Correlation between Maternal Mental Illness and Infant Abnormal Behavior

The aim of this study was to investigate the association between maternal mental health status and infant behavior: A descriptive design was used for this study which was conducted at 3 settings in Tanta Psychiatric Hospital, Tanta Inpatient University Hospital and Metkhalaf Psychiatric Hospital. A Purposive sample of 35 mothers and their infants were recruited from the previously mentioned setting. Mothers were presented with psychological health problems such as anxiety and depression. Only those mothers considered well enough to give informed consent were approached; Tools include biosocial and medical questionnaire, psychological scale, psychosocial scale, mothers perceived anxiety scale and infant behavior scale. Results indicated that there were a positive correlation between mothers’ psychological status, perceived anxiety state and infant behavior. Recommendation: Future research should focus on investigating the circumstances and context in which mental illness occurs and their predisposing factors to guide the planning of preventive interventions.


INTRODUCTION
Maternal mental health including (anxiety and depression) is a public health priority due to its impact on both maternal and child health; despite the growing number of empirical studies in this area, particularly from developing countries (Veena and Ammu, 2011). 1   Understanding infant social and emotional development in the context of maternal mental illness is a timely and urgent issue.Post-partum depression is common, affecting 10% to 20% of all mothers in the first few post-partum months.Accumulating evidence shows that maternal depression adversely influences some aspects of infant development and behavior particularly difficulty soothing, irritability (i.e.altered behavioral state regulation) and crying behavior.Arguably, excessive infant crying is a signal waiting for a response.Consequently, it may be a useful target to use for interventions in mothers with depression that improves outcomes for infants and their mothers.
Infant's mental health is often related to that of their caregivers, especially during the younger years of life.Research studies have found that infants of depressed mothers display negative behavioral symptoms as early as 6 weeks of age, when compared with their peers.A 2006 study found that infant of mothers who had been successfully treated for depression were 11 percent less likely to be diagnosed with depression themselves.
Infants whose mothers were not symptom-free were 8 percent more likely to be diagnosed (Weissman et al,   2006). 2 Although a mental health diagnosis in no way necessitates inadequacies in parenting, stressors undeniably impact in family system.The threat of infant abuse and neglect is by far the most severe risk to infant of parents with mental health issues.Mental illness can also negatively impact the family system by affecting parental employment, the quality of living situations, family relationships, resources, health, interpersonal interactions and child development.
Depression and anxiety are approximately twice as prevalent globally in women as in men, and are at their highest rates in the lifecycle during the childbearing years, from puberty to menopause.Studies of depression and anxiety show their incidence to be approximately 5% in non-pregnant women, approximately 8-10% during pregnancy and highest (13%) in the year following delivery (Javon and Yasiri 2009). 3ere are many variables; such as socio-economic status, desire for the pregnancy, family characteristics and parent stressors, which can have an impact, positively or negatively, on the development of maternal mental illness.Often times, these effects are not seen immediately, but manifest in later stages of the child's development.Though almost any psychiatric disorder affecting the mother could provoke infant disturbance, and some disorders present especial risk to her infant (Ali et al., 2003). 4epression is probably the most affective disorder that has been widely studied in relation to the purerperium and mother-child interactions.In general, infant of concurrently depressed mothers will show more behavioral disturbance, poorer cognitive functioning, more insecure attachment, more difficult temperament, and greater risk for developing depression when older (The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomized studies in meta-analyses, 1996).

