Well Moms, Well Tots :

1. Well Moms, Well Tots: Maternal Depression Screening and Mother-Child Wellbeing

2. About Docs For Tots • Non-profit, non-partisan organizationlead bypediatricians  • Mission: Bring together children’s doctors and communities topromote practices, policies and investments in children from prenatal to five that foster children’s healthy development and future success.  • Vision: All families are able to fully support the healthydevelopment of their children during early childhood.Supportingchildren’s development is the foundation for a healthy andsuccessful society. • Five Priority Areas: • Promoting the early childhoodmedical home • Increasing developmental screening • Improvingaccess to high quality early care and education • Improvingsocial-emotional health • Addressing the impacts of poverty.

3. About Us • Background • Melissa Passarelli, MA, Director of Programs • Laraib Humayun, BS, Health Liaison www.docsfortots.org

4. Overview • Goal 1: Maternal Wellbeing • Objective 1: Maternal wellbeing and long-term outcomes • Objective 2: Cross-cultural views/influences on maternal mental health • Objective 3: Risk factors and PCHP population • Goal 2: Maternal Depression Screening • Objective 1: Screening: what you need to know   • Objective 2: Screening tools- PHQ-9 vs. EPDS  • Goal 3: How can you help? • Objective 1: How you can help moms promote their wellbeing • Objective 2: How to talk to parents about concerns you or they have

6. UNDERSTANDING IMPACT OF ADVERSE CHILDHOOD EXPERIENCES Death Conception Early Death Disease & Disability Adoptionof Health-Risk Behaviors Social, Emotional, and Cognitive Impairment Adverse Childhood Experiences Freely reproducible slide from the Centers for Disease Control and Prevention.

7. Goal 1: Maternal Wellbeing: What You Need to Know www.docsfortots.org

8. Maternal Wellbeing and Child Development • Nearly 20% of mothers in the U.S. experience maternal depression. (Gaynes, 2005) • According to the ACOG, depression is the #1 most common medical complication during pregnancy and the postpartum period. • Depressive symptoms impair a mother's ability to develop healthy attachment and parenting skills in a child's early years. (Alhusen, Hayat, & Gross, 2013) • Impaired social, emotional, cognitive, and motor development • Greater risk of developmental delays www.docsfortots.org

9. Maternal Wellbeing and Child Development • Maternal depression, in conjunction with anxiety and stress, has been linked to perinatal complications (e.g. preterm birth), as well as early childhood developmental delays: • Infants show anxiety and restlessness • Negative behaviors and psychological problems • Underachieving in school and increased absences  (Alvarez, Meltzer-Brody, Mandel, & Beeber, 2015; Claessens, Engel & Curran, 2015) www.docsfortots.org

10. Risk factors • Depression during pregnancy: • Maternal anxiety • Life stress • History of depression • Lack of social support • Unintended pregnancy • Medicaid insurance • Domestic violence • Lower income • Lower education • Smoking • Single status • Poor relationship quality • Racial minorities • Comorbid conditions • Postpartum depression: • Depression during pregnancy • Anxiety during pregnancy • Experiencing stressful life events during pregnancy or the early postpartum period • Traumatic birth experience • Preterm birth/infant admission to neonatal intensive care • Low levels of social support • Previous history of depression • Breastfeeding problems Data from Lancaster CA, Gold KJ, Flynn HA, Yoo H, Marcus SM, Davis MM. Risk factors for depressive symptoms during pregnancy: a systematic review. Am J Obstet Gynecol 2010;202:5–14 and Robertson E, Grace S, Wallington T, Stewart DE. Antenatal risk factors for postpartum depression: a synthesis of recent literature. Gen Hosp Psychiatry 2004;26:289–95. www.docsfortots.org

11. Cross-Cultural Considerations • Literacy and language barriers • Inability to communicate with provider • Cultural stigma and discrimination • Mental health as a cultural taboo • Depression being “shameful” or “embarrassing”  • Stigma in workplace or personal life • Fear • Not wanting to be a “bad mother” or have child taken away What have you noticed in your experiences working with families of diverse cultures? www.docsfortots.org

12. Goal 2: Maternal Depression Screening www.docsfortots.org

13. Maternal depression screening is recommended by... • New York State Medicaid • U.S. Preventive Services Task Force • American Academy of Family Physicians (AAFP) • American College of Obstetricians and Gynecologists (ACOG) • American Academy of Pediatrics (AAP) • Bright Futures Guidelines Currently, 5 states in the U.S. have enacted legislation to require providers to screen for maternal depression. Screening is covered under Medicaid in 11 States. www.docsfortots.org

14. Why is Maternal Depression Screening Important? • The use of standardized screens builds and strengthens the longstanding tradition of detecting complications in mothers during the pregnancy and postpartum period. • Formalized, evidence-based screening detects far more complications than surveillance alone.  • Maternal depression screening and connection to supports are critical for the child's learning, behavior, and lifelong health.

15. Why is Maternal Depression Screening Important? • There is no current standardized screening process in place on the local or state level in New York. • Several cases are going undetected, undiagnosed, and untreated. • Untreated cases can linger for years and lead to poor long-term health outcomes in mother and baby. • We already know the risks associated with untreated depression!

