability and consistency and their associations with perinatal depressive symptoms. Depressive symptoms were measured prospectively throughout the perinatal period in 83 women with histories of depression and/or anxiety. Infant's EEG was recorded during baseline, feeding, and play at 3 and 6 months of age. Prenatal and postpartum depressive symptoms interacted significantly to predict 3- and 6-month-olds' EEG asymmetry scores. Asymmetry scores were consistent across contexts, except from baseline to feeding and play at 6 months, and stable across ages, except during feeding. Changes in depressive symptoms across ages were not associated with changes in infant EEG. Findings highlight the importance of considering both prenatal and postpartum depressive symptoms in the prediction of infant EEG, as well as the need to consider context to understand stability of infant EEG patterns.

Pregnant African American women's attitudes toward perinatal depression prevention

Depression during the perinatal period is common, debilitating, and consequential for women and their children, particularly among low income African American women. Viable approaches to prevention of depression have emerged. Yet little is known about women's preferences for approaches to preventing depression. A sample of 60 pregnant, low-income African American women seeking routine prenatal care was presented with standardized descriptions of three approaches to depression prevention (pharmacotherapy and two psychosocial approaches) and measures of preferences, perceived credibility, and personal reactions to each approach. Women also completed measures of perceived barriers and facilitators and current depression. Consistent with expectations, both of the psychosocial approaches were rated as more strongly preferred, more credible, and associated with more positive personal reactions relative to the pharmacotherapy approach. Depression did not alter women's preferences among the approaches. Contrary to prediction, women with clinically significant levels of depression did not find the pharmacotherapy approach to be more credible or to have more favorable personal reactions to it than women with low depression symptom levels. Exploration of women's perceptions of barriers revealed the importance of logistics, beliefs, and stigma barriers whereas women reported that concern about depression being impairing and ease of pragmatics would both facilitate engagement with preventive interventions. The findings suggest the need to examine the role of preferences in tests of the effectiveness of approaches to the prevention of perinatal depression in order to enhance service delivery among low income African American women.

Maternal antenatal depression and infant disorganized attachment at 12 months

Although high rates of attachment disorganization have been observed in infants of depressed mothers, little is known about the role of antenatal depression as a precursor to infant attachment disorganization. The primary aim of this study was to examine associations between maternal antenatal depression and infant disorganization at 12 months in a sample of women (N = 79) at risk for perinatal depression. A secondary aim was to test the roles of maternal postpartum depression and maternal parenting quality as potential moderators of this predicted association. Among women with histories of major depressive episodes, maternal depressive symptoms were assessed at multiple times during pregnancy and the first year postpartum, maternal parenting quality was measured at three months postpartum, and attachment disorganization was assessed at 12 months postpartum. Results revealed that infants classified as disorganized had mothers with higher levels of depressive symptoms during pregnancy compared to infants classified as organized. Maternal parenting quality moderated this association, as exposure to higher levels of maternal depressive symptoms during pregnancy was only associated with higher rates of infant disorganized attachment when maternal parenting at three months was less optimal. These findings suggest that enhancing maternal parenting behaviors during this early period in development has the potential to alter pathways to disorganized attachment among infants exposed to antenatal maternal depressive symptoms, which could have enduring consequences for child wellbeing.