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Very young infants can be affected by and are highly sensitive to the environment (largely represented by the mother) and the quality of care, and are likely to be affected by mothers with mental disorders -especially if the mother has anxiety, low mood, social withdrawal, irritability, impaired thinking and feelings of hopelessness.
(3) Prolonged or severe mental illness hampers the mother-infant attachment, breastfeeding and infant care.Depressed and anxious mothers are less likely to look at their infants' faces or emotionally connect with them, and they are also less likely to understand cues of hunger, happiness or distress and therefore are less responsive to the baby (Pottinger et al., 2009)   6   In addition, infants of chronically depressed mothers show less sociability with strangers, fewer facial expressions, smile less, cry more, and are more irritable than infants of normal mothers.Children of chronically depressed mothers do not perform as well on thinking and intelligence tests at 18 months of age and this is especially true for boy babies' speech development.As well as more distractible, less playful and less social up to age 5.If nurses and health providers identified those mothers promptly, and correctly treated, Its impact on infant is more ambiguous (Oates, 2003).

Theoretical framework
Anxious and depressed mothers have more negative perceptions of their infants' behavior and are less likely to offer stimulation to their infants.Such lessened stimulation may lead to disrupted learning during non-social learning tasks.Depression appears to lead the mother to ignore or misinterpret the infant signal, compounding the damage of maternal depression.In addition, in a single report, infant crying may even exacerbate or trigger maternal depression, thereby increasing infant developmental risk.Understanding maternal failure to respond appropriately may be a key element in developing interventions that promote healthy infant and child development in the presence of maternal mental health (Pamela et al., 2011). 8

Aim of the Study
To investigate the correlation between maternal mental health status (anxiety and depression) and infant behavior.

METHODOLOGY
Design: A descriptive design was used for this study

Setting
The study was conducted at 3 settings namely Tanta Psychiatric Hospital, Tanta Inpatient University Hospital and Metkhalaf Psychiatric Hospital.

Sample
A Purposive sample of 35 mothers and their infants were recruited from the previously mentioned setting.Mothers were presented with mental or psychological health problems as anxiety, and/or depression.Only those mothers considered well enough to give informed consent were approached; a member of the clinical team who knew the mother well made this decision; for choosing the mothers to be included in the study.
All mothers had received a primary diagnosis of anxiety: a depressive disorder (mild, moderate or severe episode, or recurrent depressive disorder.) All mothers were taking medication prescribed for their mental illness at the time of the study: Mothers were not excluded from the sample for the presence of other mental health problems.However, women were excluded for the following reasons: history of head injury or primary diagnosis of personality disorder.Mothers were selected according to infant age, to ensure that they were comparable with the age of the infants.

Inclusion criteria
1-Mothers have mental illness and free from physical health problems.
2-Infant free from physical problems.

A. Preparation of the study:
Data collection tools were designed after extensive review of literature.Official permissions were obtained from the administrators of the Psychiatric department hospitals mentioned before.Before conducting the study, personal communication was done with nurses, physicians and mentally ill mothers to explain the purpose of the study and assure their best possible cooperation, pilot study was carried out on 5 mentally ill mothers and excluded from the total sample to assure stability of the results.

B. Data collection procedure:
Three letters were sent from the Dean of the Faculty of Nursing in Menoufiya asking for permission for researcher to meet mentally ill mothers at previously mentioned settings for the directors after discussing the purpose of the research.Then mothers were asked for their biosocial and medical data, if she is able and accepted to participate in the study, or her medical data taking from their medical record if she is unable to perceive her state, then she is observed to assess her psychological status and interviewed for her psychosocial and perceived stress scale questionnaire.The observations were analyzed for situation as well as grouping factors of maternal mental illness, marital status, educational status, sex and age of the infant.
The study procedures were explained, mothers completed mental state questionnaires; at a point when the infant was alert and contented, mothers and infants were observed during a five-minute face-to-face interaction.The researcher, who was unknown to the mother, then entered the room; she called the infant's name, and approached mother and infant; she paused to stand alongside the mother, spoke to the infant again, and then lifted the infant from his/her chair and tried to engage him/her in social interaction, to assess his/her behavior.Also stranger anxiety was to be considered when examining infant behavior according to the situation and developmental stage.