16. www.docsfortots.org

17. How Does Screening Help? • Initiates the conversation • Implementing standardized screening recommendations can:  • Improve early childhood and lifelong outcomes for both child and parent • Save money on intervention and remediation costs later www.docsfortots.org

18. Screening Tools vs. Interviews • Many providers utilize interviews rather than a paper-based screening tool. • Interview= asking predetermined questions or questions from a screening tool • Paper Screen= standardized, valid, reliable tool • Both methods are feasible in pediatric and primary care, but paper screening tools have resulted in a greater yield.

19. Screening Tools vs. Interviews  Two Approaches to Maternal Depression Screening During Well Child Visits (Olson et al., 2005) Pediatric primary care providers utilized two methods of screening for maternal depression: Interview Vs.  Paper Screen

20. Screening Tools vs. Interviews Interview vs. Paper Screen 5.7% yield 1.6% of women referred to services 22.9% yield 7.6%of women referred to services www.docsfortots.org

21. Screening Tools • PHQ-2 • 2 self-reported items about mood • less than 1 minute to complete • Positive score triggers more comprehensive screen

22. Screening Tools • PHQ-9 • 9 self-reported items • less than 5 minutes to complete • translated into over 30 languages • low required reading level • easy to score • includes constitutional symptoms of depression, such as changes in sleeping patterns, that are common in pregnancy and the postpartum period. 

23. Patient Health Questionnaire 9 (PHQ-9) www.docsfortots.org

24. Scoring the PHQ-9 www.docsfortots.org

25. Screening Tools • EPDS • 10 self-reported items • less than 5 minutes to complete • translated into 12 languages • low required reading level • easy to score • includesanxietysymptoms, which are a prominent feature of perinatal mood disorders • excludes constitutional symptoms of depression, such as changes in sleeping patterns, that are common in pregnancy and the postpartum period. 

26. The Edinburgh Postnatal Depression Scale (EPDS) www.docsfortots.org

27. Scoring the EPDS

28. Screening Tools • PHQ-9 • 9 self-reported items • less than 5 minutes to complete • translated into over 30 languages • low required reading level • easy to score • includes constitutional symptoms of depression, such as changes in sleeping patterns, that are common in pregnancy and the postpartum period.  • EPDS • 10 self-reported items • less than 5 minutes to complete • translated into 12 languages • low required reading level • easy to score • includesanxiety symptoms, which are a prominent feature of perinatal mood disorders • excludes constitutional symptoms of depression, such as changes in sleeping patterns, that are common in pregnancy and the postpartum period. 

29. Thoughts? • Interview vs. Paper screen • PHQ-9 vs. EPDS • How do you "ask the question"? • Have you committed to any screening practices? www.docsfortots.org

30. Goal 3: How can you help?

31. Why You Need Talk About This • Not all doctors are screening, or not screening with fidelity. • Even if they are, referral processes for positive screens are not ideal and many mothers don’t get treatment.  • Only 15-20% of mothers are getting the help they need. (Postpartum Resource Center N.Y.; The Motherhood Center) www.docsfortots.org

32. Home Visiting and Maternal Depression • In a study of 17 Early Head Start families, over half of mothers reported depressive symptoms. • As someone in the home visiting field, you are uniquely situated to promote maternal wellbeing through: • Long-term, trusted relationships with families • Access to children from birth to school age www.docsfortots.org

33. Common Barriers and Opportunities for Growth Common barriers to the maternal depression conversation: • Insufficient training and understanding of MD • Lack of comfort speaking with mothers or not knowing how • Resistance and distrust by parent • Lack of knowledge about referral process and resources What are some barriers you can identify from your own experiences, and how do you work through these barriers?

34. Addressing Maternal Mental Health Haddad, M., Buszewics, M., & Murphy, B. (2011). Supporting people with depression and anxiety: aguide for practice nurses. Mind U.K. www.docsfortots.org

35. Referral Mental improvement using the Pyramid Model: www.docsfortots.org

36. How to talk about concerns • Confidence is key!  • Addressing depression is a difficult conversation to have.  • Develop confidence to ask the right questions and make a referral with ease • Screening will help initiate the conversation  • Start with physical symptoms • “We want to make sure that you are feeling well after having a child. Sometimes extra support is needed.” • PHQ-2 • Consider language and tone • Empathy and sensitivity

37. Let’s talk… • What are your thoughts on talking about depression? • Do you feel comfortable having this conversation? • What have your experiences been like? • What concerns do you have? www.docsfortots.org

38. Tips • If you suspect a mental health concern: • Define/explain maternal depression • Explain why treating it is critical for the wellbeing of the mother and child.  • Answer any questions or concerns the mother may have with honesty and sensitivity. • Describe your role  • Explain limitations  • Provide referrals to reliable sources and help with access. www.docsfortots.org

39. 3 Phrases to Remember: You are not alone. You are not to blame. You will feel better and be well with help. www.docsfortots.org

40. Thank You!   For more information regarding maternal depression and Docs For Tots, visit www.docsfortots.org • Melissa Passarelli, Director of Programs • melissa@docsfortots.org • 631-662-3176 • Laraib Humayun, Health Liaison • laraib@docsfortots.org • 516-647-3199