Validity:
Content validity of the questionnaire sheet was determined through an extensive review of literature about psychological and psychosocial data (face validity).After selecting the tool, adopting it and tested with the pilot study consisting of 5 mothers and their infant.Then, the content of interview was submitted to a panel of 2 of pediatrics nursing experts with more than five years experience in pediatrics and 3 expertise in psychiatric nursing.Modification of the tools were made according to the panels' judgment on clarity of sentences, appropriateness of content, sequence of items, and accuracy of scoring and recording of items (content validity).
Construct validity for Perceived Stress Scale (PSS) score was moderately related to responses on other measures of appraisal stress as well as potential sources of stress as assessed by event frequency (Oates,  2003).7   Validity of the Infant Behavior Scale (IBS) investigated discriminate validity of the IBQ-R by considering correlations between IBQ-R subscales and found some evidence for the independence of each.Convergent validity of prior versions of the IBQ (Gartstein and Rothbort (2003) (9) : with observed indices of temperament has been demonstrated; however associations have been relatively modest .Reliability of the IB Scale Internal reliability and inter-rater reliability of the IBSQ-R have been previously investigated by (9) : Internal reliability was at acceptable levels ranging from 0.70 to 0.90 for parents whose infant were between the ages of 3 and 12 months, these values were meet our sample criteria to be investigated by the scale.Internal reliability for (PPS) co efficiency alpha was 0.78, the test-retest reliability of the items on the scale were anchored to appraisal in the past month Tools of the Study 5 Tools were utilized to achieve the objectives of the study.

Tool I
Interview questionnaire included biomedical data which was obtained from mothers; name, age, levels of education, occupation, infant age, sex, mothers' diagnosis, and treatment given.The scale developed by the researcher to collect relevant data from mothers or from medical record according to mothers' desires.

Tool II
Psychological assessment state questionnaire consists of 7 sub items including description of mothers appearance, facial expression cry, screaming, tremulous, looking up ward, brows, sitting calm etc. Movements manner as (guarded, suspensions, angry, friendly or hostile): Motor activities (retarded , slowed movement ) talking, emotions with others, content of thinking, mothers mental operations and perceptions.The scale is a multiple choice, every item includes several choices which describe the actual mothers state at the time of assessment which developed by Health (Canda, 1993).(10)   Tool III Psychosocial Questionnaire, the scale developed by Zimmerman (1994): (11) and translated by the researcher consist of 24 questions which assessing the psychological and social factors which aggravate the mental illness of the mothers and affect the infant as depression during pregnancy, or postpartum, secure relationship with husband, husband support, exposure to family crisis or violence as well as relationship with infant and care.The scale responded by Yes or No which taking score one or Zero in relation to the normal response.The total score was calculated from 24 and categorized as mild psychosocial affection (24-16), moderate (15-8) or severe psychosocial affection <8

Tool IV
Perceived Stress Scale (PSS) developed by Cohen & Williamson, (1988) (12) and consists of 10 items which describe mothers near anxiety state in the previous month which considered a risk factor for clinical psychiatric disorders if the score was high.Every item in the scale responded by never, rarely, sometimes, often and usually.If the mothers responses including the first 2 responses considered low perceived anxiety and taking score >20 and they have medium perceived anxiety giving score (21-35) and considered have high perceived anxiety if she had taken score from (36-50).PSS scores are obtained by reversing responses e.g.1=3, 4=0, 3=1, 0=4 for the four positively stated items, then summing across scale items.

Tool V
Infant Behavior Scale (IBS): Is a Likert scale developed by (18) and translated by the researcher.The scale consists of 13 items which describe infant behavior state.Every item in the scale observed or responded by never, rarely, sometimes, often and usually.Infant behavior is generally assessed through maternal report on the infant Behavior Checklist but in this case, we didn't depend on mothers report rather than observation.The scale has been designed to measure temperament in infants between the ages of 3 to 12 months and assess dimension of temperament as 1-activity level e.g.movement of the arms, legs and locomotors.2-distress to limitation as crying due to certain place or position, or unable to perform the desired action.3-Approachas excitement, and positive or negative anticipation of pleasurable activities.4-Fears due to sudden changes, physical object or social stimuli.5-Duration of orientation with a single object for extended period of time 6-Smiling and laughter with care taker, or playing situation.7-Vocal reactivity in daily life activities.8-Sadness due to negligence, physical state, and object loses 9-Perceptual sensitivity as amount of detection of stimuli from external environment 10-High intensity pleasure related stimulus intensity .tohigh stimulus intensity.11-Low intensity pleasure related to situation involving low stimulus intensity.12-Cuddling as expression of enjoyment to being held 13-Soothe-ability as reduction of crying or distress when the care taker uses soothing technique and easy to fall asleep.If the infant observation responses including the first 2 responses considered behavior affection and taking score >26 and they have moderate behavior affection giving score (27-44) and considered to have high behavior affection if he/she takes score from (45-60).To facilitate infant behavior questionnaire interpretation, the infants were classified according to age from 3-6 months, 4 -8 months and 9-12 months, then their behavior were interpreted according to their code of behavior for their ages and gender.In most cases, infant's needs two or more session to complete their observation.

Data analysis:
The collected data was tabulated, analyzed and percentage distribution was calculated by using SPSS version 16.A computerized statistical analysis was done.Tests of significance were applied (chi square cross tabulation and correlation) to test significant statistical differences.Statistical significant difference were considered at p-values less than 0.05

Table (1) Biosocial characteristics of studied mothers and their infants
Table 1 Showed biosocial characteristics of studied mothers and their infants.71.4 % of mothers their age group from 36-40 years old, 60% of the studied mothers were married, 65.7% of them were housewives, 37.1% of them had university education, and only 8.6% had preparatory school.

Figure (1,2) represent infant age and sex in relation to perceived anxiety state
High percentage of mothers has boy infant age from 8-12 months have moderate perceived anxiety (21-35)  Table (2):-Showed the frequency distribution for psychological assessment for mental illness of the mothers.There was no significance relationship P>0.05 between the frequency distribution for psychological assessment for mental illness of the mothers with mothers appearance, mothers movement, talking, emotions with others, mental thoughts, mental operations, conceptualization , psychosocial assessment total score in contrast to statistical significance difference (P<0.05 ) in relation to mothers talking, conceptualization, perceived anxiety state and infant behavior total score.

Table (3):
-Showed that the majority (62.8% and 71.4%) of the studied mothers had depression during pregnancy or post partum, and 68.6% no changing in the eating and habits, 74,2% exposure to family or work crisis and domestic violence, 71.4 %.More than half of the studied mothers ( 54,3% ) didn't have secure relationship with her husband's, 82.9% of mothers had thoughts of hurt herself, but they didn't have 88.6 % that thought to hurt their infants, less than half of them didn't like relationship with psychologist or counselor.

Table (4):
-Perceived anxiety state of studied mothers showed that 31.9% of the mothers sometimes had anxiety last month, 42.95% usually had sense of uncontrolled in their life, 37.1% never had anxiety and worried last month, 28.6% of mothers were able to solve their problems, 34.3% of mothers often had the control and adaptation, 37.15% of mothers never had sense of overcoming problems, 25.7% sometimes had anxiety due to problems out of their control.

Table (5) Frequency distribution of Some Items of Infant Behavior Scale
Table (5) represent frequency distribution of some items of infant behavior scale which describe that more or less than thirty percent of infant usually have an abnormal pattern of infant behavior affect by their mental maternal state

Table (6) Correlation between infant characteristics and their behavior, with their mothers psychosocial assessment and perceived anxiety
Table (6) Correlation between infant characteristics and their behavior, with their mother's psychosocial assessment and perceived anxiety.There was a positive and significant correlation between infant sex with their behavior and perceived anxiety as well as psychosocial state of the mother.In addition to positive correlation with mother's psychosocial state and their perceived anxiety for infant behavior  6) Figure (5, 6) showed education level of mothers with perceived anxiety state and psychological assessment which represented that mothers graduated from the university have high level of perceived anxiety and moderate degree of their psychosocial state Table (7) Correlation between infant characteristics and their behavior, with their mother's psychosocial assessment and perceived anxiety Table (7) Correlation between infant characteristics and their behavior, with their mother's psychosocial assessment and perceived anxiety.There was a positive and significant correlation between infant sex with their behavior and perceived anxiety as well as psychosocial state of the mother.In addition to positive correlation with mothers psychosocial state and their perceived anxiety for infant behavior Figure (10)   Figure (9) Shows relationship between high perceived maternal anxiety and high total infant behavior score Figure (10) Shows relationship between moderate psychosocial total score associated with high total infant behavior score.

DISCUSSION
Rapid physical growth and development occur in early life when infants are dependent on the primary caregiver for their social and nutritional needs, this makes infants and young children vulnerable to the effects of their caregivers' mental health problems.The present study revealed that biosocial characteristics of studied mothers and their infants for majority of their mothers (71.4 %) age were from 36-40 years old, (60%) of the studied mothers were married, (65.7%) of them were housewives, (37.1%) of them had university education.(Pamela, 2011) (8) estimates that the incidence of mental illness in women in developing countries vary widely, from 15% to 57%.(Wachs, 2009) (13) stated that maternal mental illness has a complex etiology involving factors as diverse as poverty, marital conflict, domestic violence and lack of support.However, there were no correlation between maternal mental illness, mother's age, educational level or family history, this finding was consistent with (Hadley  et al. 2008) (14) who found that maternal mental health problems were associated with both global and specific developmental problems not related to their age, occupation or education.Study revealed that more or less than thirty percent of mothers have unstable psychosocial status which was a sign of different mental operations affecting on the behavior of children.Through those symptoms, the psychological status of mothers were assessed which reporting that more than half of mothers have moderate affection on their psychosocial status which correlates positively with infant behavioral disturbance.This may be due to disturbance in care giving, feeding and the degree of insecurity attachment which may all play a role in developing behavioral disturbance among those infants.Previous research suggests that maternal depression is associated with compromised parenting behavior, no responsive care giving practices which supported by (Lovejoy et.al, 2000  .(15) and Mclearn  et,al, 2006 ). (16)In addition to, a lower likelihood or shorter duration of breastfeeding.The time at which infant growth is measured may also influence the observed association with maternal depression: Also, (WHO, 2008) (17) in their Meta-analyses, support medium to large effect sizes of postpartum depression on mother-infant relations in the first year postpartum.The odds are 5.4 times higher for 18-month old infants of postpartum depression of mothers to display insecure attachment compared to infants of non-postpartum depression mothers.
About three quarter of infant age was between 8-12 months and more than half of them (56.4%) were boys.(Lovejoy et al, 2000) (15) supporting this findings stated that A host of demographic, psychosocial and culture-specific risk factors (male child preference) which have been identified for antenatal and postnatal distress among mothers.So, Interventions aimed at improving parenting and the mother-infant relationship have been effective in reducing depressive symptoms in postpartum women, which suggests that maternal mental health is modifiable.(Cooper.2009) ) . (18) reported that a reduction in the incidence of maternal anxiety and depressive symptoms in developing countries would not only have a beneficial effect on mothers, but would also improve child growth substantially, and this could in turn influence the infant's future health, development and socioeconomic status .
The most common psychosocial findings of mothers represented that majority of mothers have depression during pregnancy (62.8%), postpartum depression (71.4%), insecure relationship with their husband (75.1%), lack of their husband support (54.3%), exposed to family or work crisis (74.2%).Growing evidence suggests that antenatal mental health problems can be a precursor for subsequent mental health problems in a woman's life.In addition to other research has indicated that risk factors for poor mental health during pregnancy include past personal or family history of psychiatric illness or substance abuse, past personal history of sexual, physical or emotional abuse, current exposure to intimate partner violence or, current social adversity as well as coincidental adverse life events.Psychological disturbances during pregnancy are associated with inadequate antenatal care, low-birth weight and preterm delivery, while in the postpartum; it is associated with diminished emotional involvement, neglect and hostility towards the newborn.(Veena, 2011) (1) Also, the above findings suggest that a host of psychosocial risk factors are associated with distress during pregnancy.Past history of depression, domestic violence, stressful life events, marital disharmony and lack of social support emerged as the most salient risk factors.
Study indicated that (62.8%) of mothers suffer from depression during pregnancy and (71.4%) of mothers have post partum depressions.(Rich-Edwards et al. 2010) (19) found that the strongest predictor for antenatal depressive symptoms was a past history of depression.These findings were corroborated by studies from (Pottinger, et al, 2009) (20) , found that medical problems were associated with a 3-4-fold increase in the odds of reporting stress during pregnancy.In addition to, reported domestic violence during pregnancy experienced mothers with significant sleep disturbances, anxiety and depression.While few studies have examined protective factors associated with antenatal distress, and showed that social support and self-confidence protected women from experiencing distress.(Rich-Edwards, 2010) (19)   Mothers perceived anxiety scale represented mothers anxiety for certain occasion.Last month, Cohen and William (1988) (21) stated that the high the degree and longer the duration of self perceived stress was a predictor of lower levels of restless/disruptive temperament, which is associated with more total behavioral problems and more externalizing behavioral problems in children.Another study by Gutteling et al (2006) (22) .found that maternal life events measured during the first part of pregnancy were negatively associated with the child's attention/concentration index, while controlling for overall IQ, gender and postnatal stress.So, perceive stress should be eliminated by health staff, nurses and husband support Results indicated that there is a significant correlation between the total score of infant abnormal behavior with total score maternal psychosocial behavior, and total score of maternal perceived anxiety.Infant behavior determined by their anxious movement, slowed emotional responses, have sudden infant fear and lack of interest in kissing which are usually slowed by more than quarter of infants.Also, more than one quarter have a long length of orientation, lack of sound stimulation and anxiety with shaken.Werner, et al. (2007) (23) found that the presence of irritable behavior in the infant contributed to the persistence of mothers depression.Similarly, Murray and colleagues (1996) (21) found that certain infant characteristics significantly increased the risk that the mother would become depressed.Nevertheless, there was no evidence from the study of Murray and colleagues (1996) (24) that infant factors had an independent impact on the quality of the mother-infant relationship, and nor was there evidence for an impact of early infant characteristics on the longer term cognitive and emotional outcome of the child.Both the quality of maternal responsiveness and child outcome were principally affected by the presence of depression and social adversity In a prospective cohort study of pregnant women (n=2979) recruited at 18 weeks gestation found that a behavioral problem as assessed on the Child Behavior Check List, were predicted by maternal experience of multiple stressful events during pregnancy.Robinson, et al. ( 2008) (25) reported that maternal sensitivity rather than antenatal psychiatric diagnosis or postnatal psychiatric status modulated infant responsiveness.Also, Werner, et al. (2007) (23) found that physiological markers of individual differences in infant temperament are identifiable in the fetal period, and possibly shaped by the prenatal environment.Antenatal psychiatric diagnosis was also associated with a fourfold increase in cry reactivity in infants.
Thus, a number of both physiological and psychosocial factors have been identified as possible mediators or moderators of the link between maternal mental health and infant behavior.So, it should be promptly treated with psychosociologest, psychotherapy in addition to husband and family support

Implications for Practice, Policy and Research
Because mental illness of the mothers increase dramatically in coming years and will impose a commensurate burden on families, infant behavior and health-care systems.Future research should focus on investigating the circumstances and context in which mental illness occurs and their predisposing factors to guide the planning of preventive interventions.
Also, it will be valuable for future studies to examine the trajectories of children beyond early childhood and to compare children of parents with different subtypes of mental disorders.